Liver surgery: Imaging and image guided therapies

The liver is the most common site of malignant tumors in patients worldwide, including both primary (hepatocellular carcinoma) and metastatic liver cancer (eg colorectal liver metastases). Complete resection or thermal ablation of all tumor deposits currently offers the only potentially curative treatment for patients with a malignancy of the liver. Historically, the liver was considered an organ too fragile and prone to bleeding for elective surgery. Increasing insight in the hepatic vascular and biliary anatomy and the introduction of antisepsis and anesthesia allowed pioneers like Langenbruch and Keene to start performing partial liver resections in the late nineteenth century1,2. Ongoing insight in the hepatic anatomy -like the division of the liver in eight distinct anatomic segments by Couinaud- further encouraged surgeons to perform liver surgery for hepatic neoplasms3. However, until late in the twentieth century, the absence of any form of non-invasive diagnostic imaging severely hampered the application of liver resection at a large scale

De oudere patiënt met multipele ribfracturen

Abstract: Rib fractures resulting from blunt thoracic trauma occur frequently in elderly persons. Although usually due to a low impact trauma mechanism (e.g., fall from standing height), rib fractures are associated with significant morbidity and mortality in the elderly patient. This unfavorable clinical course is most often caused by respiratory insufficiency due to lung edema or pneumonia. This cases series presents three elderly patients who sustained multiple rib fractures and were subsequently admitted to a level I trauma center for treatment. Diagnostic challenges as well as different treatment approaches for this population are discussed. More specifically, age specific indications and contra-indications for intravenous or epidural analgesia and operative rib fixation are discussed. In addition, we show that a multidisciplinary approach, involving a trauma surgeon, anesthesiologist, intensive care physician and physical therapist is paramount for the prevention of potentially lethal complications. Samenvatting: Stomp thoracaal letsel met ribfracturen komt veel voor bij ouderen. Hoewel het traumamechanisme vaak van laag-energetische aard is, is het beloop dikwijls gecompliceerd. De morbiditeit en mortaliteit van deze letsels bij oudere patiënten zijn aanzienlijk. Enerzijds wordt dat verklaard door patiëntgerelateerde factoren, zoals een verminderde fysiologische reserve, comorbiditeit en verhoogde vatbaarheid van weefsels voor het ontstaan van letsel. Anderzijds kan de letselernst in deze populatie eenvoudig worden onderschat. Tijdige herkenning van deze factoren en de gevolgen hiervan, alsmede een multidisciplinaire behandeling zijn van essentieel belang om tot een goede diagnose te komen, een adequate behandeling in te stellen en complicaties te voorkomen. Wij illustreren dit aan de hand van 3 casussen

First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study

Purpose: The aim of this study was to compare the rate of first attempt success of endotracheal intubation performed by ambulance nurses in patients with a Glasgow Coma Scale (GCS) of 3 using video laryngoscopy versus direct laryngoscopy. Methods: A prospective cohort study was conducted in a single, independent ambulance service. Twenty of a total of 65 nurse-staffed ambulances were equipped with a video laryngoscope; a classic direct laryngoscope (Macintosh) was available on all 65 ambulances. The primary outcome was first attempt success of the intubation. Secondary outcomes were overall success, time needed for intubation, adverse events, technical or environmental issues encountered, and return of spontaneous circulation (ROSC). Ambulance nurses were asked if the intubation device had affected the outcome of the intubation. Results: The first attempt success rate in the video laryngoscopy group [53 of 93 attempts (

Decision making in prehospital traumatic cardiac arrest; A qualitative study

Background: Despite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. Methods: Twenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. Results: Eight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. Conclusion: Eight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines

Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future

Background: Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the reco

Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma

Background & aims: Neoadjuvant chemoradiotherapy (NACRT) has increased local control in locally advanced rectal cancer. Reduced skeletal muscle mass (sarcopenia), or ongoing muscle wasting, is associated with decreased survival in cancer. This study aims to assess the change in body composition during NACRT and its impact on outcome using computed tomography (CT) imaging in locally advancedrectal cancer (LARC) patients. Methods: LARC patients treated with NACRT were selected from a prospectively maintained database and retrospectively analyzed. One-hundred twenty-two patients who received treatment between 2004 and 2012 with available diagnostic CT imaging obtained before and after NACRT were identified. Cross-sectional areas for skeletal muscle was determined, and subsequently normalized for patient height. Differences between skeletal muscle areas before and after NACRT were computed, and their influenceon overall and disease-free survival was assessed. Results: A wide distribution in change of body composition was observed. Loss of skeletal muscle mass during chemoradiotherapy was independently associated with disease-free survival (HR0.971; 95% CI:0.946e0.996; p¼0.025) and distant metastasis-free survival (HR0.942; 95% CI: 0.898e0.988; p¼0.013).No relation was observed with overall survival in the current cohort. Conclusions:Loss of skeletal muscle mass during NACRT in rectal cancer patients is an independent prognostic factor for disease-free survival and distant metastasis-free survival following curative intentresection

Inhibition of activin-like kinase 4/5 attenuates cancer cachexia associated muscle wasting

Cancer mediated activation of the ActRIIB-ALK4/5 heterodimer by myostatin is strongly associated with muscle wasting. We investigated in vitro and in vivo the efficacy of ALK4/5 receptor blockers SB431542 and GW788388 in preventing muscle wasting, and explored synergy with IGF-I analogue LONG R3 (LR3) IGF-I. In vitro, C2C12 skeletal muscle cells were treated with vehicle, SB431542, GW788388 and LR3 IGF-I. A C26-CD2F1 cachexia model was used to induce cachexia in vivo. Mice were allocated as non-tumour bearing (NTB) or C26 tumour-bearing (C26 TB) vehicle control, treated with SB431542, LR3 IGF-I, SB431542 and LR3 IGF-I, or GW788388 (intraperitoneally or orally). In vitro, differentiation index and mean nuclei count increased using SB431542, GW788388, LR3 IGF-I. In vivo, GW788388 was superior to SB431542 in limiting loss of bodyweight, grip-strength and gastrocnemius weight. and downregulated Atrogin-1 expression comparable to NTB mice. LR3 IGF-I treatment limited loss of muscle mass, but at the expense of accelerated tumour growth. In conclusion, treatment with GW788388 prevented cancer cachexia, and downregulated associated ubiquitin ligase Atrogin-1

Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study

Background: High rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures. Methods: A retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected. Results: Eight hundred eighty-four patients were included. Median age was 76 years (P25–P75 70–83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P25–P75 5–18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021). Conclusions: Pneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome

Kapot hart! Alles over trauma en hoe dit de werking van het hart beïnvloedt

In de westerse wereld is trauma de grootste oorzaak van overlijden bij mensen onder de 45 jaar. Afgelopen jaar waren er 4500 zwaar gewonde traumapatiënten (ISS > 15) in Nederland. De kans dat u hiermee te maken krijgt is dan ook reëel. Na een ernstig trauma wordt vrijwel altijd aanspraak gedaan op de functionele reserves van het hart om de ontstane hemodynamische en/of metabole disbalans te herstellen. Een jong, goed werkend hart is daartoe prima in staat, maar een ouder hart of een hart dat tijdens een stomp of scherp trauma beschadigd is geraakt kan ernstig beperkt worden in het vermogen tot compenseren. Directe diagnostiek gecombineerd met onmiddellijke behandeling kan in een dergelijke situatie het verschil maken, maar vraagt meer kennis van het team en in het bijzonder van de anesthesioloog dan het verplichte basisonderwijs voor trauma (ATLS) te bieden heeft