Changes in practice in managing difficult intubation following the introduction of new airway devices

Introduction Difficult or failed tracheal intubation is a leading cause of anesthesia-related mortality and morbidity, ranging from soft tissue airway trauma to severe hypoxemia [1-3]. Direct laryngoscopy with the curved laryngoscope blade designed by Macintosh in 1943 [4] still represents the gold standard to perform endotracheal intubation. Strategies and guidelines for the management of predicted and unpredicted difficult airways have been published by the Difficult Airway Society of the UK [5-7], as by many other national societies. They incorporate essentially external airway maneuvers and patient positioning, direct laryngoscopy and stylets, extraglottic devices, fiberoptic bronchoscopy, as well as surgical techniques. Following the significant progresses in fiberoptic and video technologies, a wide variety of intubation devices have been developed recently and transposed into clinical practice. This may lead to changes in management with regard to the difficult airways. Studies are on their way [8], but the place of these new airway devices in clinical practice must be further assessed. Recognizing a difficult airway remains a challenge and the absence of any single sensitive predictive factor may lead to unexpected dangerous situations [9]. Difficult intubation ranges between 0.1% to 10.1%, depending on the definition [10], and rates as high as 8-30% have been reported in neurosurgical or ENT (ear, nose and throat) patients [11, 12]. Indeed, in patients with cervical spine injury, securing the airway while correctly immobilizing the cervical spine to avoid secondary neurological damage may be challenging. ENT disease, previous surgery, radiotherapy and chemotherapy, may lead to airway narrowing or distortion at laryngeal, sub-glottic or tracheal level. The aim of this study was to compare the management of difficult intubation before and after the introduction of the Airtraq® and the Glidescope® in our institution for patients undergoing neurosurgical or ENT procedures necessitating tracheal intubation. We also analyzed the criteria used by anesthesiologists in our teaching hospital to predict difficult intubation in the same population

Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment.

Recurrent laryngeal nerve (RLN) injury is a feared complication after thyroid and parathyroid surgery. It induces important postoperative morbidity. The present study aimed to assess the incidence of transient/permanent postoperative RLN injuries after thyroid and parathyroid surgery in the present cohort, to observe the timing of recovery, and to identify risk factors for permanent RLN injury after thyroidectomy.All consecutive patients operated on at our institution for thyroid and parathyroid pathologies from 2005 to 2013 were reviewed for vocal cord paresis. Vocal cord paresis was defined based on postoperative fiberoptic laryngoscopy. Demographics, intraoperative details, and postoperative outcomes were collected. Treatment types were assessed, and recovery times collected. Patients with vocal cord paresis on preoperative fiberoptic laryngoscopy were excluded from the analysis.The cohort included 451 thyroidectomies (756 nerves at risk) and 197 parathyroidectomies (276 nerves at risk). There were 63 postoperative vocal cord pareses after thyroidectomy and 13 after parathyroidectomy. Sixty-nine were transient (10.6%) and 7 permanent (1.1%). The main performed treatment was speech therapy in 51% (39/76) of the patients. Median recovery time after transient injuries was 8 weeks. In the group with vocal cord paresis, risk factors for permanent injuries after thyroidectomy were previous thyroidectomy and intraoperative RLN injury on univariate analysis. On multivariate analysis, only intraoperative RLN injury remained significant.Most of the patients with transient postoperative RLN injury recovered normal vocal cord mobility within 6 months. The most common performed treatment was in this cohort speech therapy. Permanent RLN injuries remained rare (1.1%)

Procalcitonin-Guided Antibiotics after Surgery for Peritonitis: A Randomized Controlled Study.

Serum procalcitonin (PCT) is a useful biomarker to tailor the duration of antibiotics in respiratory infections. The objective of this study was to determine whether PCT levels could tailor postoperative antibiotic therapy in patients operated for peritonitis. Patients with peritonitis were randomized postoperatively. The control group received antibiotics for a defined duration according to institutional guidelines. In the study group, antibiotics were stopped based on serum PCT levels. Patients were stratified into three categories: (1) gastrointestinal perforation, (2) perforated appendicitis, and (3) postoperative complication. Primary outcome was duration of antibiotics. We included 162 patients; 83 and 79 patients in the control group and study group, respectively. In the subgroup of patients with peritonitis due to gastrointestinal perforation, we found 7 days of antibiotics in the PCT group versus 10 days in the control group (p value 0.065). There was no difference in infectious complications, mortality, median length of hospital stay, and necessity to restart antibiotics. No significant differences were found in duration of antibiotics when applying PCT guidance. However, in the subgroup of primary perforation of the gastrointestinal tract, there was a difference in duration of antibiotics in favor of the PCT group without obtaining significance, as the study was not powered for subgroup analysis. Further studies including only this subgroup should be performed

Hernie hiatale : prise en charge diagnostique et thérapeutique en 2017 [Hiatal hernia : current diagnostic and therapeutic management]

Hiatal hernia is a frequent pathology. Two types have been described : sliding hernia and paraesophageal hernia (PEH). The first one is the most frequent and is associated with reflux disease. Patients with PEH have a large variety of symptoms, such as chest pain, dyspnea, regurgitation, iterative pneumonia and iron-deficiency anemia. Operative management is necessary for sliding hernia with reflux disease and for symptomatic PEH, respectively. In patients with asymptomatic PEH, operative risk must be balanced with the risk of postoperative complications. No specific operative technique has been validated so far as surgical standard. Several technical details are important and technique has to be adapted according to the size and type of hernia, preoperative symptoms and patient's comorbidities

Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis.

Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery. ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann-Whitney Fisher's exact T test or Pearson Chi-square test) was used. Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (-€2 356), intensive or intermediate care (-€8 629), medication (-€1 196)), physiotherapy (-€611), laboratory (-€1 625)) and blood transfusion (-€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group. ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery

A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study

Parastomal hernias (PSH) are one of the most frequent complications of enterostomies with a non-negligible complication rate and a significant socioeconomic effect. Therefore, preventing PSH by placing a mesh at the time of primary surgery has been advocated. The aim of our study was to evaluate the safety and feasibility of the new stomaplasty ring [Koring™, (Koring GmbH, Basel, Switzerland)] and investigate the reason why surgeons are reluctant to take preventive measures. A multicenter observational study was conducted on 30 patients between December 2013 and January 2015. In permanent end colostomies and end ileostomies, the Koring™ was implanted. The primary outcome was the 30-day morbidity (infection and other stoma-related complications). Secondary endpoints were the technical feasibility and the time needed to fix the ring. In addition, an online survey of 107 surgeons was performed. Twenty-seven patients received permanent end colostomies, and three received end ileostomies. No stoma-related complication was detected within the first 30 days post-operatively. The Koring™ ring was evaluated by the surgeons as easy and very easy to implant in more than half of the patients. Average additional operating time for ring implantation was 19 min. Koring™ implantation at the time of creating the stoma is safe, easy and only adds minimally operating time. A long-term follow-up as well as a randomized controlled study is needed to evaluate the impact of the Koring™ on PSH prevention. The ease and rapidity with which Koring™ can be implanted may help surgeons to overcome their apprehension of using a preventative device

Prise en charge chirurgicale de l’hyperparathyroïdie primaire [Surgical management of primary hyperparathyroidism]

Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia due to inappropriate parathyroid hormone (PTH) secretion mostly caused by a single adenoma. Clinical manifestations vary and include bone loss (osteopenia, osteoporosis), kidney stones, asthenia and psychiatric disorders. In 80 % of cases PHPT is asymptomatic. Secondary causes of elevated PTH such as renal insufficiency and/or vitamin D deficiency should be excluded, and 24-hour calciuria should be measured to rule out familial hyocalciuric hypercalcemia. Surgery requires radiological tests: a cervical ultrasound to exclude concomitant thyroid pathology and a functional examination (Sestamibi scintigraphy or F-choline PET scan). Management should be discussed in a multidisciplinary team. Treatment is surgical and can also be offered to asymptomatic patients

Impact of positive microscopic resection margins (R1) after gastrectomy in diffuse-type gastric cancer.

Diffuse-type gastric cancer (DTGC) is associated with poor outcome. Surgical resection margin status (R) is an important prognostic factor, but its exact impact on DTGC patients remains unknown. The aim of this study was to assess the prognostic value of microscopically positive margins (R1) after gastrectomy on survival and tumour recurrence in DTGC patients. All consecutive DTGC patients from two tertiary centers who underwent curative oncologic gastrectomy from 2005 to 2018 were analyzed. The primary endpoint was overall survival (OS) for R0 versus R1 patients. Secondary endpoints included disease-free survival (DFS), recurrence patterns as well as the overall survival benefit of chemotherapy in this DTGC patient cohort. Overall, 108 patients were analysed, 88 with R0 and 20 with R1 resection. Patients with negative lymph nodes and negative margins (pN0R0) had the best OS (median 102 months, 95% CI 1-207), whereas pN + R0 patients had better median OS than pN + R1 patients (36 months 95% CI 13-59, versus 7 months, 95% CI 1-13, p < 0.001). Similar findings were observed for DFS. Perioperative chemotherapy offered a median OS of 46 months (95% CI 24-68) versus 9 months (95% CI 1-25) after upfront surgery (p = 0.022). R1 patients presented more often early recurrence (< 12 postoperative months, 30% vs 8%, p = 0.002), however, no differences were observed in recurrence location. DTGC patients with microscopically positive margins (R1) presented poorer OS and DFS, and early tumour recurrence in the present series. R0 resection should be obtained whenever possible, even if other adverse biological features are present