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1.
The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review.
Agnes, A, Puccioni, C, D'Ugo, D, Gasbarrini, A, Biondi, A, Persiani, R
BMC surgery. 2021;(1):83
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
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2.
Exercise prehabilitation in lung cancer: Getting stronger to recover faster.
Avancini, A, Cavallo, A, Trestini, I, Tregnago, D, Belluomini, L, Crisafulli, E, Micheletto, C, Milella, M, Pilotto, S, Lanza, M, et al
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2021;(8):1847-1855
Abstract
Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far. This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients' eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.
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3.
Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease.
Shariff, S, Moran, G, Grimes, C, Cooney, RM
Nutrients. 2021;(12)
Abstract
Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.
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4.
Preoperative plasmapheresis in patients with Graves' disease intolerant to antithyroid drugs.
Apaydin, T, Gogas Yavuz, D
Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy. 2021;(6):877-883
Abstract
Antithyroid drugs (ATDs) are the mainstay of treatment for Graves' disease with possible detrimental adverse effects. Surgery or radioactive iodine (RAI) ablation is the second choice among the treatment options in cases of non-remission. Normalization of serum thyroid hormone levels as much as possible is required before surgery or RAI to prevent thyrotoxic crisis in patients with uncontrolled Graves' disease. In recent decades, therapeutic plasma exchange (TPE) has been used in the treatment of thyroid storm, drug-induced hepatotoxicity and agranulocytosis, or patients with hyperthyroidism scheduled for emergency surgery. TPE is an effective method to reduce serum FT3, FT4, and TRAB levels in severe hyperthyroid conditions. Although TPE-related complications are rare, the risk of bleeding needs to be taken into consideration in patients who were scheduled for surgery within 24 h after TPE. In terms of reducing intraoperative bleeding, patients can be referred to surgery 24-48 h after TPE, or fresh frozen plasma transfusion can be the preferred treatment for emergency cases.
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5.
Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach.
Araujo-Castro, M, Pascual-Corrales, E, Nattero Chavez, L, Martínez Lorca, A, Alonso-Gordoa, T, Molina-Cerrillo, J, Lorca Álvaro, J, Mínguez Ojeda, C, Redondo López, S, Barberá Durbán, R, et al
Journal of endocrinological investigation. 2021;(12):2545-2555
Abstract
OBJECTIVE To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). METHODS This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. RESULTS Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. CONCLUSIONS An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.
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6.
Perioperative Evaluation and Management of Endocrine Disorders.
Himes, CP, Ganesh, R, Wight, EC, Simha, V, Liebow, M
Mayo Clinic proceedings. 2020;(12):2760-2774
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
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7.
Preoperative Risk Assessment and Management in Adults Receiving Maintenance Dialysis and Those With Earlier Stages of CKD.
Bahrainwala, JZ, Gelfand, SL, Shah, A, Abramovitz, B, Hoffman, B, Leonberg-Yoo, AK
American journal of kidney diseases : the official journal of the National Kidney Foundation. 2020;(2):245-255
Abstract
With an increasingly aging population and improved mortality in individuals with end-stage kidney disease, more surgeries are being performed on patients with all stages of chronic kidney disease (CKD). This high-risk population carries unique risk factors that have been associated with increased adverse perioperative outcomes, including acute kidney injury, cardiovascular events, and mortality. In this article, we review the literature describing absolute risks associated with common surgeries performed in patients with CKD and patients receiving maintenance dialysis. We also review perioperative optimization with special risk assessment including evaluation of cardiovascular and bleeding risk evaluation, hypertension management, and timing of dialysis. Predictive model scores are reviewed as a method to stratify risk for acute kidney injury, major adverse cardiac events, or other serious complications with elective surgeries. A multidisciplinary approach with individualized counseling is necessary to counsel the patient with advanced CKD or patients treated with maintenance dialysis considering elective surgery.
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8.
Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery.
Badia, JM, Rubio Pérez, I, Manuel, A, Membrilla, E, Ruiz-Tovar, J, Muñoz-Casares, C, Arias-Díaz, J, Jimeno, J, Guirao, X, Balibrea, JM
Cirugia espanola. 2020;(4):187-203
Abstract
Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.
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9.
Targeted Oncogene Therapy Before Surgery in Pediatric Patients With Advanced Invasive Thyroid Cancer at Initial Presentation: Is It Time for a Paradigm Shift?
Kazahaya, K, Prickett, KK, Paulson, VA, Dahl, JP, Manning, SC, Rudzinski, ER, Rastatter, JC, Parikh, SR, Hawkins, DS, Brose, MS, et al
JAMA otolaryngology-- head & neck surgery. 2020;(8):748-753
Abstract
IMPORTANCE Initial data suggest the effectiveness of oncogene-specific targeted therapies in inducing tumor regression of diverse cancers in children and adults, with minimal adverse effects. OBSERVATIONS In this review, preliminary data suggest that systemic therapy may be effective in inducing tumor regression in pediatric patients with unresectable invasive thyroid cancer. Although most pediatric patients with thyroid cancer initially present with operable disease, some children have extensive disease that poses substantial surgical challenges and exposes them to higher than usual risk of operative complications. Extensive disease includes thyroid cancer that invades the trachea or esophagus or encases vascular or neural structures. Previous efforts to manage extensive thyroid cancer focused on surgery with near-curative intent. With the recent development of oncogene-specific targeted therapies that are effective in inducing tumor regression, with minimal drug-associated adverse effects, there is an opportunity to consider incorporating these agents as neoadjuvant therapy. In patients with morbidly invasive regional metastasis or with hypoxia associated with extensive pulmonary metastasis, neoadjuvant therapy can be incorporated to induce tumor regression before surgery and radioactive iodine therapy. For patients with widely invasive medullary thyroid cancer, in whom the risk of surgical complications is high and the likelihood of surgical remission is low, these agents may replace surgery depending on the response to therapy and long-term tolerance. CONCLUSIONS AND RELEVANCE With oncogene-specific targeted therapy that is associated with substantial tumor regression and low risk of adverse reactions, there appears to be an opportunity to include children with advanced invasive thyroid cancer in clinical trials exploring neoadjuvant targeted oncogene therapy before or instead of surgery.
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10.
Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes.
Gritsenko, K, Helander, E, Webb, MPK, Okeagu, CN, Hyatali, F, Renschler, JS, Anzalone, F, Cornett, EM, Urman, RD, Kaye, AD
Best practice & research. Clinical anaesthesiology. 2020;(2):199-212
Abstract
Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.