Background: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the opioids and general anesthetics’ needs. This study compared the erector spinae plane (ESP) block and the pectoral plane (PECS) block effects on the opioid consumption postoperatively, stress response, fentanyl needs intraoperatively, pain scores, and incidence of complications in female patients subjected to MRM surgery. Patients and Methods: Fifty patients were allocated randomly and divided into two groups. Forty-seven patients were included in the final analysis after exclusion. ESP block group (E group, n = 24) received 20 mL of 0.25% levobupivacaine plus 0.5 μ/kg dexmedetomidine that was injected in-between erector spinae muscle and transverse process. PECS block group ( P group, n = 23) received 30 mL of 0.25% levobupivacaine plus 0.5 μg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the interfascial plane and the other was 20 mL injected between the serratus anterior and the pectoralis minor. Results: Postoperative morphine consumption and stress hormone level in P group were significantly lower than E group. The pain scores and number of patients requested analgesic postoperatively showed significantly higher values in E group. Hemodynamic parameters, fentanyl needed intraoperatively and the incidence of postoperative complications recorded no significant difference between the two groups. Conclusion: The current study demonstrated that PECS block provides better quality of analgesia than ESP block in patients subjected to MRM operations.

The Thoracoscore mortality risk model has been incorporated into the British Thoracic Society guidelines on the radical management of patients with lung cancer. The discriminative and predictive ability to predict mortality and post-operative pulmonary complications (PPCs) in this group of patients is uncertain.A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 42 months. 128 out of 703 subjects developed a PPC. 16 (2%) patients died in hospital. In a logistic regression analysis the Thoracoscore was not a significant predictor of mortality (OR 1.07, 95% CI 0.99-1.17; p50.11) but was a significant predictor of PPCs (OR 1.08, 95% CI 1.03-1.13; p50.002). However, the area under the receiver operator characteristic curve for the Thoracoscore was 0.68 (95% CI 0.56-0.80) for predicting mortality and 0.64 (95% CI 0.59-0.69) for PPCs, indicating limited discriminative ability.In a logistic regression analysis, another risk model, the European Society Objective Score, was predictive of mortality (OR 1.43, 95% CI 1.11-1.83; p50.006) and PPCs (OR 1.48, 95% CI 1.30-1.68; p,0.0001).Therefore, Thoracoscore may have poor discriminative and predictive ability for mortality and PPCs following elective lung resection.

ObjectiveSevere decompensated aortic valve stenosis is associated with noticeable reduction in survival. Until recently the options for such patients were either high-risk surgery or percutaneous balloon valvuloplasty and medical therapy which does not add any survival benefits and associated with high rate of complications. We present our experience in the use of transcatheter aortic valve implantation (TAVI) in patients with decompensated severe aortic stenosis requiring urgent intervention in the same hospital admission.MethodsIn this observational study, all patients who were admitted with decompensated severe aortic stenosis were enrolled. Elective patients were excluded from the study. Perioperative records were analysed and clinical, echocardiographic and survival data were presented.Results76 patients with a mean age of 81±6 years were enrolled. All patients presented with New York Heart Association (NYHA) IV status. Femoral approach was performed in 86.8%. Median postoperative hospital stay was 6 days and intensive care unit admission rate was 15%. At follow-up, 61.8% of patients were in NYHA status I/II. Moderate or more paravalvular leak occurred in 5.2% of patients. Permanent pacemaker was required in 14.4% of patients. The incidence of in-hospital death was 2.6%. Kaplan-Meier analysis indicated a survival rate of 81% at 1 year.ConclusionsUrgent in-hospital TAVI is feasible as the first-line treatment in decompensated severe aortic stenosis. In our cohort, it showed to be safe and achieved satisfactory survival rates and symptom control.

Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

Laparoscopic liver surgery is becoming more popular, and many high-volume liver centers are now gaining expertise in this area. Laparoscopic left lateral hepatectomy (LLLH) is a standardized and anatomically well-defined resection and may transform into a primarily laparoscopic procedure for cancer surgery or living donor hepatectomy for transplantation. Five case-control series were identified comparing a total of 167 cases (86 cases of LLLH plus 81 cases of open left lateral hepatectomy). Groups were matched by age and sex, with broadly similar indications for surgery and resection techniques. LLLH is associated with shorter hospital stays and less blood loss without compromising the margin status or increasing complication rates. Donors of LLLH grafts did not have higher graft-related morbidity. Prospective studies are required to define the safety in terms of disease-free and overall survival in this new avenue in laparoscopic liver surgery.

Purpose: The study aims to assess the functional outcome of anal sphincter-sparing procedures (SSP) with total mesorectal excision (TME) for anorectal adenocarcinoma.Methods: In a multicentric, prospective, single-group study in the period between December 2012 and November 2017, 93 patients presented with anorectal adenocarcinoma were included in the study. Sixty-nine patients underwent SSP with TME. SSP included the combined approach of transabdominal TME with intersphincteric resection (ISR) or transanal transabdominal TME. Using the per anal examination scoring system (PASS), postoperative anal function was assessed after 1 year.Results: Bowel motility time was 50±19 hours. The time needed for narcotic analgesia was 54±18.8 hours. Mean hospital stay was 15.4±10.25 days. Incidence of evident fecal incontinence after ISR is 10.6% (7 of 67 cases). The PASS findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (18 cases), normal tone 58% (40 cases), slightly stenotic 3 cases (4.3%), or occluded 2.9% (2 cases). Urinary dysfunction occurred in 1 case (1.4%). Temporary diversion was performed in 61 patients (87.1%).Conclusion: Sphincter preservation with TME for anorectal adenocarcinoma helps avoid permanent stoma and provides reasonable functional outcomes. PASS is a new application for postoperative assessment of anal function.

A 73 year old man developed chest pains 5 minutes after fibreoptic bronchoscopy. The procedure had been performed without sedation following an intratracheal injection of 5 ml 2.5% cocaine solution and xylocaine spray to the pharynx for topical anaesthesia. A 12-lead electrocardiogram showed an evolving anterior myocardial infarction. Cardiac catheterisation revealed coronary artery spasm in the proximal left anterior descending artery at the site of non-significant plaque disease. The risk factors, mechanisms, and treatment of cocaine induced myocardial infarction following intratracheal injections are discussed.C ardiovascular complications of fibreoptic bronchoscopy, although infrequent, are more common in the elderly.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether prophylactic minitracheostomy (PM) is beneficial in high-risk patients undergoing thoracotomy and lung resection. Altogether, 115 papers were found using the reported search, of which four represented the best evidence to answer the question. Three randomised controlled trials (RCT) compared a total of 161 patients who underwent thoracotomy and received either PM or standard postoperative treatment alone. Another non-RCT of 144 patients observed the reduction of toilet bronchoscopy with the increased use of PM. These are summarised in the Table. The studies assessed the benefit of PM inserted immediately after lung resection surgery in patients perceived as at high-risk of developing pulmonary complications. High-risk defined patients as those who smoked, have poor lung function, ischaemic heart disease, chronic obstructive pulmonary disease, absence/failure of regional analgesia, and/or cerebrovascular accident. In the largest randomised study (102 patients), Bonde et al. [Bonde P, Papachristos I, McCraith A, Kelly B, Wilson C, McGuigan JA, McManus K. Sputum retention after lung operation: prospective randomized trial shows superiority of prophylactic minitracheostomy in high-risk patients. Ann Thorac Surg 2002;74:196-202] concluded that the PM group had a significant reduction in sputum retention and postoperative atelectasis. The authors also reported a reduction in the incidence of pneumonia and toilet bronchoscopy but this did not achieve statistical significance. Issa et al. [Issa MM, Healy DM, Maghur HA, Luke DA. Prophylactic minitracheotomy in lung resection. A randomized controlled study. J Thorac Cardiovasc Surg 1991;101:895-900] were able to demonstrate a significant reduction in the rate of pneumonia in the PM group and Randell et al. [Randell TT, Tierala E, Lepäntalo MJ, Lindgren L. Prophylactic minitracheostomy: a prospective, random control, clinical trial. Eur J Surg 1991;157:501-504] showed a significant reduction in postoperative atelectasis and toilet bronchoscopy in their PM group. Au et al. [Au J, Walker WS, Inglis D, Cameron EW. Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: results of therapeutic and prophylactic use. Ann Thorac Surg 1989;48:850-852] observed a reduction in toilet bronchoscopy from 9% to 4% in a four-year period; however, the authors could not directly relate this to the use of PM but believed it was likely. None of the studies demonstrated a statistical difference in mortality or intensive care unit or hospital length of 38 stay. All the studies reported some complications associated with minitracheostomy (MT) insertion, the incidence of which ranged from 5.6% to 57%. One percent of 227 patients who received MT in the studies experienced a life-threatening complication, the rest were minor and easily controlled. None of the complications resulted in death.