Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and “string sign”

Most patients diagnosed with pancreatic cancer are classified as nonoperative candidates based on the contemporary guidelines of resectability. The advent of more potent control of systemic disease using neoadjuvant chemotherapy has enabled more aggressive operative interventions. In our multidisciplinary practice, patients with Stage III, locally advanced pancreatic cancer and superior mesenteric artery (SMA) encasement are now carefully triaged with high quality, preoperative imaging to determine if they can be considered candidates for operative resection with periadventitial dissection of the SMA. Patients displaying a “halo sign,” where the encased SMA remains fully patent and free from arterial invasion, are now candidates for SMA periadventitial dissection. This procedure involves the surgical stripping of the infiltrated neurolymphatic tissue off the SMA leaving behind a bare “skeletonized artery.” Alternatively, the “string sign” involving the SMA confers a more likely case of arterial invasion, where a complete oncologic resection cannot be achieved successfully. This method of patient selection in case of SMA involvement abandons the traditional metrics of circumferential degrees of the arterial encasement to guide surgical decisions. Our institutional approach has allowed us to meaningfully expand our operative methods of resection with the potential for improved longitudinal outcomes to pancreatic cancer patients who were deprived historically from the more effective and possibly curative treatment.     

Comparison of the C‐MAC® and GlideScope® videolaryngoscopes in patients with cervical spine disorders and immobilisation

In‐line stabilisation of the neck can increase the difficulty of tracheal intubation with direct laryngoscopy. We randomly assigned 56 patients with cervical spine pathology scheduled for elective surgery to tracheal intubation using either the C‐MAC^® (n = 26) or GlideScope^® (n = 30), when the head and neck were stabilised in‐line. There was no significant difference in the median (IQR [range]) intubation times between the C‐MAC (19 (14–35 [9–90]) s and the GlideScope (23, (15–32 [8–65]) s. The first‐attempt failure rate for the C‐MAC was 42% (95% CI 23–63%) compared with 7% (95% CI 1–22%) for the GlideScope, p = 0.002. The laryngeal view was excellent and comparable with both devices, with the C‐MAC requiring significantly more attempts and optimising manoeuvers (11 vs 5, respectively, p = 0.04). There were no significant differences in postoperative complaints e.g. sore throat, hoarseness and dysphagia. Both devices provided an excellent glottic view in patients with cervical spine immobilisation, but tracheal intubation was more often successful on the first attempt with the GlideScope.     

Perceived information provision and satisfaction among lymphoma and multiple myeloma survivors—results from a Dutch population-based study

To improve posttreatment care for (long-term) lymphoma survivors in the Netherlands, survivorship clinics are being developed. As information provision is an important aspect of survivorship care, our aim was to evaluate the current perceived level of and satisfaction with information received by non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HL) and multiple myeloma (MM) survivors, and to identify associations with sociodemographic and clinical characteristics. The population-based Eindhoven Cancer Registry was used to select all patients diagnosed with NHL, HL and MM from 1999 to 2009. In total, 1,448 survivors received a questionnaire, and 1,135 of them responded (78.4?%). The EORTC QLQ-INFO25 was used to evaluate the perceived level of and satisfaction with information. Two thirds of survivors were satisfied with the amount of received information, with HL survivors being most satisfied (74?%). At least 25?% of survivors wanted more information. Young age, having had chemotherapy, having been diagnosed more recently, using internet for information and having no comorbidities were the most important factors associated with higher perceived levels of information provision. Although information provision and satisfaction with information seems relatively good in lymphoma and MM survivors, one third expressed unmet needs. Furthermore, variations between subgroups were observed. Good information provision is known to be associated with better quality of life. Survivorship care plans could be a way to achieve this.     

Is pulmonary resistance constant, within the range of tidal volume ventilation, in patients with ARDS?

When managing patients with acute respiratory distress syndrome(ARDS), respiratory system compliance is usually consideredfirst and changes in resistance, although recognized, are neglected.Resistance can change considerably between minimum and maximumlung volume, but is generally assumed to be constant in thetidal volume range (V_T). We measured resistance during tidalventilation in 16 patients with ARDS or acute lung injury bythe slice method and multiple linear regression analysis. Resistancewas constant within V_T in only six of 16 patients. In the remainingpatients, resistance decreased, increased or showed complexchanges. We conclude that resistance within V_T varies considerablyfrom patient to patient and that constant resistance withinV_T is not always likely. Br J Anaesth 2001; 86: 176–82     

Compliance is nonlinear over tidal volume irrespective of positive end-expiratory pressure level in surfactant-depleted piglets

Between the lower and the upper inflection point of a quasistatic pressure-volume (PV) curve, a segment usually appears in which the PV relationship is steep and linear (i.e., compliance is high, with maximal volume change per pressure change, and is constant). Traditionally it is assumed that when positive end-expiratory pressure (PEEP) and tidal volume (V T) are titrated such that the end-inspiratory volume is positioned at this linear segment of the PV curve, compliance is constant over VT during ongoing ventilation. The validity of this assumption was addressed in this study. In 14 surfactant-deficient piglets, PEEP was increased from 3 cm H(2)O to 24 cm H(2)O, and the compliance associated with 10 consecutive volume increments up to full VT was determined with a modified multiple-occlusion method at the different PEEP levels. With PEEP at approximately the lower inflection point, compliance was minimal in most lungs and decreased markedly over VT, indicating overdistension. Compliance both increased and decreased within the same breath at intermediate PEEP levels. It is concluded that a PEEP that results in constant compliance over the full VT range is difficult to find, and cannot be derived from conventional respiratory-mechanical analyses; nor does this PEEP level coincide with maximal gas exchange.