Safety of Epidural Analgesia in the Perioperative Care of Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Background

The perioperative coagulopathy, hemodynamic instability, and infectious complications that may occur during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has raised concerns about the safety of epidural analgesia in patients undergoing such procedures.

Methods

We conducted a retrospective review of the perioperative anesthetic management of 215 adult patients who had undergone CRS with HIPEC with epidural analgesia. We reviewed epidural-related complications and analyzed the effect of early initiation of continuous epidural analgesia on estimated blood loss, intraoperative fluid administration, blood transfusion and vasopressor requirements, time to extubation, and length of stay.

Results

No epidural hematomas or abscesses were reported. Two patients (0.9 %) had delays in epidural removal because of thrombocytopenia, and two had epidural-site erythema (0.9 %). The majority of postoperative epidural-related hypotensive episodes were successfully treated with fluid boluses. Early initiation of epidural analgesic infusions (before HIPEC) was associated with significantly less surgical blood loss and fluid requirements (P = 0.005 and 0.02, respectively). Pre-HIPEC initiation of epidural infusions was not associated with a statistically significant difference in the following: volume of blood transfused, intraoperative vasopressors use, time to extubation, and length of hospital stay.

Conclusions

With close hematologic monitoring and particular attention to sterility, epidural analgesia can be safely provided to patients undergoing CRS with HIPEC. Early initiation of continuous epidural infusions during surgery could lead to decreased blood loss and less intraoperative fluid administration. Prospective randomized studies are required to further investigate these potential benefits.     

Effect of Preoperative MRI on Mastectomy and Contralateral Prophylactic Mastectomy rates at a Community Hospital by a Single Surgeon

Magnetic resonance imaging (MRI) use in the preoperative evaluation of newly diagnosed breast cancer (BC) patients is rising. We evaluated MRI as a function of surgical year with respect to mastectomy and contralateral prophylactic mastectomy (CPM) rates by a single surgeon. From January 2000 to December 2010, 1,279 patients with 1,296 breast cancers were identified. Our breast MRI was installed in April 2006. Mastectomy and CPM rates were evaluated by surgical year and stratified as “pre‐MRI” or “MRI” depending on whether surgery occurred before or after April 2006. There was a significant increase in the percentage of patients undergoing MRI in the “pre‐MRI” versus “MRI” era (17.2% versus 78.7%, p < 0.001). In contrast, mastectomy rates decreased with 29.9% undergoing mastectomy before 2006 versus 24.5% after 2006 (p = 0.038). Except for 2007, where CPM rates dropped to 7.1%, CPM rates increased from 16.7% in 2000 to 51.9% in 2010 (p = 0.033). The use of MRI, additional MRI findings and additional MRI biopsies were not associated with the decision for CPM. Age <50 was the only factor associated with CPM (RR = 2.12, p = 0.001). In our community hospital, mastectomy rates have decreased despite the increased use of preoperative MRI. MRI alone may not explain the increasing rates of mastectomy reported in other series. CPM rates have dramatically increased over time, seemingly independent of MRI use. Prospective studies are needed to assess the role of surgeon bias, along with other factors, in surgical decision making.     

Patients with metabolic syndrome and widespread high grade prostatic intraepithelial neoplasia are at a higher risk factor of prostate cancer on re-biopsy: A prospective single cohort study

ObjectivesTo test the hypothesis that patients with widespread high grade prostatic intra epithelial neoplasia (wHGPIN) and metabolic syndrome (MetS) are at a higher risk of prostate cancer (PCa) at a repeat biopsy.Methods and MaterialsWe prospectively evaluated 161 patients submitted from December 2004 to December 2011 to prostate rebiopsy after a initial diagnosis of HGPIN in a tertiary academic center. A 12 core biopsy template was used for all the biopsies. Rebiopsy was performed six months after the initial biopsy independently from PSA level and the DRE finding. wHGPIN was defined as≥4 biopsy cores involved. MetS was defined according to the National Cholesterol Education Program’s Adult Treatment Panel III criteria.ResultsOverall, 64 patients (39.7%) presented wHGPIN and 97 isolated HGPIN (60.3%). MetS was found in 63 patients, 39.1% of the whole population. Out of them 16 (25.3%) and 47 (74.7%) patients had a diagnosis of isolated and wHGPIN (P = 0.001). PCa detection rate at repeat biopsy was significantly higher in patients with MetS and wHGPIN than in those with wHGPIN and no MetS (57.4% Vs 23.5%; P = 0.016). A logistic regression model confirmed that wHGPIN and MetS are independent risk factors of prostate cancer diagnosis (respectively: Odds ratio (OR) = 4.187, 95%CI: 1.65–10.57 p = 0.002 and OR=3.603, 95%CI: 1.41-9.19, p = 0.007).ConclusionPatients with MetS and wHGPIN are at a higher risk of PCa, therefore performing a new prostate biopsy in those patients should be recommended.     

The Use of Dietary Supplements to Alleviate Androgen Deprivation Therapy Side Effects during Prostate Cancer Treatment

Prostate cancer (PCa), the most commonly diagnosed cancer and second leading cause of male cancer death in Western societies, is typically androgen-dependent, a characteristic that underlies the rationale of androgen deprivation therapy (ADT). Approximately 90% of patients initially respond to ADT strategies, however many experience side effects including hot flashes, cardiotoxicity, metabolic and musculoskeletal alterations. This review summarizes pre-clinical and clinical studies investigating the ability of dietary supplements to alleviate adverse effects arising from ADT. In particular, we focus on herbal compounds, phytoestrogens, selenium (Se), fatty acids (FA), calcium, and Vitamins D and E. Indeed, there is some evidence that calcium and Vitamin D can prevent the development of osteoporosis during ADT. On the other hand, caution should be taken with the antioxidants Se and Vitamin E until the basis underlying their respective association with type 2 diabetes mellitus and PCa tumor development has been clarified. However, many other promising supplements have not yet been subjected large-scale clinical trials making it difficult to assess their efficacy. Given the demographic trend of increased PCa diagnoses and dependence on ADT as a major therapeutic strategy, further studies are required to objectively evaluate these supplements as adjuvant for PCa patients receiving ADT.