Day 1 :
University of Miami, USA
Time : 10:00-10:30
Background: Intraoperative peritoneal carcinomatosis index (I-PCI) and completeness of cytoreduction surgery (CRS) are predictors of survival in patients with peritoneal surface malignancy (PCM) from multiple gastrointestinal malignancies. However, I-PCI is not a reliable predictor in patients with PCM from appendiceal origin. We sought to analyze the impact of postoperative radiological PCI (PR-PCI) on survival rates in this population.
Methodology: From August 2002 to January 2015, 29 consecutive patients with PCM from appendiceal origin undergoing CRS/HIPEC (hyperthermic intraperitoneal chemotherapy) were included in the analysis. Patient demographics, tumor characteristics and perioperative outcomes were collected. Kaplan- Meier survival analysis and Cox proportional hazards model evaluated factors associated with increased mortality. PCI cutoff of 16 was used for both PR-PCI and I-PCI.
Results: Tumor characteristics, intraoperative variables (including PCI, HR 2.41, 95% CI 0.49-11.77) and postoperative complications were not identified as predictors of survival. Mean I-PCI and PR-PCI were 19.1±11.3 and 6.6±10.4 (p<0.001), respectively. PR-PCI <16 was associated with increased survival rates (HR 4.53, 95% CI 1.10-18.69, p=0.030)
Conclusions: PR-PCI seems to be a more reliable predictor of survival than conventional I-PCI in patients with PCM from appendiceal origin undergoing CRS/HIPEC, likely due to a superior correlation with completeness of resection.
The First Affiliated Hospital of Guangzhou University of Chinese Medicine, China
Keynote: Hepatic resection versus TACE in UICC stage T3 Hepatocellular carcinoma patients: A propensity scores matching study
Time : 10:30-11:00
Chong Zhong, MD, PhD has his expertise in surgical oncology and minimally invasive surgery in hepatobiliary and pancreatic surgery in the Department of Surgery at The First Affiliated Hospital of Guangzhou University of Chinese Medicine, China. His clinical interest is hepatobiliary and pancreatic surgery. He has been involved in cancer research for more than ten years. His researches focus on liver cancer and epithelial-mesenchymal transition and signal transduction pathway. His researches received supports from National Natural Science Foundation of China.
The aim of this study is to compare the clinical outcomes following hepatic resection (HR) versus transarterial chemoembolization (TACE) for UICC (the Union for International Cancer Control) stage (7th) T3 HCC (hepatocellular carcinoma). From 2005 to 2013, 1179 patients who underwent HR or TACE were divided into two groups, HR (n=280) or TACE (n=899). The propensity model matched 244 patients in HR and TACE group, respectively, for further analyses. After matching, medium overall survival, 1, 3, and 5-year OS (overall survival) rates in TACE group were 11.8 months (95%CI, 9.9, 13.7), 49.6%, 16.5%, and 8.4%, respectively, whereas HR group were 17.8 months (95% CI, 14.8-20.8), 63.1%, 33.3%, and 26.4%, respectively; (P<0.01). Patients in HR group were more likely to developed pleural effusion. Multivariate analysis indicated that PT, tumor size, tumor numbers, UICC stage, and initial treatment were independent prognostic factors. This study revealed hepatic resection was safe and yielded a survival benefic compared with TACE in UICC stage T3 HCC patients. HR seemed to represent the optimal therapy strategy and should be recommended as a preferable treatment for the management of UICC stage T3 HCC.
Tulane University School of Medicine, USA
Keynote: Anesthesia practice: US and international trends in anesthesiology manpower and practice management
Time : 11:00-11:30
Gary Haynes is a practicing Anesthesiologist, Professor, and the Merryl and Sam Israel Chair in Anesthesiology at Tulane University School of Medicine in New Orleans, Louisiana. He is a Graduate of Illinois College (BS), the University of Cincinnati (MS), and Case Western Reserve University (PhD and MD) and had US Residency Training in Anesthesiology at the Medical University of South Carolina. He is a Diplomat of the American Board of Anesthesiology. Prior to becoming Chair at Tulane, he was Professor of Anesthesiology at the Medical University of South Carolina, Professor and Chair of Anesthesiology and Critical Care at Saint Louis University, and a Medical Director with a US national anesthesia practice management company. His interests include resuscitation, blood transfusion and management of acquired bleeding disorders, department administration, and quality management.
Statement of the Problem: Anesthesia practice management requires the availability of well-trained medical professionals who can enter, and be retained in practice settings. Estimating both the needed, and the available professional personnel, and aligning educational programs to meet those needs is a tremendous challenge. Several studies conducted in the US during the past 25 years failed to assess correctly future manpower requirements. During this same period the US healthcare system experienced continuing growth despite major efforts made to reshape the national healthcare system. Coupled with numerous financial challenges, practice management must evolve with the growth of medical education, advances in anesthetic and surgical care, and growing demands for anesthesia services outside the traditional operating room environment. The problem of aligning anesthesia clinicians with demand is a major issue in the United States; however, it is likely an even greater international problem.
Methodology & Theoretical Orientation: Analyzing anesthesia manpower is a longitudinal problem that requires combining information over the span of decades. Analysis of published manpower studies, surveys, institutional and government reports provides the basis for practice management forecasting.
Findings: Past efforts to estimate future anesthesia manpower needs consistently underestimated the actual requirement for anesthesia personnel. Multiple factors including incorrect study assumptions, evolving demographic trends in patient populations, expansion of medical education, changing characteristics in anesthesia professionals, and growth in the use of anesthesia services outside the traditional operating room environment provide some of the explanations for the unexpected results.
Conclusion & Significance: Developed countries will likely have a continuing need for anesthesia professional staff for many years. The need is far greater in many areas of the world. New technological solutions and changes in the delivery of perioperative care will be sought as alternative solutions to the constraints of anesthesia professionals.
All India Institute of Medical Sciences, India
Keynote: Confirmation of endotracheal tube placement: Comparison of ultrasound based versus conventional methods-An exploratory study
Time : 12:00-12:20
Choro Athiphro Kayina is working as a Senior Resident Doctor, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Delhi, India. She graduated from the Regional Institute of Medical Sciences, Imphal, India, and was awarded a gold medal for her Excellence in Obstetrics and Gynecology. She received her MD (Anesthesia) in 2016 from the University College of Medical Sciences, Delhi. Her interest is in Airway Management and Obstetric Anesthesia.
Statement of the Problem: Correct positioning of endotracheal tube (ETT) is necessary to ensure adequate ventilation. Various methods are used for this purpose. Ultrasonography (USG) is a useful, quick and non-invasive method for identification of ETT placement. Three USG methods have been described in literature viz., direct USG visualization of ETT in trachea, “sliding lung sign” and diaphragmatic dome movement. However, the time taken for each of these methods to correctly identify the ETT position has not been previously studied. This study is designed to compare the time taken and the accuracy of detection of position with the three USG methods, conventional auscultation and capnography techniques.
Methodology & Theoretical Orientation: This prospective, randomized controlled trial was conducted on ninety ASA I/II patients, 18–60 years requiring general anesthesia (GA) with tracheal intubation. Patients were randomized on the basis of a computer generated table into three groups depending upon the USG probe position: Group T (tracheal), Group P (pleural) and Group D (diaphragmatic). The time taken for confirmation of ETT placement was recorded.
Findings: Time taken to identify ETT placement was significantly less in Group T compared to the other two groups (p=0.000). The time taken in Group P and Group D was less than that required for confirmation by capnography but was more compared to auscultation.
Conclusion & Significance: All three USG techniques could accurately confirm ETT placement. Real time passage of ETT through the trachea was the fastest amongst the three USG techniques. It was faster than conventional auscultation and capnography techniques. We recommend the use of real time USG visualization of trachea for confirmation of ETT placement especially in trauma victims and patients who are at high risk of aspiration, as it does not require ventilation and hence avoids gastric insufflations in case of accidental esophageal intubation.
Augusta University, USA
Keynote: Evaluation of simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer - Related clinical lymphedema after axillary lymph node dissection
Time : 12:20-12:40
Vinyard A is a Board Certified General Surgeon and Fellowship Trained Breast Surgical Oncologist at the Georgia Cancer Center in affiliation with the Augusta University Medical Center in Augusta, Georgia, USA. She attended UNC-Chapel Hill where she completed her pre-medical degree. She completed medical school in 2011 at the Georgia Campus of Philadelphia College of Osteopathic Medicine, Pennsylvania, USA. She completed general surgery training at Augusta University. She decided to specialize in breast surgical oncology to help other breast cancer survivors like herself with a special interest in young breast cancer patients and the obstacles they face. She obtained a fellowship in breast surgical oncology at the University of Miami-Miller School of Medicine in Miami, Florida, USA. She is now employed by the Georgia Cancer Center to lead the breast cancer program as the primary breast surgeon.
Background: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. Lymphatic microsurgical preventing healing approach (LYMPHA) has been proposed as an effective adjunct to ALND for the prevention of LE. This procedure however requires microsurgical techniques.
Aim: The aim of this study was to assess the efficiency of simplified-LYMPHA (SLYMPHA) in preventing LE in a prospective cohort of patients.
Methodology: All patients, undergoing ALND with or without SLYMPHA between January 2014 and December 2016 were included in the study. SLYMPHA is a slightly modified and simplified version of LYMPHA. It is performed by the operating surgeon performing the ALND. One or more lymphatic channels identified by reverse arm mapping are inserted using a sleeve technique into the cut end of a neighboring vein. During follow-up visits, tape-measuring limb circumference method was used to detect clinical LE. Demographic, clinical, surgical and pathologic factors were recorded. The incidence of clinical LE was compared between ALND with and without SLYMPHA. Univariate and multivariate analysis were used to assess the role of other factors in the appearance of clinical LE.
Results: 406 patients were included in the study. SLYMPHA procedure was attempted in 81 patients and was completed successfully in 90% of patients. Early complication rates were similar between patients who underwent SLYMPHA and who did not (4% vs. 4.13%; p=0.948). Median follow-up time was 15±13.73 [1-32] months. Patients, who underwent SLYMPHA, had a significantly lower rate of clinical LE both in univariate and multivariate analysis (3% vs 19%; p=0.001; OR 0.12 [0.03-0.5]). Excising >22 lymph nodes and a co-diagnosis of diabetes were also correlated with higher clinical LE rates on univariate analysis, but only excising >22 lymph nodes remained to be significant on multivariate analysis.
Conclusions: SLYMPHA is a safe and relatively simple method, which decreases incidence of clinical LE dramatically. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.