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Roux-en-Y gastric bypass (RYGB) is associated with an increased risk of kidney stone formation. This is not observed after sleeve gastrectomy (SG). Aim of this study was to assess whether preoperative metabolic profiling is helpful in selecting the most optimal bariatric procedure for patients with a kidney stone history. General hospital, the Netherlands. Patients with a kidney stone history and in the run up to bariatric surgery were screened with non-contrast abdominal computed tomography (CT), serum profiling, and 24-hour urine analysis. Those with stones on radiologic imaging and/or high preoperative urinary oxalate were advised to undergo SG instead of RYGB. Pre- and postoperative urine and serum profile differences between both groups were evaluated retrospectively. Postoperatively, RYGB (N = 28, M:F = 8:20) was associated with a 23.5% reduction in urinary volume, a 85% increase in urinary oxalate excretion with a 230% increase in calcium oxalate (CaOx) supersaturation and a 62% decrease in urinary citrate. Although SG (N = 30, M:F = 12:18) was also associated with a reduction in urinary volume, it had no adverse effects on urinary oxalate and citrate excretion, nor on calcium oxalate supersaturation (CaOx-SS). Both RYGB and SG showed favorable effects on postoperative sodium, calcium, uric acid, and phosphate excretion. This study indicates that preoperative metabolic profiling is important to select the optimal bariatric procedure in patients with an a priori increased risk of kidney stone development. These patients should be strongly encouraged to undergo SG instead of RYGB to prevent progressive or recurrent kidney stone disease. • Roux-en-Y gastric bypass (RYGB) in stone formers shows an increase in oxalate excretion in 50% of patients. • Sleeve gastrectomy (SG) in stone formers had no adverse effects on urinary oxalate and citrate excretion. • Both show favorable effects on sodium, calcium, uric acid, and phosphate excretion. • Metabolic profiling helps to select the best bariatric procedure in stone formers. [ABSTRACT FROM AUTHOR]

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections. [ABSTRACT FROM AUTHOR]

The Society for Vascular Surgery and the Enhanced Recovery After Surgery Society formally collaborated and elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based recommendations related to all the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites) for aortic aneurysm and aortoiliac occlusive disease. Structured around the Enhanced Recovery After Surgery core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations. [ABSTRACT FROM AUTHOR]

In women, bariatric surgery (BS) leads to a decline in bone mineral density (BMD) and may ultimately lead to premature osteoporosis. The impact in men is largely unknown. To assess the effect of BS on bone metabolism in males. Single-center prospective cohort study. Twenty-four male BS candidates were prospectively enrolled. Anthropometric characteristics, serum gonadal hormones, markers of bone metabolism, and BMD were measured at baseline, 6-, 12- and 36-months postoperatively. Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) were performed in 15 and 9 patients, respectively. Nineteen patients completed the 3-year follow-up. At 3 years, BMD of the right and left femur had decreased by 9.1 ± 7.2% and 9.4 ± 5.8% for RYGB and by 6.7 ± 3.9% and 4.5 ± 2.8% for AGB. Radius BMD had decreased by 14.0 ± 5.6% for RYGB and 5.9 ± 4.1% for AGB, i.e., significantly stronger for RYGB (P =.006). Serum parathyroid hormone increased in both groups and 13 of 19 patients developed Vitamin D deficiency. A significant increase of the bone resorption marker was seen only during the first year despite continuation of bone loss. Four patients developed de novo osteopenia or osteoporosis. No fractures were observed. There are strong indications that male bone metabolism response after BS differs from female metabolism. The most affected site is the radius. In males, the cause of this BMD loss seems multifactorial, including mechanical unloading, hyperparathyroidism, and hypogonadism. However, clinical relevance remains unknown and therefore studies with longer-term follow-up are necessary. [ABSTRACT FROM AUTHOR]

Iron deficiency (ID) is one of the most common postoperative deficiencies that may develop after Roux-en-Y gastric bypass (RYGB). The optimal mode of treatment is uncertain. To compare the efficacy of oral ferrous fumarate (FF), oral ferrous gluconate (FG), and a single intravenous infusion of ferric carboxymaltose (FCM) in women with ID after RYGB. Multicenter randomized controlled trial including 120 women with a serum ferritin <20 μg/l during follow-up after RYGB. They were randomized into three groups: 41 patients were treated with FF 200 mg three times a day (total daily dose: 195 mg elemental iron), 39 received FG 695 mg twice a day (total daily dose: 160 mg elemental iron) for three months, and 39 patients were treated with a single intravenous dose of FCM (1000 mg elemental iron). Serum ferritin levels were measured at six weeks, and three, six and twelve months after the start of supplementation. At three months, persistence of ID was observed in 29.4% and 42.4% of the patients treated with FF and FG, respectively, but in none of those treated with FCM (p < 0.001). Over the next nine months, recurrence of ID was observed in 56.5% of patients treated with FF, in 52.9% treated with FG, and in 27.8% of those treated with FCM. Adverse effects were most common during oral treatment. In women developing ID after RYGB, a single dose of intravenous FCM is more effective and better tolerated than the standard treatment with either FF or FG. The study was registered at clinicaltrials.gov under number NCT02271997. • Treatment of iron deficiency in women after Roux-en-Y gastric bypass. • Randomized controlled trial: ferrous fumarate, -gluconate and ferric carboxymaltose. • High rate of women with persistent deficiency after 3 months of oral treatment. • Many patients experience a re-deficiency within one year. • Intravenous ferric carboxymaltose significantly better, also 1 year after treatment. [ABSTRACT FROM AUTHOR]

After Roux-en-Y gastric bypass (RYGB), 15% to 35% of patients fail to lose sufficient weight. Distalization of the limbs of the RYGB (D-RYGB) with shortening of the common channel (CC), has been used to induce additional weight loss. However, this may increase the risk of malnutrition. The aim of this study was to assess postoperative outcomes after D-RYGB with an alimentary limb of 250 to 300 cm and CC of 100 cm. General hospital, specialized in bariatric surgery. We retrospectively studied all patients who underwent revision of RYGB to D-RYGB between January 2014 and April 2018. Data were collected from medical records, including weight loss, nutritional deficiencies, and co-morbidities. Questionnaires on defecation pattern, quality of life, and patient satisfaction were obtained. Forty-seven patients were included. Total weight loss (%TWL) increased significantly from 12% to 30% after D-RYGB. In 62% of patients %TWL >25% was achieved. Patients with %TWL <25% after primary RYGB, lost significantly more weight than initially reached after RYGB. Diabetes and hypertension remission occurred in 67% and 50%, respectively. Five patients (11%) needed subsequent lengthening of the CC to 250 cm due to protein malnutrition or debilitating defecation patterns. Nutritional deficiencies were present in 89% of patients after D-RYGB despite the prescription of specialized multivitamins. Conversion of the primary RYGB to D-RYGB improves weight loss and co-morbidities in patients with insufficient weight loss after primary RYGB. After D-RYGB, nutritional complications and diarrhea are a risk. Based on this study, a modified D-RYGB with a longer CC of >200 cm will be considered. • Forty-seven patients had revisional surgery from primary gastric bypass to distal gastric bypass (D-RYGB) with an alimentary limb of 250-300 cm and common channel of 100 cm. • Total weight loss (TWL) increased significantly from 12% to 30% after D-RYGB and in 62% of patients %TWL>25% was achieved. • Nutritional deficiencies were present in 89% of patients after D-RYGB despite the prescription of specialized multivitamins. • Five patients (11%) needed subsequent lengthening of the common channel to 250 cm due to protein malnutrition or a debilitating defecation pattern. • The results of our study imply that a longer common channel (>200 cm) might be a better option. [ABSTRACT FROM AUTHOR]

Purpose: To compare the histologic features of the cartilage from the capitellum with 2 proposed alternative donor sites from the ipsilateral elbow in the treatment of capitellar osteochondritis dissecans (OCD): the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip.Methods: Ten human cadaveric elbow specimens with macroscopically normal articular surfaces were used to obtain 5-mm osteochondral grafts: 10 from the capitellum (60° anteriorly relative to the humeral shaft), 10 from the radial head (nonarticulating part at 80°), and 4 from the olecranon (lateral side of the olecranon tip). Grafts were fixated in formalin (4% formaldehyde), decalcified, and processed into standard 8-μm-thick hematoxylin and eosin-and Toluidine Blue-stained sections. These were assessed for cartilage thickness, shape of articular surface, and 13 histologic parameters of the International Cartilage Repair Society II. Olecranon scores were excluded from statistical analysis.Results: Mean cartilage thickness was 1.5 ± 0.22 mm at the capitellum; 1.3 ± 0.34 mm at the radial head; and 1.9 ± 1.0 mm at the olecranon. There was no difference in cartilage thickness between the capitellum and radial head (P = .062). All grafts demonstrated a convex articular surface. International Cartilage Repair Society II scores ranged from 82 to 100 for the capitellum, from 81 to 100 for the radial head, and from 67 to 87 for the olecranon tip. There was less chondrocyte clustering at the capitellum (84 ± 14) than in the radial head (94 ± 3.2; P = .019). Mid/deep zone assessment of the capitellum scored higher (97 ± 6.7) than the radial head (91 ± 4.6; P = .038).Conclusions: This study demonstrates appropriate histologic similarities between the cartilage from the capitellum and 2 alternative donor sites of the ipsilateral elbow in the treatment of capitellar OCD: the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip.Clinical Relevance: From an histologic point of view, there seem to be no obstacles to use grafts from these alternative donor sites for reconstruction of the capitellum when performing osteochondral autologous transplantation. [ABSTRACT FROM AUTHOR]

Abstract Purpose One of the major challenges in stereotactic body radiation therapy (SBRT) of renal cell carcinoma is internal motion during treatment. Previous literature has aimed to mitigate the effects of motion by expanding the treatment margins or respiratory tracking. Online magnetic resonance imaging (MRI)-guided radiation therapy has the potential to further improve the treatment of renal cell carcinoma by direct visualization of the tumor during treatment. The efficacy of 2 motion management techniques were assessed: tumor trailing and respiratory tracking. The simulation of a single-fraction, MRI-based SBRT was performed to quantify intrafraction motion and assess the efficacy of the different motion management strategies. Methods and materials Fifteen patients were included in the study. At the beginning and end of the scanning protocol, 2 cine-MRI scans were acquired to assess cyclic respiratory motion. In addition, 3-dimensional spoiled gradient echo scans were acquired at 4 different time points to assess the slow drifts over 25 minutes. The systematic and random errors owing to intrafraction drift were calculated, as well as the random error induced by respiratory motion. The motion margins were calculated for tumor trailing and respiratory tracking and compared with the margin when no motion compensation would be performed to assess the relative efficacy of each technique. Results The largest respiratory tumor motion was observed along the caudo-cranial direction with a median 95% maximum amplitude of approximately 12 mm. Σ DRIFT , σ DRIFT , and σ RESP were determined to be 1.0 mm 1.8 mm, and 3.8 mm, respectively. Without mechanical immobilization, intrafraction drift accounted for 75% of the total intrafraction motion margin for online midposition-based SBRT treatments. Conclusions The contribution of intrafraction drift to the total internal motion margin is much larger than periodic respiratory motion. This makes tumor trailing a viable option to consider on the MRI linac because it allows for 3-dimensional MRI acquisitions during beam delivery, which simplifies the introduction of new techniques, such as dose accumulation and online intrafraction replanning. [ABSTRACT FROM AUTHOR]

Resumo O transplante cardíaco é um procedimento frequente no tratamento da disfunção cardíaca em estágio final. Portanto, essa população de pacientes também será exposta com mais frequência a outros procedimentos cirúrgicos mais comuns após o transplante. Em sua avaliação, o anestesiologista deve ter em mente algumas questões específicas relacionadas à história de transplante cardíaco desses pacientes, tais como a reversão do bloqueio neuromuscular. Vários estudos relataram que os inibidores da colinesterase, como a neostigmina, podem produzir uma bradicardia dose‐dependente que ameaça a vida em receptores de transplante cardíaco, enquanto um estudo relatou o uso seguro de neostigmina. A reversão do bloqueio neuromuscular com sugamadex é outra possibilidade, mas os dados na literatura são escassos. Descrevemos cinco casos nos quais a reversão bem‐sucedida do bloqueio neuromuscular foi realizada com sugamadex em receptores pediátricos de transplante cardíaco sem deixar sequelas e discutimos a reversão do bloqueio neuromuscular nessa população de pacientes. Heart transplantation is a frequent procedure in the treatment of end‐stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose‐dependent life‐threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequelae and discuss the reversal of neuromuscular block in this patient population. [ABSTRACT FROM AUTHOR]

Summary Background & aims Roux-en-Y gastric bypass (RYGB) is an effective treatment for obesity. However, it also leads to multiple nutritional deficiencies. Much is known about the short term prevalence, but hardly any long term data is available on deficiencies. The aim of this study was to assess the long term outcome of nutritional status after RYGB. Methods We performed a retrospective analysis of prospectively collected data obtained from 51 morbidly obese patients who underwent a primary laparoscopic RYGB. Primary outcomes were iron, vitamin B12 and vitamin D deficiencies. Secondary outcomes were deficiencies of other vitamins and minerals and compliance of the patients to multivitamin use. Results The mean follow-up was 81 ± 27 months. A total of 35%, 16% and 55% of the patients had deficiencies for iron, vitamin B12 and vitamin D respectively. Sixty-nine percent of patients used a (nonspecific) multivitamin supplement on a daily basis. Patients with multivitamin usage had a lower rate of iron deficiency (26% vs. 56%, p = 0.034), vitamin B12 (11% vs. 25%, p = 0.46) and vitamin D (46% vs. 75%, p = 0.07), compared to non-compliant patients. Conclusions Nutritional deficiencies are common after a RYGB operation. Therefore, strict follow-up by a bariatric surgeon, endocrinologist or general practitioner is required, both short and long term. [ABSTRACT FROM AUTHOR]

Opioids are widely used in clinical anesthesia. However, side effects include postoperative nausea and vomiting, shivering, ileus, and urine retention and are specifically discussed here. From the available evidence, it appears that the use of opioids is strongly associated with impaired gastrointestinal motility. Therefore, to prevent postoperative ileus, the use of opioids should be minimized and opioids should be replaced by other drugs. With regard to the risk of postoperative urinary retention, one problem is the lack of standardized definition. Nevertheless, the use of opioids is clearly an important risk factor. Postoperative nausea and vomiting have high incidences. Even if the mechanisms are partially understood, opioid-sparing strategies have been shown to decrease its incidence. Finally, the problem of postoperative shivering has been, at least partially, solved by the avoidance of (high doses) remifentanil and the use of alpha-2 agonists. In conclusion, postoperative urinary retention, postoperative ileus, nausea and vomiting, and shivering are complex problems seen after surgery. Management is possible, but prevention is possible with the avoidance of high doses of intraoperative opioids, conjointly to opioid-sparing techniques. [ABSTRACT FROM AUTHOR]

Background and Aims The duodenal-jejunal bypass liner (DJBL) is an endoscopic device that induces weight loss and improves glycemic control in patients with type 2 diabetes mellitus (T2DM). The aim of the current study was to assess the effects of DJBL explantation on glycemic control and body weight. Methods This prospective, observational study included only patients with T2DM who had the DJBL implanted for at least 6 months and had a follow-up of at least 12 months after explantation. The primary endpoints were changes in glycosylated hemoglobin A 1c (HbA 1c ) and body weight during the 12 months after explantation. Secondary endpoints were changes in fasting plasma glucose, blood pressure, and plasma lipid levels. Results In total, 59 patients completed the 12-month follow-up after explantation. During this period body weight increased by 5.6 (standard deviation, 6.4) kg ( P < .001) and HbA 1c rose from 65 (SD 17) to 70 (SD 20) mmol/mol ( P < .001). However, body weight remained 8.0 (SD 8.6) kg ( P < .001) lower than before implantation, that is, corresponding to a net total body weight loss of 7.4% (SD 7.6) ( P < .001). Although HbA 1c was significantly higher 12 months after explantation compared with baseline and the mean daily dose of insulin used was comparable, the number of patients on insulin remained significantly lower than before implantation. Conclusions Explantation of the DJBL is associated with weight gain and worsening of glycemic control, although some beneficial effects remained detectable 12 months after explantation. A change in strategy is needed to preserve the beneficial effects of DJBL treatment. (Clinical trial registration number: 746∖100111.) [ABSTRACT FROM AUTHOR]

Background and purpose Breath hold is increasingly used for cardiac sparing in left-sided breast cancer irradiation. We have developed a fast automated method to verify breath hold stability in each treatment fraction. Material and methods We evaluated 504 patients treated with breath hold. Moderate deep inspiration breath hold was audio-guided. Medial and lateral large tangential field segments were delivered in a single breath hold and movieloops of these fields were acquired with an EPID. The thoracic wall position was automatically detected in each frame and the full range of thoracic wall motion (RTWM) was determined. If the RTWM >4 mm more than 3 times, the patient was excluded from breath hold treatment if further coaching did not yield improvement. Results Unstable breath hold was observed in 2.8% of the patients. However, this frequency dropped from 9.5% in the first 6 months to 1.6% in the subsequent 16 months. The 97% of patients with proper breath hold showed excellent stability: the average RTWM was 0.9 ± 0.5 mm. The reproducibility of the breath hold depth was confirmed by (1) the small difference between the thoracic wall positions in the medial and lateral fields within one fraction and (2) the setup errors of breath hold patients showed no significant differences with those of right-sided breast patients. Conclusions We have developed and clinically applied an imaging tool to automatically determine stability of breath holds in each treatment fraction during beam delivery. [ABSTRACT FROM AUTHOR]

Background Reduced serum vitamin K levels are frequently observed after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). The criteria for treatment are not precisely defined. Objectives To assess the effects of standardized vitamin K supplementation in patients who develop vitamin K deficiency after BPD or BPD/DS. Setting Teaching hospital specializing in bariatric surgery. Methods Serum vitamin K levels, clotting times, and vitamin K-dependent coagulation factors were measured after an overnight fast at baseline and then at 4 days and 1, 4, and 52 weeks after the start of vitamin K supplementation in 10 consecutive patients who had developed severe vitamin K deficiency after BPD or BPD/DS. Vitamin K was administered in a dose of 5 mg/d for 1 week, followed by a maintenance dose of 5 mg once a week. Results At baseline, all patients had serum vitamin K 1 levels below the limit of detection, but none reported symptoms of easy bleeding. Minor prolongation of the prothrombin time and minimal decreases of some coagulation factors were observed in a minority of patients. During the first week of vitamin K loading, median serum vitamin K 1 levels rose into the high normal range. During maintenance treatment, median vitamin K 1 levels settled in the low normal range. Conclusion Vitamin K 1 deficiency in patients with BPD or BPD/DS is not commonly associated with bleeding or clinically relevant decreases in coagulation factor activity. We hypothesize that vitamin K 2 production in the large intestine is usually sufficient to compensate for vitamin K 1 deficiency and to maintain total liver vitamin K stores within the range required for (near) normal coagulation factor production. [ABSTRACT FROM AUTHOR]

Background Subclinical hypothyroidism (SH), defined as a raised serum thyroid-stimulating hormone (TSH) with a normal free thyroxine (FT4), is occasionally observed in morbidly obese patients. Objectives It is currently not known whether thyroid hormone treatment is indicated. The aim of the present study was to assess the changes in thyroid hormone levels in thyroxine-naïve patients with SH in response to weight loss induced by Roux-en-Y gastric bypass (RYGB). Setting General hospital specialized in bariatric surgery. Methods Serum levels of TSH and FT4 were measured at baseline in 503 patients presenting for RYGB. In patients diagnosed with SH, these measurements were repeated 12 months postoperatively. Results SH de novo was present in 71 out of 503 patients (14.1%). One-year follow-up was available in 61 out of 71 patients (86%). TSH level>10 mU/L was observed in 3 patients (.5%). RYGB induced a decrease in BMI from 47±8 kg/m 2 to 33±6 kg/m 2 at 12-month follow-up ( P <.001), and this was associated with a decrease in TSH from 5.8±2.0 to 2.8±1.3 mU/L ( P <.001) and a decrease in FT4 from 15.2±2.1 to 13.9±2.3 pmol/L ( P <.001), respectively. SH completely resolved in 53 (87%) of the de novo cases. Conclusion The prevalence of SH de novo is high in morbidly obese patients. After RYGB it resolves in about 90% of patients. This high degree of spontaneous recovery suggests that follow-up alone is sufficient in the majority of patients. [ABSTRACT FROM AUTHOR]

Background: Hypophosphatemia occurs in about 25% of patients admitted to the intensive care unit. To date, a safe and validated phosphate replacement protocol is not available. Objective: To evaluate an individualized phosphate replacement regimen. Design: Fifty consecutive intensive care unit patients with a serum phosphate level <0.6 mmol/L were treated with sodium-potassium-phosphate intravenously at a rate of 10 mmol/h. The dose was calculated according to the following equation: Phosphate dose in mmol = 0.5 × Body Weight × (1.25 - [serum Phosphate]). Phosphate levels were measured immediately upon completion of the infusion, as well as the next morning at 8 AM. Results: Post-infusion phosphate levels were >0.6 mmol/L in 98% of the patients. Hyperphosphatemia, hyperkalemia or a decrease in serum calcium were not observed. In about a third of patients serum phosphate decreased to <0.6 mmol/L within the next 24 hours after infusion. The phosphate distribution volume calculated from the results of infusion and corrected for renal phosphate loss during the infusion period was 0.51 L/kg (95% CI 0.42-0.61 L/kg). Conclusion: This study shows that phosphate replacement with dose calculation based on serum phosphate levels and a Vd of 0.5 L/kg is effective and safe. [ABSTRACT FROM AUTHOR]

Purpose: When one is performing online setup correction for prostate positioning displacements prior to daily dose delivery, intrafraction motion can become a limiting factor to prostate targeting accuracy. The aim of this study was to quantify and characterize prostate intrafraction motion assessed by multiple kilovoltage (kV) and megavoltage (MV) imaging of implanted markers during treatment in a large patient group. Methods and Materials: Intrafraction motion in the sagittal plane was studied by retrospective analysis of displacements of implanted gold markers on (nearly) lateral kV and MV images obtained at various time points during the treatment fractions (mean, 27 per patient) in 108 consecutive patients. The effective prostate motion in a fraction was defined as the time-weighted mean displacement. Results: Prostate displacements in the sagittal plane increased during the fraction (mean, 0.2 ± 0.2 mm/min). Forty percent of patients had a systematic (i.e., appearing in all fractions) effective displacement in the sagittal plane greater than 2 mm. Observed effective population mean-of-means (μeff) +/− systematic (Σeff) intrafraction motion (μeff ± Σeff) was 0.9 ± 1.1 mm and 0.6 ± 1.0 mm for the anterior–posterior and superior inferior directions, respectively. Corresponding random motion (σeff) was 1.2 mm and 1.1 mm. Mean effective prostate motion in the first 5 fractions was predictive for mean effective displacement in the remaining fractions (p < 0.001). Conclusion: For a large subgroup of patients, the systematic component of intrafraction prostate motion was substantial. Intrafraction motion correction prior to each beam delivery or offline corrections could likely be beneficial for the subgroup of patients with significant motion. The systematic component is well predicted by measurements in the initial fractions. [Copyright &y& Elsevier]

Purpose: To develop a method for margin evaluation accounting for all measured displacements during treatment of prostate cancer. Methods and Materials: For 21 patients treated with stereographic targeting marker-based online translation corrections, dose distributions with varying margins and gradients were created. Sets of possible cumulative delivered dose distributions were simulated by moving voxels and accumulating dose per voxel. Voxel motion was simulated consistent with measured distributions of systematic and random displacements due to stereographic targeting inaccuracies, deformation, rotation, and intrafraction motion. The method of simulation maintained measured correlation of voxel motions due to organ deformation. Results: For the clinical target volume including prostate and seminal vesicles (SV), the probability that some part receives <95% of the prescribed dose, the changes in minimum dose, and volume receiving 95% of prescription dose compared with planning were 80.5% ± 19.2%, 9.0 ± 6.8 Gy, and 3.0% ± 3.7%, respectively, for the smallest studied margins (3 mm prostate, 5 mm SV) and steepest dose gradients. Corresponding values for largest margins (5 mm prostate, 8 mm SV) with a clinical intensity-modulated radiotherapy dose distribution were 46.5% ± 34.7%, 6.7 ± 5.8 Gy, and 1.6% ± 2.3%. For prostate-only clinical target volume, the values were 51.8% ± 17.7%, 3.3 ± 1.6 Gy, and 0.6% ± 0.5% with the smallest margins and 5.2% ± 7.4%, 1.8 ± 0.9 Gy, and 0.1% ± 0.1% for the largest margins. Addition of three-dimensional rotation corrections only improved these values slightly. All rectal planning constraints were met in the actual reconstructed doses for all studied margins. Conclusion: We developed a system for margin validation in the presence of deformations. In our population, a 5-mm margin provided sufficient dosimetric coverage for the prostate. In contrast, an 8-mm SV margin was still insufficient owing to deformations. Addition of three-dimensional rotation corrections was of minor influence. [ABSTRACT FROM AUTHOR]

Resumo Relato do caso de uma criança recém‐nascida de três dias de idade com um cisto ovariano gigante programada para a cirurgia. A paciente recebeu uma dose de sugamadex para reverter o bloqueio neuromuscular induzido por rocurônio. Uma recuperação rápida e eficiente do bloqueio neuromuscular foi obtida dentro de 90 segundos. Não foram observados efeitos adversos ou outros problemas de segurança. Além disso, uma revisão da literatura sobre o uso de sugamadex em recém‐nascidos foi feita. A case is reported in which a 3‐days old neonate with a giant ovarian cyst was scheduled for surgery. The patient received a dose of sugammadex to reverse a rocuronium‐induced neuromuscular block. A fast and efficient recovery from neuromuscular block was achieved within 90 s. No adverse events or other safety concerns were observed. Furthermore, a review of the literature on the use of sugammadex in neonates was performed. [ABSTRACT FROM AUTHOR]

Abstract: Background and purpose: We are developing a technique for highly focused vocal cord irradiation in early glottic carcinoma to optimally treat a target volume confined to a single cord. This technique, in contrast with the conventional methods, aims at sparing the healthy vocal cord. As such a technique requires sub-mm daily targeting accuracy to be effective, we investigate the accuracy achievable with on-line kV-cone beam CT (CBCT) corrections. Materials and methods: CBCT scans were obtained in 10 early glottic cancer patients in each treatment fraction. The grey value registration available in X-ray volume imaging (XVI) software (Elekta, Synergy) was applied to a volume of interest encompassing the thyroid cartilage. After application of the thus derived corrections, residue displacements with respect to the planning CT scan were measured at clearly identifiable relevant landmarks. The intra- and inter-observer variations were also measured. Results: While before correction the systematic displacements of the vocal cords were as large as 2.4±3.3mm (cranial–caudal population mean±SD Σ), daily CBCT registration and correction reduced these values to less than 0.2±0.5mm in all directions. Random positioning errors (SD σ) were reduced to less than 1mm. Correcting only for translations and not for rotations did not appreciably affect this accuracy. The residue random displacements partly stem from intra-observer variations (SD=0.2–0.6mm). Conclusion: The use of CBCT for daily image guidance in combination with standard mask fixation reduced systematic and random set-up errors of the vocal cords to <1mm prior to the delivery of each fraction dose. Thus, this facilitates the high targeting precision required for a single vocal cord irradiation. [Copyright &y& Elsevier]

Abstract: Sugammadex is the first selective relaxant binding agent which was originally designed to reverse the steroidal NMB drug rocuronium. The results of recent studies demonstrate that sugammadex is effective for reversal of rocuronium and vecuronium-induced neuromuscular block without apparent side-effects. This is in contrast to the currently available cholinesterase inhibitors used to reverse neuromuscular block and which are even ineffective against profound neuromuscular block and have a number of undesirable side-effects. Sugammadex-rocuronium complexes are highly hydrophilic and it has been demonstrated that sugammadex is excreted in a rapid and dose-dependent manner in urine, resulting in a complete elimination from the body. The ability of sugammadex to reverse rocuronium and vecuronium-induced neuromuscular block may have major implications for routine anesthetic practice. Once sugammadex becomes commercially available, anesthesiologists will be capable of maintaining the desired depth of neuromuscular block at any time, thereby assuring optimal surgical conditions. The mechanism by which sugammadex encapsulates rocuronium and vecuronium appears to be superior to currently used neuromuscular block reversal strategies in terms of speed, efficacy and side effects. In this article, clinical studies of sugammadex are discussed. [Copyright &y& Elsevier]

Abstract: Background and Purpose: To quantify respiratory motion of the vocal cords during normal respiration using 4D-CT. The final goal is to develop a technique for single vocal cord irradiation (SVCI) in early glottic carcinoma. Sparing the non-involved cord and surrounding structures has the potential to preserve voice quality and allow re-irradiation of recurrent and second primary tumors. Material and methods: Four-dimensional CTs of 1mm slice thickness from 10 early glottic carcinoma patients were acquired. The lateral dimensions of the air gap separating the vocal cords were measured anteriorly, at mid-level and posteriorly at each phase of the 4D-CTs. The corresponding anterior–posterior gaps were similarly measured. Cranio-caudal vocal cords movements during breathing were derived from the shifts of the arythenoids. Results: The population-averaged mean gap size±the corresponding standard deviation due to breathing (SDB) for the lateral gaps was 5.8±0.7mm anteriorly, 8.7±0.9mm at mid-level, and 11.0±1.3mm posteriorly. Anterior–posterior gap values were 21.7±0.7mm, while cranio-caudal shift SDB was 0.8mm. Conclusion: Vocal cords breathing motions were found to be small relative to their separation. Hence, breathing motion does not seem to be a limiting factor for SVCI. [Copyright &y& Elsevier]

Purpose: A fully automated, fast, on-line prostate repositioning scheme using implanted markers, kilovoltage/megavoltage imaging, and remote couch movements has been developed and clinically applied. The initial clinical results of this stereographic targeting (SGT) method, as well as phantom evaluations, are presented. Methods and Materials: Using the SGT method, portal megavoltage images are acquired with the first two to six monitor units of a treatment beam, immediately followed by acquisition of an orthogonal kilovoltage image without gantry motion. The image pair is automatically analyzed to obtain the marker positions and three-dimensional prostate displacement and rotation. Remote control couch shifts are applied to correct for the displacement. The SGT performance was measured using both phantom images and images from 10 prostate cancer patients treated using SGT. Results: With phantom measurements, the accuracy of SGT was 0.5, 0.2, and 0.3 mm (standard deviation [SD]) for the left–right, craniocaudal, and anteroposterior directions, respectively, for translations and 0.5° (SD) for the rotations around all axes. Clinically, the success rate for automatic marker detection was 99.5%, and the accuracy was 0.3, 0.5 and 0.8 mm (SD) in the left–right, craniocaudal, and anteroposterior axes. The SDs of the systematic center-of-mass positioning errors (Σ) were reduced from 4.0 mm to <0.5 mm for all axes. The corresponding SD of the random (σ) errors was reduced from 3.0 to <0.8 mm. These small residual errors were achieved with a treatment time extension of <1 min. Conclusion: Stereographic targeting yields systematic and random prostate positioning errors of <1 mm with <1 min of added treatment time. [Copyright &y& Elsevier]

Abstract: Purpose: To determine adequate three-dimensional (3D) margins around the clinical target volume (CTV) of oropharyngeal cancers. Methods and materials: The CTV, bounded by implanted markers, was recorded under fluoroscopy in antero-posterior (AP) and lateral view. The peak-to-peak motion was measured in lateral, AP and cranio–caudal (CC) directions. Results: During swallowing, the mean amplitude of motion measured was 9.4mm (0.9–18.5) and 4.1mm (0.6–11.4) in AP view in the CC and lateral direction, respectively; and 8.6mm (0.5–16.5) and 7.6mm (0.9–14.5) in lateral view in the CC and AP direction, respectively. In the non-swallowing period the motion was 1.5mm (0.3–3.2) and 1mm (0.4–3.6) in AP view in the CC and lateral direction, respectively; and 1.3mm (0.4–3.1) and 1.3mm (0.4–3.4) in lateral view in the CC and AP direction, respectively. This motion was believed to be due to breathing. Conclusion: If swallowing can be suppressed during CT acquisition, the contribution to the internal margin for this motion is negligible. Breathing related motion is also believed to be of limited clinical relevance in current practice. However, it might become of importance in future, with further reduction of margins. [Copyright &y& Elsevier]

Purpose: The no action level (NAL) protocol reduces systematic displacements relative to the planning CT scan by using the mean displacement of the first few treatment fractions as a setup correction in all subsequent fractions. This approach may become nonoptimal in case of time trends or transitions in the systematic displacement of a patient. Here, the extended NAL (eNAL) protocol is introduced to cope with this problem. Methods and Materials: The initial setup correction of eNAL is the same as in NAL. However, in eNAL, additional weekly follow-up measurements are performed. The setup correction is updated after each follow-up measurement based on linear regression of the available measured displacements to track and correct systematic time-dependent changes. We investigated the performance of eNAL with Monte Carlo simulations for populations without systematic displacement changes over time, with large gradual changes (time trends), and with large sudden changes (transitions). Weekly follow-up measurements were simulated for 35 treatment fractions. We compared the outcome of eNAL with NAL and optimized shrinking action level (SAL) protocol with weekly measurements. Results: Without time-dependent changes, eNAL, SAL, and NAL performed comparably, but SAL required the largest imaging workload. For time trends and transitions, eNAL performed superiorly to the other protocols and reduced systematic displacements to the same magnitude as in case of no time-dependent changes (SD ∼1 mm). Conclusion: Extended NAL can reduce systematic displacements to a minor level irrespective of the precise nature of the systematic time-dependent changes that may occur in a population. [Copyright &y& Elsevier]

Early postoperative urinary catheter removal decreases urinary tract infection and accelerates patients mobilisation. Low risk patients should have routine removal of catheter on the first day after surgery, while patients with moderate or high risk require catheterization for up to 3 days. B Results: b Ninety-eight patients were identified (age 76y range 25-92y) and are presented in table 1. recatheterisation after early removal of the urinary catheter was needed in 12.9% and 7.3% for colon and rectal surgery respectively. [Extracted from the article]

Purpose: To evaluate the efficacy of the No Action Level (NAL) off-line correction protocol in the reduction of systematic prostate displacements as determined from electronic portal images (EPI) using implanted markers. Methods and Materials: Four platinum markers, two near the apex and two near the base of the prostate, were implanted for localization purposes in patients who received fractionated high dose rate brachytherapy. During the following course of 25 fractions of external beam radiotherapy, the position of each marker relative to the corresponding position in digitally reconstructed radiographs (DRRs) was measured in EPI in 15 patients for on average 17 fractions per patient. These marker positions yield the composite displacements due to both setup error and internal prostate motion, relative to the planning computed tomography scan. As the NAL protocol is highly effective in reducing systematic errors (recurring each fraction) due to setup inaccuracy alone, we investigated its efficacy in reducing systematic composite displacements. The analysis was performed for the center of mass (COM) of the four markers, as well as for the cranial and caudal markers separately. Furthermore, the impact of prostate rotation on the achieved positioning accuracy was determined. Results: In case of no setup corrections, the standard deviations of the systematic composite displacements of the COM were 3-4 mm in the craniocaudal and anterior-posterior directions, and 2 mm in the left-right direction. The corresponding SDs of the random displacements (interfraction fluctuations) were 2-3 mm in each direction. When applying a NAL protocol based on three initial treatment fractions, the SDs of the systematic COM displacements were reduced to 1-2 mm. Displacements at the cranial end of the prostate were slightly larger than at the caudal end, and quantitative analysis showed this originates from left-right axis rotations about the prostate apex. Further analysis revealed that significant time trends are present in these prostate rotations. No significant trends were observed for the prostate translations. Conclusions: The NAL protocol based on marker positions in EPI halved the composite systematic displacements using only three imaged fractions per patient, and thus allowed for a significant reduction of planning margins. Although large rotations of the prostate, and time trends therein, were observed, the net impact on the measured displacements and on the accuracy obtained with NAL was small. [ABSTRACT FROM AUTHOR]

Purpose: In a recent study, large systematic setup errors were detected in patients with lung cancer when a conventional simulation procedure was used to define and mark the treatment isocenter. In the present study, we describe a procedure to omit the session at a conventional simulator to remove simulation errors entirely. Isocenter definition and verification was performed at a computed tomography (CT) simulator, and digitally reconstructed radiographs (DRRs) were used for setup verification and correction at the treatment unit.Methods and Materials: A CT simulation protocol was developed, in which radiopaque markers were used to verify the coincidence of the isocenter marked on the patients’ skin with the isocenter defined in the planning CT scan. This protocol was evaluated for 20 patients. Subsequently, electronic portal images were acquired at the treatment unit. The three-dimensional setup error was established from a template match of the appropriate anatomy visible in two orthogonal beams with the corresponding anatomy in DRRs. An offline setup correction protocol was applied to reduce systematic setup errors.Results: For all patients, the skin marks defined the planning CT scan isocenter to within ± 1.5 mm in each of the three main directions. Random setup errors at the treatment unit were 1.8, 2.0, and 1.9 mm (1 SD) for the lateral (x), the superior-inferior (y), and the anterior-posterior (z) directions, respectively. With the use of the correction protocol, the systematic errors for x, y, and z were 1.5, 1.5, and 1.3 mm (1 SD).Conclusions: Because the distributions of treatment setup errors measured against DRRs obtained in our CT simulation were equal to previously obtained distributions measured against simulator films, conventional simulation can be omitted and DRRs are well-suited for setup verification. By adopting our CT simulation procedure, the large systematic simulation setup errors, which remain hidden if a conventional simulation is performed, can be avoided. [Copyright &y& Elsevier]