Background and objective Efforts to improve gastrointestinal (GI) endoscopy unit efficiency may lead to increases in colon cancer screening volumes. LEAN management principles applied to GI endoscopy unit practices may serve as a novel foundation for efficiency improvements. We conducted a pilot study in an outpatient, hospital-based GI endoscopy unit with the goal of improving endoscopy efficiency by using LEAN principles Methodology A single endoscopist and anesthesiologist along with the nursing care team implemented changes to their practice based on LEAN principles. Efficiency metrics were tracked before these changes and after to assess for improvements. Results We observed statistically significant improvements in waiting room time (13.1 minutes vs. 25.6 minutes, p<0.001), recovery room duration (55.5 minutes vs. 61.8 minutes, p=0.01), total facility time (172.5 minutes vs. 196.1 minutes, p<0.001), and true completion time (19.7 minutes vs. 32.3 minutes, p=0.002) after the implementation of LEAN interventions. Conclusions A systematic and standardized approach using LEAN methodology can improve GI endoscopy unit operational efficiency. Larger studies are needed to validate our findings and generalize the results to the field broadly.

The optimal treatment for patients with locally advanced gastric adenocarcinoma is multimodal. Surgery is the cornerstone of therapeutic strategies with curative intent. The addition of chemotherapy or chemoradiation decreases rate of recurrence and prolongs survival. Guidelines differ between countries and there is no universal standard of care. Modern studies of patients with locally advanced gastric cancer showed that adjuvant chemotherapy improves survival over surgery alone in Asia. These studies could not be replicated in Europe. Peri-operative chemotherapy strategies, conversely, have been effective in Europe for improving overall and disease free survival. Adjuvant chemoradiation has also demonstrated improved survival when compared to surgery alone, but studies comparing chemotherapy with chemoradiation have not shown significant difference. Trials are ongoing to examine the role of chemoradiation in a neoadjuvant fashion. A D2 extent of lymphadenectomy improves cancer related survival for those who do not undergo distal pancreatectomy/splenectomy. Survival is also associated not only with the extent but also the number of lymph nodes examined. There are ongoing trials related to immunotherapy and targeted therapies, which may also impact or change the treatment paradigm for locally advanced gastric cancer.

Technological advances in medicine and surgery have undoubtedly changed today’s practice. One of the most important recent developments to surgical practice has been the adoption of computer assisted robots. Although robots have been around for the past 75 years, it is only recently that their use in surgery has dramatically increased1. With the growing market pressures for minimally invasive procedures, the role of robotic assisted surgery and its advantages of improved surgical precision over standard open and laparoscopic procedures will likely grow. To date since 1998, there have been approximately 80,000 robotic assisted surgical procedures. Currently about 400 medical centers in the United States have surgical robotic systems. As the number of surgeons adopt and learn to master this new tool, which is still in the learning phase, anesthesiologists should have a basic knowledge of these systems in order to formulate an anesthetic plan, recognize potential complications and provide safe patient care.

Cancer is the second leading cause of death in the United States. During the course of treatment, a cancer patient may present emergently to the hospital because of either the cancer itself or a manifestation of cancer therapy. Rarely, patients with cancer can present to the operating room with several emergent conditions that require the services of an anesthesiologist. The main oncologic emergencies affecting anesthesiologists relate to airway obstruction and cardiac-, neurologic-, gastrointestinal-, and endocrine-related conditions. Mismanagement of these crises can increase morbidity and mortality. This article addresses emergencies in patients with cancer and how they relate to anesthetic care.

BACKGROUND:Haemodynamic changes associated with pneumoperitoneum and steep Trendelenburg position were investigated in non-obese, ASA I-II males, using general anaesthesia (sevoflurane in air/O2, 40%) undergoing robotic-assisted laparoscopic prostatectomy.METHODS:A trans-oesophageal echo-Doppler probe (Arrow International) measured cardiovascular changes in heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), stroke volume (SV) and aortic diameter (AoD) in 35 of 37 males. Assessments were conducted after induction of general anaesthesia in: the supine position; at 45 degrees Trendelenburg; Trendelenburg + pnuemoperitoneum (intra-abdominal 15 mmHg); and at the end of surgery in the supine position.RESULTS:The Trendelenburg position increased stroke volume. Trendelenburg position + pneumoperitoneum increased MAP and SVR and decreased AoD.CONCLUSIONS:Pneumoperitoneum and steep Trendelenburg position significantly increase MAP and SVR. Trendelenburg position increased stroke volume. Pneumoperitoneum decreases aortic diameter. No significant changes in cardiac output or stroke volume were noted.

The authors and reviewer have no relationships with pharmaceutical companies or manufacturers of products to disclose. This educational activity may contain discussion of published and/or investigational uses of agents for the treatment of disease. Some uses of these agents have not been approved by the US Food and Drug Administration. Please refer to the official prescribing information for each product for approved indications, contraindications, and warnings.