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Perioperative Management of Robotic-Assisted Gynecological Surgery in a Super Morbidly Obese Patient – Cureus



Perioperative management of a patient with super-morbid obesity (MO), defined as having a body mass index (BMI) of ≥50 kilograms per meter squared (kg/m2), is challenging due to large physiological changes, especially in the respiratory system [1-3]. Laparoscopic gynecological surgeries using robotic-assisted (RA) technology have been reported to reduce postoperative morbidity in morbidly obese patients [4-6] but suggested that the steep Trendelenburg position and pneumoperitoneum required for this surgery cause deterioration in respiratory physiology [2,4,6]. High-volume centers and university hospitals report [6,7] the necessity of multidisciplinary coordination for these complex cases [5,6]. The increase in the prevalence of obesity [8] means that there will be more opportunities for perioperative management of morbidly obese patients, even in hospitals without specific experience with obese patients.

In this case report, the perioperative management of a woman with super-MO who underwent RA total laparoscopic hysterectomy (TLH) with bilateral salpingo-oophorectomy (BSO) for treatment of endometrial cancer in a facility that is not a high-volume center for obese patients is described.

The patient was a 32-year-old American Society of Anesthesiologists physical status 3 female with super-MO. Her height was 157.8 cm, body weight was 151.6 kg, and BMI was 60.9, and she was diagnosed as having endometrial cancer. She had no past medical history and was referred to a gynecologist for planning for RA-TLH with BSO. There was no high-volume center for morbidly obese patients with gynecological malignant diseases on our main island, so her gynecologist decided to perform her surgery in our hospital. Fourteen days after this, she was admitted and had a checkup by her anesthesiologist. Her neck circumference was 48 cm, she could not maintain a supine position due to dyspnea, and her oxygen saturation on pulse oximetry (SpO2) was over 90% on room air. A respiratory function test showed that vital capacity as a percentage of predicted (%VC) was 75.6%.

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After admission, a program for preoperative weight loss by dietary restriction, exercise therapy, and respiratory rehabilitation was started. The goal for reduction in BMI was set to 10% at the time of the initial referral [9]. A total energy intake starting from 1360 kcal/day was decided.

Three days after admission, the initial simulation was performed by the patient, gynecologists, anesthesiologists, and dedicated room staff in the surgical theater. Her BMI was 59.9, and she suffered from dyspnea in the supine position. Dyspnea deteriorated, and slippage was seen in the Trendelenburg position of 15º.

The target BMI was achieved five weeks after admission and preoperative dieting was determined to continue until her gynecological procedure. The patient was scheduled for surgery two weeks later by consultation between gynecologists and anesthesiologists. The second simulation, performed 39 days after admission, verified her acceptance of the respiratory condition in Trendelenburg tilt of 15º. The patient’s BMI reduced to 54 kg/m2, and her %VC improved to 82.2%.

Arterial blood gas analysis performed seven weeks post-admission on room air, reported arterial oxygen saturation of 93.6% with a partial pressure of carbon dioxide (PaCO2) of 47.8 millimeters of mercury (mmHg), and a serum bicarbonate concentration of 27.9 mmol/L. Sleep studies revealed that the patient had severe obstructive sleep apnea with multiple desaturation episodes along with obesity hypoventilation syndrome. The obesity surgery mortality risk stratification (OS-MRS) [10] and the STOP-BANG screening questionnaire for obstructive sleep apnea [11] were scored as two and five, respectively.

On the day of surgery (49 days after admission), her BMI was 53.3 kg/m2. SpO2 was 94% on air. An upper body wedge was used to posture a ramped position [3], and the reverse Trendelenburg position was applied at the induction of anesthesia. Preoxygenation with 10 L/min of 100% oxygen via a face mask was conducted for 5 min. Remifentanil was dosed on lean body weight (LBW) and infused at 0.1 μg/kg/min. After the injection of 1 mg of midazolam, 8% of lidocaine was sprayed around her pharynx, larynx, and glottis using blade #3 of McGrath Mac (Covidien Japan, Tokyo, Japan) in an awakening state. A tracheal tube (internal diameter of 7.0 mm) was successfully inserted into the trachea, and 60 mg of rocuronium (ROC) and 4 mg of midazolam were injected, and inhalation of sevoflurane was started. She was ventilated mechanically with the ventilator instrumented in a Carestation 650 Anesthesia Delivery System (GE Healthcare Japan, Tokyo, Japan) using a pressure-controlled ventilation volume-guaranteed mode. Tidal volume was set at 400 mL, positive end-expiratory pressure (PEEP) was 10 cm of water (cmH2O), peak inspiratory pressure (Ppeak) did not exceed 35 cmH2O, and respiratory rate was adjusted to maintain end-tidal partial pressure of carbon dioxide (PETCO2) within 45-55 mmHg. The inspiratory oxygen fraction was set at 0.5, and the anesthesia was maintained using sevoflurane, remifentanil, and fentanyl. Repetitive train-of-four (TOF) stimulation with the TOF-Watch SX monitoring program (MSD, Tokyo, Japan) using the corrugator supercilii muscle was performed. Ultrasound-guided subcostal transverse abdominis plane blocks were performed bilaterally.

After insertion of intra-abdominal trocars and establishment of pneumoperitoneum with 10 mmHg of insufflation pressure, the surgical procedure with a da VinciTM Robotic System (Intuitive Surgical, Inc, Sunnyvale, USA) was commenced in the Trendelenburg position of 15º. During the surgical procedure, PETCO2 could be maintained between 41 and 46 mmHg with a respiratory rate of 13-16 breaths/min, and Ppeak was 21 and 32 cmH2O in the supine and Trendelenburg position with pneumoperitoneum, respectively. Continuous infusion of ROC at 7 µg/kg of LBW/min was started at the appearance of T1. About two hours after starting the anesthetic management, the volatile anesthetic was changed to desflurane. Hyperinflation of the lungs by holding the inspiratory airway pressure at 30 cmH2O for five seconds was applied several times, and SpO2 could be maintained between 99% and 100% throughout the surgery.

Spontaneous breathing resumed 3 min after the cessation of anesthetics, and sugammadex at 2 mg/kg of real body weight was injected. After awakening and recovering from adequate spontaneous breathing, extubation was performed in the reverse Trendelenburg position. The duration of anesthesia was 304 min. Inhalation of 3 L/min of oxygen via a nasal cannula was started, and SpO2 was 99%. A continuous infusion of fentanyl at a dose of 25 µg/hr was started.

She was inhaling 2 L/min of oxygen via a nasal cannula with a 45º head-up tilt, and SpO2 was over 90% at the time of transfer to the intensive care unit. She was transferred to the general ward the next day without any complications.

Perioperative management of a woman with super-MO who underwent RA-TLH was achieved in a facility that is not a high-volume center for obese patients. Preoperative optimization using dietary restriction and several simulations performed by gynecologists, anesthesiologists, and operation staff were useful for achieving complex anesthetic management safely. Consultation between gynecologists and anesthesiologists was crucial to determining the duration of preoperative optimization.

Perioperative management of a patient with super-MO is challenging due to large physiological changes, especially in the respiratory system [1-3]. Guidelines for perioperative management of obese patients have been established [3,9], and preoperative optimization, ideally for four to eight weeks, is recommended to perform surgical procedures safely [9].

It has been reported that the OR-MRS score is associated with risk factors of mortality for obese patients undergoing gastric bypass surgery [10], and this would be applicable to obese patients undergoing non-bariatric surgery [3]. The mortality odds ratio for BMI ≥50 is 3.6 (the highest among variables in the score), and BMI could be the only adjustable factor for preoperative optimization. We decided, therefore, to attempt preoperative weight reduction even though our patient had a malignant disease. It has been recommended that preoperative dieting should be performed to reduce BMI by 10% or to <55 kg/m2 to perform laparoscopy safely [9].

The time from diagnosis to the first and definitive surgery, defined as time to surgery (TTS), has been reported to have a negative impact on overall survival in patients with several types of cancer [12-14]. A decrease in survival rate with the prolongation of TTS has also been reported for patients with endometrial cancer. TTS of more than six to eight weeks has a negative impact on overall survival in patients with endometrial cancer [15-17]. Prolongation of TTS in morbidly obese patients with endometrial cancer would improve respiratory function but worsen overall survival. TTS in the present case was nine weeks, and the period was determined by consultation between gynecologists and anesthesiologists. Shalowitz et al. [17] suggested that adequate preoperative optimization should have priority over expedited surgery. The discussion of the risk of case delay weighed against the risk of not optimizing the patient’s health status should be performed between gynecologists and anesthesiologists. It has been reported that body weight can be reduced in two weeks by using a very low-calorie diet [18-20]. Weight reduction in the preoperative period should be considered for super-MO patients, even if the duration of preoperative optimization is short compared with that in the present case.

Teamwork and high-volume experience among multidisciplinary physicians and staff are necessary for achieving RA gynecological surgery in a patient with morbid obesity [5,6], and outcomes have been improved as the surgical team gains experience [5]. An increase in the prevalence of obesity has been reported [8], and there will be more opportunities for perioperative management of morbidly obese patients, even in hospitals without specific treatment for obese patients. We could not find high-volume centers for morbidly obese patients with gynecological malignancies on our main island. We, therefore, decided to perform her surgery in our hospital. Simulations were thought to have the potential for improving outcomes and reducing complications while enhancing teamwork in the present case. Good communication among all members of the team throughout the perioperative period is necessary for completing surgery safely in challenging situations [6].

Preoperative optimization using dietary restriction and several simulations performed by gynecologists, anesthesiologists, and operation staff were useful for achieving the perioperative management of a patient with super-MO safely in a hospital that is not specialized for obese patients. With multidisciplinary discussion, this specific high-risk patient had a good outcome from a high-risk anesthetic and procedure. The determination of the optimal time for surgery by consultation between gynecologists and anesthesiologists is crucial in the care of such a complex patient. Weight reduction in the preoperative period should be considered for super-MO patients with malignant diseases, even if the duration of preoperative optimization is shorter than four to eight weeks.

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Dedicated flu, COVID, cold clinic opens at St. Joe's on Hamilton Mountain – CHCH News



A dedicated flu, COVID, and cold clinic opens on Tuesday at St. Joseph’s Healthcare on the Hamilton Mountain.

The clinic at the West 5th campus is intended to offer more timely care for COVID, cold, and flu patients who can’t get in to see a family doctor.

The opening of the new clinic is part of measures aimed at easing pressure on emergency departments.

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The clinic is open to both adults and children and a doctor’s referral is not required, but it’s not a walk-in clinic.

Patients are expected to make an appointment at St. Joseph’s Healthcare’s website.

The clinic can be accessed from the door beside the Fennell Ave. outpatient entrance and St. Joe’s stresses that patients must not access the flu, COVID, cold clinic through other hospital entrances or walk through the hospital.

The clinic is open from 4:30-9 p.m. during the week and from 8-4 p.m. on the weekends.

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Aid group with Canadian funding leads mission to deliver medical supplies in Ukraine



POLTAVA, Ukraine — As the Toyota Tundra following a tractor trailer loaded with humanitarian aid heads into dangerous territory in eastern Ukraine, “Promiscuous” by Nelly Furtado and Timbaland plays over the speakers.

The small convoy transporting 20 tonnes of medical supplies is headed for Balakliya in a part of the country that was retaken by the Ukrainian army in September after six months of brutal Russian occupation. Their mission to help the devastated region crosses areas where Russian shelling continues. In Kupiansk, not far from Balakliya, shells continue to rain down.

At the wheel of the Tundra last Friday was Dr. Christian Carrer, a pediatrician from France. With his partner Tetyana Grebenchykova, he runs the Association internationale de coopération médicale, a non-governmental organization that receives support from the Canada-Ukraine Foundation and the Ontario government.

It will take the vehicles, which also include a minivan ahead of the tractor trailer, five hours to travel from a warehouse in Poltava to Balakliya, a distance of barely 200 kilometres. The roads are pockmarked from fallen bombs, and there are frequent stops at military checkpoints on guard against Russian infiltration.

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The strapping pediatrician with the face of an old adventurer has been on the ground since 2014, helping people in the Donbas region after it was invaded by the Russians. Last January, he suspected Ukraine’s menacing neighbour was planning something.

“There were strange gatherings and constant provocations,” Carrer said as he drove. “Everyone knew that clearly, something was going to happen.”

His organization started ensuring various supplies, in particular bandages, were positioned ahead of the feared assault. The last hospital received its delivery on Feb. 24, he said, the day the Russians launched their war.

“The people funding us had confidence in us because we sensed the attack,” he said.

Canada is the third most generous contributor to his group, which has also drawn donations from French, American and British sources.

The organization is well stocked and knows the terrain, and it focuses its aid in a few administrative regions in the northeast of the country. It has more than 800 items available, general or specialized medicines that hospitals and pharmacies in disaster zones can order.

Even in regions that have officially been liberated, the needs remain desperate.

The road crosses sprawling plains, and in one village after another, homes have been destroyed and gas stations and other businesses are shuttered. Crops remain unharvested in the fields. The tires make a constant purring noise as they drive over asphalt perforated by constant tank traffic.

Signs of the suffering and destruction of war are everywhere, and residents have little left to survive on. The occupiers emptied pharmacies and pillaged hospitals.

The convoy passes Chuhuiv, a municipality where the Association internationale de coopération médicale positioned medical supplies ahead of the war but that was later occupied. “The Russians took everything,” says Carrer, who has lived in Ukraine since 2006.

He describes the health condition of those who lived for weeks in shelters as pitiful, looking like “zombies.” Some are even losing their teeth, and he said visiting physicians are shocked by what they find.

As a pediatrician, he is especially worried about the state of pregnant women, young mothers and their children: a large part of that day’s delivery is destined for them.

Once in Balakliya, a desolated city with some buildings completely gutted, the aid valued at $4 million is unloaded in an old warehouse. It will later be distributed among eight municipalities in the area. A small welcoming committee includes the administrative head of Izyum district to the south, Stepan Maselski.

“This aid is very important because we are still at war,” Maselski said in an interview. “The invader destroyed our infrastructures. Just two days ago, we didn’t have electricity or water. The occupation was painful — no medicine, no medical supplies, no good food.”

A forklift empties pallets from the tractor trailer, containing cases and cases of medicine to treat chronic illnesses, epilepsy and heart problems, anesthetics for surgeries, surgical equipment, bandages, gloves, stethoscopes and diapers, among other items. There is also baby formula because infant malnutrition is widespread, Carrer says.

“Often women who give birth have trouble nursing because of the stress and the situation,” he explained. He said Ontario has provided vitamins, and the impact was practically miraculous.

There are also supply kits for those left homeless and even boxes of pet food, which is in short supply.

A special big red bag, which resembles an insulated delivery bag, is handed to Paulina, a medical official who intervenes in the provision of urgent care across the region. It is a kit conceived by doctors in California to treat people in war zones, whether for injuries caused by a landmine or for heart attacks. Paulina says the supplies are of superior quality and they are badly needed.

Suddenly the unloading operation is halted when the forklift breaks down. But the Ukrainians are creative: they tow the old forklift out of the way with a tractor — like their compatriots were often seen doing with Russian tanks on viral videos — and build a wobbly wooden ramp to complete the unloading.

Counting on Ukrainians’ ability to adapt, Carrer’s group has also delivered large numbers of warm blankets as well as small wood-burning stoves manufactured in the Poltava region for residents who have no way to heat their homes due to power outages.

Carrer says there are complex  reasons why the Ukrainian government is struggling to provide basic services in liberated territories. For one thing, he explains, the budget for health spending was cut by about one fifth to fund the war effort. And the annual provision of equipment and funding for the health system comes in February or March, which was when the Russians invaded. The number of refugees has also drained local resources.

“The needs are enormous in all the hospitals,” he says. “And now it’s serious. We see hospitals that are at the end of their tether. We used to deliver two boxes, and now we deliver whole pallets, basic supplies like plaster, gloves, cotton.”

Night falls quickly, and it is cold. The rig is empty, and it is time to leave so the group can make it through all the checkpoints on the way back to Poltava. Carrer knows his group will likely have to return soon with another load.

“Either a good soul is there to help, or they’ll call us back in a month …. We are the first to help, and perhaps the last to help.”

This report by The Canadian Press was first published Nov. 28, 2022.

— Patrice Bergeron is a Quebec-based journalist with The Canadian Press. In addition to two decades of political and general news experience, he was a CP war correspondent in Afghanistan in 2009.


Patrice Bergeron, The Canadian Press

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COVID-19 Outbreak Declared at Southbridge Roseview



November 28, 2022 – The Thunder Bay District Health Unit (TBDHU) and Southbridge Care Homes confirm that the COVID-19 outbreak previously declared at Southbridge Roseview has been updated to include Cheshire and Renaissance Units only, Primrose Unit has been resolved.

TBDHU has initiated a thorough assessment of the situation. Further measures will be taken as needed to manage this situation.

Prior to the outbreak, significant measures were already in place to reduce likelihood of transmission of the virus within the facility. For additional information about COVID-19 and the TBDHU area, please see the TBDHU Website.


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