The rapid detection and evaluation of patients presenting with perioperative neurological dysfunction is of great clinical relevance. Biomarkers have been defined as biological molecules that can be used as an indicator of new onset or progression of a biological process or effect of treatment. Biomarkers have become increasingly important in this setting to supplement other modalities of diagnosis such as EEG, sensory- or motor-evoked potential, transcranial Doppler, near-infrared spectroscopy, or imaging methods. A number of neuro-proteins have been identified and are currently under investigation for potential to provide insights into injury severity, outcome, and the ability to monitor cellular damage and molecular events that occur during neurological injury. S100B is a protein released by glial cells and is considered a marker of blood-brain barrier dysfunction. Clinical studies in patients undergoing cardiac and non-cardiac surgery indicate that serum levels of S100B are increased intraoperatively and after operation. The neurone-specific enolase has also been extensively investigated as a potential marker of neuronal injury in the context of cardiac and non-cardiac surgery. A third biomarker of interest is the Tau protein, which has been linked to neurodegenerative disorders. Tau appears to be more specific than the previous two biomarkers since it is only found in the central nervous system. The metalloproteinase and ubiquitin C terminal hydroxylase-L1 (UCH-L1) are the most recently researched markers; however, their usefulness is still unclear. This review presents a comprehensive overview of S100B, neuronal-specific enolase, metalloproteinases, and UCH-L1 in the perioperative period.

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Background: The optimal postoperative analgesic regimen for HPB surgery patients remains controversial. The primary objective of this single-center randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient controlled analgesia (PCA) for adequacy of pain control over the first 48 hours after surgery. Methods: Using a 2.5:1 randomization strategy, 140 patients undergoing HPB resections were randomized to TEA (N = 106) or PCA (N = 34). Patient-reported pain was measured on a Likert scale (0-10) at standard time intervals. Cumulative pain area under the curve (AUC) was determined using the trapezoidal method. Results: Demographic, comorbidity, clinical and operative variables, including incision type, operative time, EBL and postoperative drain placement were equivalent. The median AUC of the postoperative pain scores was significantly lower in the TEA group (81.15 vs 109.6, p = 0.029) with a 35% reduction in patients with pain episodes > = 7/ 10 (43% vs 66%, p = 0.05). Anesthesia related events were comparable (10.4% vs 3.1%, p = 0.29). Grade > = 3 surgical complications occurred in 7 TEA group patients (6.6%) and 3 PCA group patients (9.4%, p = 0.7). Median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the OR (0.9 vs 3.1%) were similar (all p > 0.05). There were no mortalities. Conclusion: In major HPB surgery, TEA provides a superior patient experience through improved pain control without increased length of stay or complications.

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Objective: To determine the optimal perioperative care strategy for hepatectomy patients by measuring patient reported outcomes. Methods: One-hundred seventy-four patients with liver malignancy were administered a validated patient reported outcomes tool before and after hepatectomy to assess symptom scores (core and GI-specific symptoms) and life interference ratings. The median age was 56 years (range: 22e98 yrs), 54% were male, and 94% were ASA score 3. 51 patients (29%) had 4 liver segments resected and 51 patients (29%) were operated with a minimally-invasive approach. Anesthetic approaches included epidural (94 pts, 54%), TAP block (63 pts, 36%), non-narcotic intraoperative IV analgesia (36 pts, 21%) and enhanced recovery protocol (ERP, 123 pts, 71%), consisting of nonnarcotic oral analgesia, early feeding and early ambulation. Results: The median length of hospital stay was 5 days (range: 1e19 days), with 11 patients (6%) experiencing major complications, including 1 patient (0.6%) with liver failure and 5 patients (3%) with postoperative bile leak. Within 90 days of surgery, 3 patients required reoperation, 3 were readmitted and there were no mortalities. In multivariate analysis, return to baseline for core symptoms was associated with LOS <6 days (OR: 2.78, p = 0.004) and absence of complications (OR: 2.63, p = 0.007), return of GI function was only associated with smaller magnitude of surgery (OR: 5.1, p = 0.001), and return to overall functional status was associated with absence of complications (OR: 2.32, p = 0.03) and ERP-directed care (OR: 2.29, p = 0.04). Conclusion: Independent of surgical approach and perioperative anesthetic technique, patients report that the strongest predictor of rapid return to normal function after hepatectomy is management on an enhanced recovery protocol.