Continuous intravenous analgesia with fentanyl or morphine after gynecological surgery: a cohort study.

PURPOSE: This retrospective study aims to compare postoperative pain relief offered by continuous intravenous infusion of either fentanyl or morphine. METHODS: Sixty American Society of Anesthesiologists Physical Status I and II women who had undergone open gynecological surgery were enrolled. All patients received total intravenous postoperative analgesia for 24 h with continuous infusion of either fentanyl or morphine at comparable doses (38 patients received 0.3 µg/kg/h fentanyl and 22 received 0.02 mg/kg/h morphine). The primary endpoint was the need for analgesic rescue therapy during the postoperative period as assessed by an experienced nurse blinded to the design of the study, while the time to gastrointestinal bowel recovery was the main safety outcome measure. Visual analog scale was used to evaluate postoperative pain. Ramsay sedation score, multiparametric monitoring, bowel function and adverse effects were also recorded at 1, 6, 12, 18 and 24 h after the end of surgery. RESULTS: Data analysis showed that four patients (10 %) in the fentanyl group versus eight patients (36 %) in the morphine group needed to be treated with analgesic rescue drugs [unadjusted OR for fentanyl 0.2 (0.05-0.80); p = 0.02]. Patients treated with fentanyl showed a faster gastrointestinal recovery [1 (1-2) vs 3 (2.7-4) days; p < 0.001] and a shorter hospital length of stay [4 (3-5) vs 5.5 (5-7.2) days; p < 0.001]. CONCLUSION: In low-risk patients undergoing open gynecological surgery, continuous intravenous infusion of both fentanyl and morphine for postoperative pain relief is effective. In our cohort of patients, continuous intravenous infusion of fentanyl was associated with lower need for analgesic rescue drug, faster bowel recovery and shorter hospital length of stay.

Case Scenario: Perioperative Management of a Young Woman with Fontan Repair for Major Gynecologic Surgery.

Effective treatment for many congenital heart diseases diagnosed before birth has become available since the last three decades. Continuous improvements in surgical knowledge and techniques have allowed patients born with severe heart defects to survive through adulthood. However, palliative surgery often implies profound modifications of classical circulatory physiology, which must be taken into account particularly when general anesthesia is needed for major noncardiac surgery. Among the palliative surgeries, Fontan repair is an intervention aiming at excluding the right heart chambers with a total cavopulmonary conduit, which directs blood flow from both inferior and superior vena cavae directly to the right pulmonary artery. In such condition, patients are very sensitive to both preload reduction and pulmonary vascular resistances increase, so that a careful monitoring during anesthesia is required. Unfortunately, standard monitoring with a pulmonary artery catheter is not possible because of altered anatomy of right sections. In this case scenario, the authors report the perioperative management of a young woman who underwent major gynecologic surgery, who was managed using a transpulmonary thermodilution technique that was deemed more accurate than noncalibrated pulse-contour method and also able to provide more information regarding preload status. The authors adopted an integrated approach merging together hemodynamic and functional data (ScvO2 and venoarterial CO2 difference) to assess the appropriateness of hemodynamic management. The authors describe also pathophysiologic changes during such condition and also potential drawbacks of chosen technique.

Laparoendoscopic single-site surgery for the treatment of benign adnexal diseases: a pilot study.

BACKGROUND: This study aimed to validate the feasibility, efficacy, and safeness of laparoscopic treatment for benign adnexal diseases through a single transumbilical access in a prospective series of patients. METHODS: A prospective clinical trial including 30 women was conducted in our teaching and research division. Patients underwent different laparoscopic procedures by the laparoendoscopic single-site (LESS) approach using a multiport trocar, conventional laparoscopic instrumentation, and standardized surgical technique, with evaluation of the multiaccess conversion rate. RESULTS: The patients underwent different laparoscopic procedures (10 bilateral adnexectomies; 22 cystectomies, and 3 chromosalpingographies) by the LESS approach using a multiport trocar and conventional laparoscopic instrumentation with standardization of this innovative minimally invasive technique. The laparoscopic procedures were completed through a single access in 28 cases (93.4%). In two cases, at the end of the intervention, hemostasis required one additional sovra-pubic access. No major intra- or postoperative complications were observed. The mean hospital stay was 1.3 days. CONCLUSIONS: The results of this study suggest the feasibility of the LESS approach in gynecologic surgery with a low conversion rate for multi-access laparoscopy, a rapid learning curve, limited complications, and good results in terms of cosmesis and postoperative pain. More clinical data are needed to confirm these advantages over standard laparoscopic technique.

Diastolic function: the influence of pneumoperitoneum and Trendelenburg positioning during laparoscopic hysterectomy.

BACKGROUND AND OBJECTIVE: Several reports concerning the haemodynamic changes during gynaecologic laparoscopy have been published so far, and the effects of head-down tilt and pneumoperitoneum have not been clearly separated. However, its main effect seems to be an increase in systemic vascular resistance. We investigated how the augmented afterload can affect diastolic function. METHODS: : Our study involved 20 healthy women, classified as having ASA status I: 10 undergoing laparoscopic hysterectomy and 10 undergoing conventional open hysterectomy. Measurements were made in awake patients and after induction of anaesthesia and then repeated after carbon dioxide insufflation and head-down positioning and at the end of surgery. Diastolic function was primarily studied by transthoracic echocardiography. RESULTS: We observed that pneumoperitoneum caused a significant reduction in stroke volume, cardiac output and left ventricular end-diastolic volume; the diastolic filling times showed a progressive reduction in the E-velocity (the velocity of early mitral inflow, corresponding to the ventricular passive filling phase, measured by pulsed-wave Doppler), a prolonged deceleration time and an augmented isovolumetric relaxation time. After head-down tilting, stroke volume, cardiac output and left ventricular end-diastolic volume increased in both laparoscopic hysterectomy and conventional open hysterectomy groups. CONCLUSION: We have found that pneumoperitoneum has important effects on left ventricular volumes, causing a drop in left ventricular end-diastolic volume; it also affects diastolic function with a delay in deceleration time and isovolumetric relaxation time without any effects on intracavitary pressures.

Minilaparotomy in the management of benign gynecologic disease.

BACKGROUND: Considering the enormous advantages of minimally invasive surgery, attempts to explore less invasive trans-abdominal incisions could represent an alternative to laparoscopic gynecologic surgery. The aim of this study was to assess the feasibility and clinical outcome of minilaparotomy in a large series of patients. METHODS: In this retrospective study we describe our 6-year experience on 252 patients undergoing surgery by minilaparotomy for benign adnexal or uterine disease. Surgical treatments included total abdominal hysterectomy, myomectomy, mono or bilateral salpingo-oophorectomy and adnexal surgery. RESULTS: The mean population age and BMI were 39.2 years (+/-13.2 S.D.) and 23.6 (+/-3.31 S.D.), respectively. The mean operative time was 75.4 min (+/-31.8) and the estimated blood loss was never significant except in two cases (0.8%). The mean duration of ileus was 1.58 days (+/-0.6 S.D.) and the mean days until discharge were 3.06 (+/-1.14 S.D.), with a significantly lower duration of recovery in the group of simple adnexal surgery with respect to the others (p = 0.0001). No severe early post-operative morbidity was observed. CONCLUSIONS: The current report describes minilaparotomy as a feasible surgical approach in benign gynecological diseases. The operative time is quite similar or shorter than reported for laparoscopy, laparotomy and vaginal surgery. The estimated blood loss is not significant as well as the duration of the ileus and discharge. Moreover, a prospective randomised study, already ongoing in our department, will better answer the question of whether minilaparotomy could be an alternative to laparoscopic and vaginal surgery.

Positive end-expiratory pressure during laparoscopy: cardiac and respiratory effects.

STUDY OBJECTIVE: To determine the effect of positive end-expiratory pressure (PEEP) on the respiratory system and on cardiac function. DESIGN: Prospective randomized study. SETTING: Operating room. PATIENTS: 60 ASA physical status 1 women scheduled for pelvic laparoscopic surgery. INTERVENTIONS: Patients were ventilated normally during surgery; PEEP was modified depending on patient group allocation. Group A was the control group and did not receive PEEP. Group B received PEEP 5 cmH2O and Group C received PEEP 10 cmH2O. MEASUREMENTS: Respiratory parameters measured were partial pressure of arterial oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), and end-tidal carbon dioxide tension (ETCO2). Cardiac parameters measured were left ventricular end-diastolic volume index (LVEDVI), ie, ratio of LVEDV/body surface area (BSA; [LVEDVI = end-diastolic volume [EDV]/BSA); left ventricular (LV) systolic function, tricuspid annular plane systolic excursion (TAPSE), right ventricular (RV) fractional area change (FAC), RV dimensions in the apical 4-chamber view, tracing basal and mid-cavity minor dimensions and longitudinal dimension, cardiac index, systolic pulmonary artery pressure (PASP), and systolic RV pressure (RVSP). Respiratory and cardiac measurements were recorded at T0 (baseline); T1 (after anesthesia induction, before pneumoperitoneum induction); at 10 (T2), 20 (T3), and 30 (T4) minutes after CO2 insufflation; and at the end of surgery (T5). MAIN RESULTS: Ventilation with PEEP at 10 cm H2O led to significant improvement in both respiratory and cardiac parameters. A reduction in pulmonary vascular resistance and enhanced washout of expiratory CO2 occurred. Ten and, to a lesser extent, 5 cm H2O of PEEP decreased LV stroke work. CONCLUSIONS: Ventilation with PEEP (up to 10 cm H2O) recruits the hypoventilated areas of the lungs and reduces cardiac afterload.

Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: a randomized trial.

OBJECTIVE: To compare postoperative pain after laparoendoscopic single-site surgery (LESS) approach with conventional multiaccess laparoscopy (LPS). STUDY DESIGN: Prospective randomized trial. SETTING: University hospital. PATIENT(S): Benign adnexal disease. INTERVENTION(S): Postoperative pain was measured by using the visual analog scale (VAS) at 20 minutes, 2 hours, 4 hours, and 8 hours after surgery. The need for postoperative rescue doses of analgesia was also recorded. MAIN OUTCOME MEASURE(S): Pain after surgery. RESULT(S): A total of 60 patients were enrolled. Within 8 hours, patients who underwent conventional LPS complained of statistically significant greater postoperative pain at VAS evaluation than those undergoing LESS, both at rest and after Valsalva maneuver, with a higher need for rescue analgesia. CONCLUSION(S): LESS provides an advantage over conventional multiaccess LPS in terms of postoperative pain and need for rescue analgesia, with similar perioperative outcomes.

Neuroendocrine stress response in gynecological laparoscopy: TIVA with propofol versus sevoflurane anesthesia.

STUDY OBJECTIVE: To compare intraoperative and postoperative neuroendocrine stress responses during total intravenous anesthesia (TIVA) using propofol and remifentanil versus sevoflurane anesthesia, during laparoscopic surgery. DESIGN: Prospective, randomized study. SETTING: Tertiary-care university hospital. PATIENTS: 46 ASA physical status I patients undergoing laparoscopic surgery for benign ovarian cysts. INTERVENTION: Patients were randomly allocated to two groups to receive either TIVA (Group A=23) or sevoflurane anesthesia (Group B=23). MEASUREMENTS: Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH), prolactin (PRL), and thyroid hormones (TSH, FT3, FT4) were measured. Blood samples were collected preoperatively, 30 minutes after the beginning of surgery, after extubation, and two and 4 hours after the end of surgery (times 0, 1, 2, 3, and 4). MAIN RESULTS: In Group A, perioperative levels of NE, E, ACTH, cortisol, and GH compared with preoperative values significantly decreased; in Group B they increased (Groups A vs. B: time 1, P<0.001 for all markers; time 2, P<0.001 for E, ACTH, cortisol, and GH; time 3, P<0.01 for cortisol, NE, and E, and P<0.05 for ACTH and GH). Perioperative PRL levels were significantly enhanced in both groups versus preoperative values. In both groups, TSH levels increased while FT3 levels decreased significantly relative to basal values. In both groups, perioperative FT4 levels significantly increased compared with preoperative values. CONCLUSIONS: TIVA inhibited the ACTH-cortisol axis and reduced NE, E, and GH levels, but it enhanced PRL and had a weak effect on thyroid hormone concentrations as compared to sevoflurane anesthesia.

Management of adnexal cystic masses with unexpected intracystic vegetations detected during laparoscopy.

STUDY OBJECTIVE: To evaluate a prospective series of consecutive patients with unexpected intracystic vegetations detected during operative laparoscopy for adnexal masses. DESIGN: Prospective series of consecutive patients (Canadian Task Force classification: II-2). SETTING: Tertiary care university hospitals. PATIENTS: Consecutive patients found during surgery to have unexpected intracystic vegetations and treated by operative laparoscopy, out of a total series of 667 patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillarities, or solid components. INTERVENTIONS: Operative laparoscopy and follow-up. MEASUREMENTS AND MAIN RESULTS: Thirty-five (5.2%) of 667 patients were found at surgery to have unexpected intracystic vegetations. A frozen section was sent for pathologic analysis in all 35 patients. Frozen section diagnosis was benign in 32 patients and borderline in 3 patients. Final pathology diagnosis was borderline ovarian tumor in five of the 35 patients (14.3%), and benign in 30 patients (85.7%). No case of invasive carcinoma was diagnosed either at frozen section or at final pathology examination. The patients with borderline tumors are alive with no evidence of disease after a mean follow-up of 60 months. CONCLUSIONS: In the present series, with accurate preoperative selection, the rate of adnexal cysts with unexpected intracystic vegetations was 5%, of which 14% were borderline tumors. The laparoscopic management of these adnexal masses did not adversely affect the prognosis.

Perioperative morbidity and mortality in elderly gynecological oncological patients (>/= 70 Years) by the American Society of Anesthesiologists physical status classes.

BACKGROUND: We evaluated the morbidity and mortality associated with American Society of Anesthesiologists (ASA) classes III and IV versus ASA classes I and II in elderly women (>/= 70 years) undergoing gynecological oncological surgery. METHODS: From 1986 to 2000, we retrospectively collected patients >/= 70 years of age undergoing oncological gynecological surgery. The study population consisted of 121 ASA class III and IV patients. The control group consisted of the same number of patients with ASA classes I and II, and these were matched to study patients (1:1) by clinical and surgical data. The morbidity and mortality of patients with ASA status III and IV were analyzed before and after 1992. RESULTS: In ASA class III and IV patients, compared with ASA class I and II, a higher rate of severe morbidity (P =.000) occurred, whereas the median postoperative stay was similar (8 days). No differences between patients with ASA class III and IV and ASA class I and II for median operative time, transfusion rate, or median blood loss were found. Mortality was 3% in ASA classes III and IV. CONCLUSIONS: Our study suggests that surgery in elderly gynecological oncological patients aged >/= 70 years with ASA class III or IV results in an acceptable perioperative morbidity and mortality rate.

Laparoscopic excision of adnexal masses.

STUDY OBJECTIVE: The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria. DESIGN: Prospective series of consecutive patients (Canadian Task Force classification II-2). SETTING: Tertiary care university hospitals. PATIENTS: Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid. INTERVENTIONS: Operative laparoscopy and follow-up. MEASUREMENTS AND MAIN RESULTS: After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months. CONCLUSIONS: In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.

Neuroendocrine stress response in patients undergoing benign ovarian cyst surgery by laparoscopy, minilaparotomy, and laparotomy.

STUDY OBJECTIVE: To quantify and compare neuroendocrine stress responses during and immediately after surgery by laparoscopy, minilaparotomy, and laparotomy for benign ovarian cysts. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: Tertiary care university hospital. PATIENTS: Thirty healthy women with no major diseases and without endocrine disorders. INTERVENTIONS: Surgery for benign ovarian cysts performed by laparoscopy (10), minilaparotomy (10), or laparotomy (10). MEASUREMENTS AND MAIN RESULTS: Venous blood samples were collected at fixed times as follows: at 8 A.M. in the ward before transferring the patient to the operating room (time 0), 30 minutes after the beginning of surgery (time 1), at the end of surgery after extubation with the patient awake (time 2), and 2 and 4 hours after the end of surgery (times 3 and 4). We evaluated intraoperative and postoperative variations of the following stress-related markers: norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), human growth hormone (hGH), prolactin (PRL), and cortisol, and postoperative pain. No differences were present in demographic characteristics and operating times in the three groups. No anesthesiologic or surgical complications occurred. Postoperative pain was similar in the laparoscopy and minilaparotomy group but significantly higher in the laparotomy group (p <0.001). Serum levels of markers were not significantly different among the groups at baseline. In the laparoscopy group the increase of hGH was limited to intraoperative time (p <0.05); increases in NE, E, ACTH, and PRL were limited to intraoperative and early postoperative time after extubation (p <0.01), with only PRL persisting with significantly higher levels after the end of surgery (p <0.05). In the minilaparotomy group no increase was detected for hGH, a significant intraoperative increase in cortisol was present (p <0.05), and NE, E, ACTH, and PRL were significantly higher even after the end of surgery (p <0.01). In this group levels of NE, E, and hGH were significantly higher than in the laparoscopy group 2 and 4 hours after the end of surgery (p <0.05). In the laparotomy group significant intraoperative increases were present for all stress markers and persisted until after extubation for ACTH (p <0.01) and to the postoperative period for NE (p <0.01), E (p <0.01), cortisol (p <0.01), PRL (p <0.05), and hGH (p <0.01). In this group levels of NE, E, ACTH, and hGH were significantly higher than those in the laparoscopy group from the beginning (NE p <0.05, E p <0.01, ACTH p <0.05, hGH p <0.01) until after the end of surgery. Comparison of laparotomy and minilaparotomy groups showed the former to have significantly higher plasma levels of E, cortisol, and hGH in intraoperative and postoperative times (p <0.001); significantly higher NE at sampling times 1 and 2 (p <0.001) and time 4 (p <0.01), and no difference at sampling time 3; and ACTH significantly higher only during surgery (p <0.01). CONCLUSION: Laparoscopic surgery causes minimal activation of stress hormones, which in some instances is confined to the intraoperative period. Minilaparotomy may be a valid alternative to laparoscopy in high-risk patients who cannot tolerate abdominal distention.

Sevoflurane improves the neuroendocrine stress response during laparoscopic pelvic surgery.

PURPOSE: Stress response to surgery is modulated by several factors, including magnitude of the injury, type of procedure (e.g., laparoscopy vs laparotomy) and type of anesthesia. Our purpose was to compare intra- and postoperative hormonal changes during isoflurane vs sevoflurane anesthesia, in a clinical model of well defined operative stress (laparoscopic pelvic surgery). METHOD: In this prospective randomized clinical study, 20 women requiring laparoscopic pelvic surgery for benign ovarian cysts received either a standard isoflurane plus fentanyl (Group A) or sevoflurane plus fentanyl anesthesia (Group B). Blood samples were collected preoperatively, 30 min after the beginning of surgery, at the end of surgery after extubation, and two and four hours after the end of surgery. Intra- and postoperative plasma levels of norepinephrine, epinephrine, adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH) and prolactin (PRL) were measured. RESULTS: Catecholamine levels and postoperative pain were similar in both groups. Nonetheless, in comparison to Group A, Group B showed a significant decrease of ACTH, cortisol and GH levels (A vs B at the end of surgery: ACTH 160 +/- 45 vs 100 +/- 40 pg.mL(-1); cortisol 45 +/- 8 vs 23 +/- 7 microg.dL(-1); GH 3 +/- 2 vs 0.8 +/- 0.4 ng.mL(-1); P < 0.001 for all), but enhanced PRL levels (A vs B, at 30 min after the beginning of surgery: 139 +/- 54 vs 185 +/- 22 ng.mL(-1); at the end of surgery: 100 +/- 27 vs 141 +/- 45 ng.mL(-1); P < 0.001 for both). CONCLUSIONS: In the clinical setting of low stress laparoscopic surgery, the type of volatile anesthetic significantly affected the stress response; the changes associated with sevoflurane suggested a more favourable metabolic and immune response compared to isoflurane.