Abdominal aortic aneurysm treatment: minimally invasive fast-track surgery and endovascular technique.

In our department we started a program in order to offer a mini-invasive approach to all patients affected by abdominal aortic aneurysms (AAAs), trying to offer this option also to patients not eligible for endovascular aneurysm repair (EVAR) due to unfavorable anatomy, age under 65 years and aorto-iliac occlusive disease, considering nowadays EVAR is the gold-standard for the mini-invasive treatment of AAAs. The aim of this study was to compare endovascular versus fast-track surgical treatment in patients undergoing elective surgery for AAAs. We wanted to verify if it was possible to be totally mini-invasive in the treatment of AAAs. A total of 128 patients were chosen for the study. Ninety-four patients were enrolled in the OPEN group and 34 were enrolled in the EVAR group. This study demonstrates that minimally invasive treatment with the fast-track protocol may be a valid alternative to EVAR.

Worsening of chronic pain: the treatment.

Chronic pain is a symptom that inevitably goes along with a condition of critical ischemia of the lower limbs, termed also as "obstructive peripheral arteriopathy". This sometimes displays worsening, provoking difficult physical and psychological behaviors of the patients. The complexity of this kind of patients results in difficulties in their clinical management. A multidisciplinary team, namely the close and coordinated collaboration of various kinds of professionists, could give better results, than an individual approach, thanks to strategies of re-equilibrating the systemic homeostasis of the given patient.

Psychological aspects of pain.

The patients affected by critical limb ischemia (CLI) are patients generally considered difficult cases, destined to repeated approach to the sanitary structures. They are patients affected by many pathologies since years, that they know to be potentially lethal often have already faced many interventions, with partial and not long-lasting benefits, they go from one specialist to another and sometimes they entrust themselves to alternative medicine. Physicians have to take in charge not the pathology but to take in charge the patient. For the control of the pain it turns out essential, near the block of the perception of the pain, to act with psychological participation, in order to interfere with the perception of the pain and the meant one of the pain, modify the feelings associated to the pain, modify the behavior induced by pain.

Mininvasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach.

AIM: Clinical experience in gastrointestinal surgery demonstrated that a multimodal approach can improve the outcome and reduce the length of hospital stay. In this paper we investigate the impact of a multimodal clinical program, based on mininvasive surgery, epidural anesthesia and early feeding and mobilization, on postoperative morbidity and hospitalization after abdominal aortic surgery. METHODS: A 2-armed study was designed. All patients undergoing abdominal aortic surgery between May 2000 and April 2001 were enrolled in a multidisciplinary clinical program including thoracic epidural anesthesia and analgesia, left sub-costal minilaparotomy without evisceration, encouragement to feed and mobilize soon after surgery (Multidisciplinary group: n=82). For comparison purposes, a retrospective analysis was conducted using the data of all patients operated on between January and December 1997, receiving standard anesthesia care and a standard surgical and nursing program (Standard group: n=64). RESULTS: In the Multidisciplinary group we observed significantly better pain relief (p<0.01), earlier restoration of ambulation (p<0.01), earlier feeding (p<0.01) and passage of stools (p<0.01). The incidence of complications was significantly lower in the Multidisciplinary group: pulmonary (0% vs 14.1%), cardiac (2.4% vs 9.4% ) and gastrointestinal (0% vs 10.9%). None of the patients in the Multidisciplinary group required admission to Intensive Care. Median postoperative hospitalization was 3 days in the Multidisciplinary group compared to 9 days in the Standard group (p<0.01). CONCLUSION: These results suggest that a multidisciplinary intervention with review of the traditional surgical care program would enhance recovery, decrease morbidity and hospitalization after abdominal aortic surgery.

[Fast track in abdominal aortic surgery]. / Fast track in chirurgia dellaorta addominale.

BACKGROUND: The aim of this work is to evaluate the efficacy of a new perioperative approach to improve the outcome and to reduce hospitalisation after abdominal aortic surgery. EXPERIMENTAL DESIGN: observational study on patients operated from October 1996 to October 1997 (Group 1996), and from November 1997 to November 1998 (group 1998). CENTRE: Anaesthesiology Department of Regional Hospital. PATIENTS: historical group: 56 patients surgically treated with abdominal aortic bypass in 1996. CASE CONTROL GROUP: 58 patients surgically treated with abdominal aortic bypass in 1998. INTERVENTION: group 1996: maintenance of anaesthesia with forane and fentanyl; postoperative infusion of mepivacaine 1% through lumbar epidural catheter. GROUP 1998: preoperative anaesthesia through thoracic (T 4) epidural catheter with infusion of bupivacaine 0.5%; maintenance of anaesthesia with propofol, fentanyl and infusion of bupivacaine 0.125%; postoperative infusion of bupivacaine 0.125%, early rehabilitation care (early removal of nasogastric tube and urinary catheter, early deambulation, feeding and physiotherapy). EVALUATION: analgesia efficacy, day of deambulation, day of removal of the urinary catheter and the nasogastric tube, day of bowel canalization, day of discharge, major complications. RESULTS: In group 1998 analgesia was better. Furthermore a significant improvement consisted in the earlier removal of the nasogastric tube and the urinary catheter, earlier return of the gastrointestinal function and earlier deambulation. The length of stay is significantly reduced. In group 1998 we have less complications. CONCLUSIONS: Total intra-venous anaesthesia associated with a thoracic epidural anaesthesia, connected with early rehabilitation may improve the outcome and reduce the length of stay in patients submitted to abdominal aortic surgery.

Regional anaesthesia in vascular surgery: a multidisciplinary approach to accelerate recovery and postoperative discharge.

A multimodal, rehabilitative, fast discharge approach to abdominal aortic surgery is analyzed. The approach was developed in two phases during the years 1997-2000: in the first phase (1997) patients had thoracic epidural anesthesia plus TIVA and analgesia. They had improvement of the classical surrogate outcomes and analgesia: pain relief, nasogastric tube withdrawal, mobilization, ileus, hospital length of stay were significantly (p< 0,01) improved when compared to a historical, standard management group (1996: general anesthesia or lumbar epidural anesthesia plus general anesthesia with gas). In the second phase we started a more aggressive perioperative approach based on thoracic epidural anesthesia plus general anesthesia with gas and spontaneous breathing and postoperative epidural analgesia, left subcostal minilaparotomy incisions, aggressive postoperative nursing and pain relief on the ward. Preliminary results on 44 patients show no mortality, low postoperative morbility (cardiac complications 2,2%, peripheral embolization 2,2%, no pulmonary complications), no ICU stay and fast hospital discharge (median: 3,5 days, range: 2-8 days) without complications. We conclude that preliminary data support the safety and the need for further improvement of a multimodal, aggressive rehabilitative approach in abdominal vascular surgery.

[The effect on breastfeeding rate of regional anesthesia technique for cesarean and vaginal childbirth]. / Influenza sulla frequenza di allattamento al seno delle tecniche di anestesia regionale nel parto cesareo e nel parto per via vaginale.

BACKGROUND: To evaluate the influence of regional techniques of anesthesia and analgesia on breastfeeding rate after cesarean section and vaginal delivery. STUDY DESIGN: prospective, area-based. SETTING: Obstetrics and Pediatrics Department at Aosta Valley Regional Hospital. SUBJECTS: all the mothers and their newborns during a three-year period (1993-1995). Maternal wish to breastfeed was the main inclusion criterion. Data recorded: feeding modality at discharge, anesthesia and analgesia modality, maternal/neonatal socio-demographic and clinical data. RESULTS: 2725 records were examined, among them 1920 vaginal deliveries and 355 cesarean sections were statistically analyzed. chi 2 analysis showed a significant greater incidence of breastfeeding after cesarean section under regional anesthesia (spinal or epidural) versus general anesthesia: 95% vs 85.5%, p = 0.002. Breastfeeding rate was not different after vaginal delivery with epidural analgesia versus delivery without analgesia: 96.5% vs 97.8%. Logistic regression confirmed the positive role of regional anesthesia and few other maternal and neonatal variables on breastfeeding rate after cesarean section. CONCLUSIONS: Regional anesthesia seems to be advantageous for breastfeeding after cesarean section, probably because of a faster neonatal-maternal bonding if compared with general anesthesia. Epidural analgesia for vaginal delivery does not adversely affects breastfeeding if compared with delivery without analgesia.

[Peridural anesthesia versus subarachnoid anesthesia in cesarean section. Prospective clinical study]. / Anestesia peridurale versus anestesia subaracnoidea nel parto cesareo. Studio clinico prospettico.

OBJECTIVE: To compare technical and clinical differences between epidural and spinal anesthesia for cesarean section. STUDY DESIGN: Randomized prospective trial. PATIENTS AND METHODS: 64 pregnant women at term scheduled for elective cesarean section. Two groups were randomized: A) PD Group (n = 32): continuous epidural anesthesia by administration of bupivacaine 0.5% plus epinephrine 1/400,000 via an epidural catheter. Epidural morphine 3 mg was administered at the end of surgery. B) SP Group (n = 32): "single shot" spinal anesthesia by intrathecal administration of hyperbaric 1% bupivacaine 1-1.4 ml plus morphine 0.2 mg. The pin prick block level reached T2-T6 at incision time. DATA COLLECTION: 1) Time from the beginning of anesthesia to surgical incision. 2) Hypotension episodes. 3) Ephedrine consumption. 4) Intraoperative discomfort at delivery, traction and uterine manipulation, peritoneal toilette. 5) Nausea and vomiting. 6) Apgar score. 7) Postoperative headache. RESULTS: Women in the SP group had more hypotensive episodes (81% vs 53%: p < 0.05) and more ephedrine consumption with a large individual variability (29.12 mg +/- 20.4 vs 12.83 +/- 13.8: p < 0.01) when compared to PD group, without any difference in the Apgar score. The SP group required less time consumption (10.5 min. +/- 6.7 vs 35.9 min. +/- 17.3: p < 0.01) and had less intraoperative discomfort with less analgesic and/or sedative drugs consumption (9.7% vs 29%: p < 0.05) and less vomiting (3% vs 22.5%: p < 0.05). No postoperative headache was noticed in both groups. CONCLUSIONS: With the described pharmacological and technical approach, spinal anesthesia is more suitable than continuous epidural technique for cesarean section, unless contraindicated.