Interdisciplinary Laparoscopic Implantation of Neuromodulation Leads to the Sacral Plexus for Therapy of Chronic Pelvic Pain and Neurogenic Bladder Dysfunctions.

OBJECTIVE: The aim of this study was to report on the use of laparoscopic implantation of leads on the branches of the sacral plexus for neuromodulation in the treatment of chronic pelvic pain (CPP) in a multidisciplinary setting with the help of electrophysiological neuromonitoring. MATERIALS AND METHODS: Between 2012 and 2019, six female patients complaining of chronic pain and bladder and bowel dysfunctions underwent laparoscopic exposure and nerve identification with the help of electrophysiological neuromonitoring. A lead was placed laparoscopically in direct contact with the affected nerve. Pain intensity (numerous ranking scale [NRS]), generic health status (EQ-5D-5L), Becks Depressions Inventory (BDI-V), Pain Catastrophizing Scale (PCS), and Client Satisfaction Questionnaire (CSQ-8) were assessed pre-/postoperatively as well as three and six months after surgery. Statistical analysis was performed using Mann-Whitney U and Wilcoxon rank-sum test. RESULTS: The median age was 36.5 years. NRS improved from a median of 9.5 preoperatively to 3.0 (p < 0.001) at six-month follow-up. Median EQ-5D-5L index value before treatment was 0.18, indicating a notably lowered quality of life and increased up to 0.83 after six months (p < 0.001). Preoperative median BDI-V scores indicated a major depressive mood and improved from a median of 46.0 to 12.0 after six months (p = 0.007). Preoperative PCS was elevated with a median score of 41.0 and decreased to 4.0 after six months (p < 0.001). CSQ showed that patients were satisfied with the treatment. CONCLUSIONS: This unique method is an alternative and effective treatment option for CPP even years after primary endometriosis surgery.

Evaluation of pulse wave transit time analysis for non-invasive cardiac output quantification in pregnant patients.

Pregnant patients undergoing minimally-invasive foetoscopic surgery for foetal spina bifida have a need to be subjected to advanced haemodynamic monitoring. This observational study compares cardiac output as measured by transpulmonary thermodilution monitoring with the results of non-invasive estimated continuous cardiac output monitoring. Transpulmonary thermodilution-based pulse contour analysis was performed for usual anaesthetic care, while non-invasive estimated continuous cardiac output monitoring data were additionally recorded. Thirty-five patients were enrolled, resulting in 199 measurement time points. Cardiac output measurements of the non-invasive estimated continuous cardiac output monitoring showed a weak correlation with the corresponding thermodilution measurements (correlation coefficient: 0.44, R2: 0.19; non-invasive estimated continuous cardiac output: 7.4 [6.2-8.1]; thermodilution cardiac output: 8.9 [7.8-9.8]; p ≤ 0.001), while cardiac index experienced no such correlation. Furthermore, neither stroke volume nor stroke volume index correlated with the corresponding thermodilution-based data. Even though non-invasive estimated continuous cardiac output monitoring consistently underestimated the corresponding thermodilution parameters, no trend analysis was achievable. Summarizing, we cannot suggest the use of non-invasive estimated continuous cardiac output monitoring as an alternative to transpulmonary thermodilution for cardiac output monitoring in pregnant patients undergoing minimally-invasive foetoscopic surgery for spina bifida.

Partial amniotic carbon dioxide insufflation (PACI) during minimally invasive fetoscopic interventions on fetuses with spina bifida aperta.

BACKGROUND: Percutaneous partial amniotic carbon dioxide insufflation (PACI) is one of the most important means for improving visualization during minimally invasive fetoscopic surgery of fetal spina bifida. The purpose of the present study was to analyze maternal and fetal safety aspects of PACI in a recent patient cohort and to present management improvements. METHODS: PACI under general materno-fetal anesthesia was performed during 65 interventions for fetoscopic patch coverage of fetal spina bifida aperta between 21 + 0 and 29 + 1 weeks of gestation. Filtered carbon dioxide was insufflated into the amniotic cavity via three percutaneously introduced trocars. Maternal ventilatory and hemodynamic parameters during PACI as well as insufflation pressures, BMI, parity, and placental position were recorded and statistically analyzed in order to detect potential risk groups. RESULTS: Maternal respiration parameters during PACI showed a typical variation over time, which was similar in patients with BMI ≤ 25 or BMI > 25. The necessary insufflation pressures were significantly higher in nulliparae than multiparae. There was no statistically significant relationship between insufflation pressure and maternal BMI, or between the expired maternal carbon dioxide concentration (etCO2) and the placental position. PACI was safe for all mothers and fetuses. Postnatal demise in one neonate, one fetus, and two infants occurred unrelated to PACI and resulted from trisomy 13, infection, and severe Chiari II malformations, respectively. CONCLUSION: PACI seems safe in order to improve visualization of intraamniotic contents during minimally invasive fetoscopic surgery. Nevertheless, continued assessments of its benefits and risks are important.

Geburtshilfe: Anästhesie bei fetaler Chirurgie.

Due to the responsibility for the mother and the unborn child, fetal surgery represents a challenging task for the anesthesiologist. Maternal changes during pregnancy have to be considered as well as the fetal physiology and the surgeon's needs. Main principles of the anesthesiological management of fetal surgery include the stabilization of the mean arterial pressure in order to preserve a sufficient placental blood flow, sustainment of an adequate oxygenation and ventilation as well as thorough temperature surveillance. Since the mothers are at risk for perioperative pulmonary edema, extended hemodynamic monitoring might be necessary. This article presents the principles of fetal surgery, informs about pregnancy-related changes in circulatory and respiratory physiology and contains anesthesiological considerations to this topic.

Laryngeal mask airway versus endotracheal tube for outpatient surgery: analysis of anesthesia-controlled time.

STUDY OBJECTIVE: To show that efficiency of operating room times can be improved significantly using rapid changes between operative procedures. DESIGN: Randomized, prospective clinical study. SETTING: Tertiary care university hospital, elective peripheral trauma-related orthopedic surgery. PATIENTS: 72 adult, ASA physical status I, II, and III patients scheduled for elective peripheral trauma-related orthopedic surgery requiring general anesthesia. INTERVENTIONS: Patient airways were managed using either a Laryngeal Mask Airway (LMA) or an endotracheal tube (ETT) in the hands of anesthesiologists experienced in both. They were not informed as to the primary intention of the study. All perioperative data, including the preoperative and postoperative outpatient stay at the outpatient surgical ward, were recorded with an anesthesia information management system. MEASUREMENTS: The primary outcome measures were: time needed for anesthesia induction and emergence from anesthesia. All manual recording into the anesthesia information management system during anesthesia was accomplished by nurses who were uninformed as to the aim of the study. MAIN RESULTS: Anesthesia induction was significantly (p < 0.01) shorter using LMAs (means +/- SD, medians, [interquartile ranges]) (LMA: 5.8 +/- 1.5, 5, [5;7] vs. ETT: 7.4 +/- 1.8, 7, [7;8] min), whereas emergence from anesthesia was not different (LMA: 11.8 +/- 3.3, 11, [9;14] vs. ETT: 13.2 +/- 4.8; 12, [10;16] min). CONCLUSION: The clinical relevance of reduced anesthesia induction time using LMA is questionable. The lack of difference in emergence time could be a result of the use of total intravenous anesthesia.