Modified reconstruction approach after pancreaticoduodenectomy optimizes postoperative outcomes: Results from a multivariate cohort analysis.

Despite technical advances in recent decades and a decrease in hospital mortality (<5%), pancreaticoduodenectomy (PD) is still associated with major postoperative complications, even in high-volume centers. The present study aimed to assess the effect of a modified reconstruction technique on postoperative morbidity and mortality. A cohort study of all patients (n=218) undergoing PD between January 2010 and December 2019 was performed at Attikon University Hospital (Athens, Greece). Several variables were studied, including demographic data, past medical history, perioperative parameters, tumor markers and pathology, duration of hospitalization, postoperative complications, 30-day-survival, postoperative mortality and overall survival using multivariate logistic regression and survival analysis techniques. In this cohort, 123 patients [modified PD (mPD) group] underwent a modified reconstruction after a pylorus-preserving pancreaticoduodenectomy, which consisted of gastrojejunostomy and pancreaticojejunostomy on the same loop and an isolated hepaticojejunostomy on another loop. In the standard PD (StPD) group, 95 patients underwent standard reconstruction. The median age was 67 years, ranging from 25 to 89 years. Compared with in the StPD group, the mPD group had significantly lower rates of grade B and C pancreatic fistula (4.9% vs. 28.4%), delayed gastric emptying (7.3% vs. 42.1%), postoperative hemorrhage (3.3% vs. 20%), intensive care unit admission (8.1% vs. 18.9%), overall morbidity (Clavien-Dindo grade III-V: 14.7% vs. 42.0%), perioperative mortality (4.1% vs. 14.7%), and shorter hospitalization stay (11 days vs. 20 days). However, no difference was noted regarding median survival (35 months vs. 30 months). In this single-center series, a modified reconstruction after PD appears to be associated with improved postoperative outcomes. However, further evaluation in larger multi-center trials is required.

Beyond the debut: unpacking six years of Hypotension Prediction Index software in intraoperative hypotension prevention - a systematic review and meta-analysis.

PURPOSE: Intraoperative hypotension (IOH) during general anesthesia is associated with higher morbidity and mortality, although randomized trials have not established a causal relation. Historically, our approach to IOH has been reactive. The Hypotension Prediction Index (HPI) is a machine learning software that predicts hypotension minutes in advance. This systematic review and meta-analysis explores whether using HPI alongside a personalized treatment protocol decreases intraoperative hypotension. METHODS: A systematic search was performed in Pubmed and Scopus to retrieve articles published from January 2018 to February 2024 regarding the impact of the HPI software on reducing IOH in adult patients undergoing non-cardio/thoracic surgery. Excluded were case series, case reports, meta-analyses, systematic reviews, and studies using non-invasive arterial waveform analysis. The risk of bias was assessed by the Cochrane risk-of-bias tool (RoB 2) and the Risk Of Bias In Non-randomised Studies (ROBINS-I). A meta-analysis was undertaken solely for outcomes where sufficient data were available from the included studies. RESULTS: 9 RCTs and 5 cohort studies were retrieved. The overall median differences between the HPI-guided and the control groups were - 0.21 (95% CI:-0.33, -0.09) - p < 0.001 for the Time-Weighted Average (TWA) of Mean Arterial Pressure (MAP) < 65mmHg, -3.71 (95% CI= -6.67, -0.74)-p = 0.014 for the incidence of hypotensive episodes per patient, and - 10.11 (95% CI= -15.82, -4.40)-p = 0.001 for the duration of hypotension. Notably a large amount of heterogeneity was detected among the studies. CONCLUSIONS: While the combination of HPI software with personalized treatment protocols may prevent intraoperative hypotension (IOH), the large heterogeneity among the studies and the lack of reliable data on its clinical significance necessitate further investigation.

Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block.

Background and Aims: Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Material and Methods: Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. Results: The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Conclusion: Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.

A Comparative Study of the Impact of the Covid-19 Pandemic on Mental Health, Healthcare Access, and Pain Levels of Patients with Chronic Pain from Spring 2020 to Spring 2021.

Purpose: The short-term impact of the Covid-19 pandemic on patients with chronic pain has been under the microscope since the beginning of the pandemic. This time-lag design study aimed to track changes in pain levels, access to care, mental health, and well-being of Greek chronic pain patients within the first year of the Covid-19 pandemic. Patients and Methods: 101 and 100 chronic pain patients were contacted during the Spring of 2020 and 2021, respectively. A customized questionnaire was used to evaluate the perceived impact of the pandemic on pain levels and healthcare access. Psychological responses, personality characteristics, and overall well-being were evaluated using the Depression, Anxiety, and Stress Scale (DASS-42), the Ten-Item Personality Index (TIPI) and the Personal Wellbeing Index (PWI). Results: The perceived effect of the pandemic and the Covid-related restrictions affected significantly access to healthcare, pain levels and quality of life. Differences were detected in the PWI sub-scales regarding Personal Safety, Sense of Community-Connectedness, Future Security, Spirituality-Religiousness, and General Life Satisfaction. Marital status, parenthood, education and place of residence were associated with differences in pain levels, emotional and psychological responses. Conclusion: Changes in chronic pain levels, emotional responses, and overall well-being took place throughout the year. Also, an evident shift took place in the care delivery system. Both tendencies disclose an ongoing adaptation process of chronic pain patients and healthcare services that needs further monitoring.