Transition from Open Repair to Endovascular Aneurysm Repair for Rupture Aortic Aneurysms throughout a 16-Year Period of Time in a Single Tertiary Center.

BACKGROUND: Endovascular aneurysm repair (EVAR) is recommended as the first option for both elective and ruptured abdominal aortic aneurysms (rAAAs) with suitable anatomy. The aim of this study was to evaluate the outcomes of the gradual adoption of ruptured EVAR (rEVAR) as first option in the management of rAAAs in a reference tertiary center over a 16 year-period. METHODS: A retrospective analysis of prospectively collected clinical data was undertaken, including all patients that were treated for rAAA infrarenal or juxtarenal either with open surgical repair (OSR) or EVAR from 2006-2023. Three periods were identified and analyzed: Initial (2006-2011); intermediate (2012-2017); and current (2018-2023). The primary outcomes were the 30-day mortality rate in relation to the changing pattern of treatment. Secondary outcomes were re-intervention and mortality during the follow up period. RESULTS: Two hundred patients were treated for rAAA; 52% by endovascular means [EVAR (94), Ch-EVAR (9), and branched endovascular aneurysm repair (1)] and 48% by OSR (96). In the initial period, 61 patients were treated for rAAA (21% EVAR vs. 79% OSR), 68 in intermediate patients (47% EVAR vs. 53% OSR), and 71 in current period (83% EVAR vs. 17% OSR). Only in the current period juxta -renal rAAAs were treated by endovascular means (14%). The 30-day mortality rate was 46% in initial period (31% for EVAR vs. 50% for OSR), 64% in second period (46% in EVAR vs. 80% for OSR), and 35% in third period (25% for EVAR vs. 83% for OSR). The mean follow up did not differ between the groups, (EVAR 28.3 ± 2 months, vs. OSR 33.1 ± 3 months, P = 0.56). The survival rate did not differ between the groups; in rEVAR was 82% (SE 5%), 74% (SE 6%), 68% (SE 6.5%), and 63% (SE 7.7%) at 12, 24, 36, and 48 months, respectively, and in OSR was 76% (SE 7%), 66% (SE 8%), and 56% (SE 9.5%) at 6, 24, and 48 months, respectively (P = 0.544). CONCLUSIONS: Through a 16-year period, the implementation of EVAR as treatment of choice for rAAAs over OSR resulted in a noticeable reduction in the 30-day mortality. rEVAR was feasible in over 80% of rAAA patients.

Wide Awake Open Carpal Tunnel Release: The Effect of Local Anesthetics in the Postoperative Outcome.

Introduction Wide awake open carpal tunnel decompression is a procedure performed under local anesthesia. This study aimed to present the effect of various local anesthetics in peri and postoperative analgesia in patients undergoing this procedure. Materials and Methods A total of 140 patients, with 150 hands involved, underwent carpal tunnel release under local anesthesia. Patients were divided in five groups according to local anesthetic administered: lidocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, and chirocaine 0.25%. Total 400 mg of gabapentin were administered to a subgroup of 10 cases from each group (50 cases totally), 12 hours before surgery. Patients were evaluated immediately, 2 weeks and 2 months after surgery according to VAS pain score, grip strength, and two-point discrimination. Results In all patients, pain and paresthesia improved significantly postoperatively, while the use of gabapentin did not affect outcomes. Grip strength recovered and exceeded the preoperative value 2 months after surgery, without any difference between the groups. No case of infection, hematoma, or revision surgery was reported. Conclusion Recovery after open carpal tunnel release appears to be irrelevant of the type of local anesthetic used during the procedure. Solutions of low local anesthetic concentration (lidocaine 2%, ropivacaine 0.375%, and chirocaine 0.25%) provide adequate intraoperative analgesia without affecting the postoperative course.

Patients' Perceptions of Chronic Pain During the Economic Crisis: Lessons Learned from Greece.

BACKGROUND: Chronic pain is well known to be influenced by various social factors; however, the impact of financial issues on pain has not been extensively studied. OBJECTIVE: The aim of this study was to investigate the impact of the economic crisis on pain and quality of life in Greek patients suffering from chronic pain. STUDY DESIGN: The study employed a prospective, open-label design. SETTING: The study setting was the Pain Unit of Attikon University Hospital in Athens, Greece. METHODS: The study surveyed 200 randomly selected outpatients with chronic pain during two different time periods (2012 and 2016). Patients completed a structured questionnaire to assess the impact of the economic crisis on multiple aspects of pain and pain management, health care, and quality of life. Personality characteristics and stress were also evaluated using the DASS-42 and the LOT-R questionnaires. RESULTS: Most patients in both periods believed that the economic crisis led to a worsening of their symptoms (75%) and quality of life (97%). Most patients (97.5%) also believed that the intensity of their pain would have been improved if their financial status had been better. Their main concerns about the future were "the possibility of not having access to health care facilities and medication" (94.5%), "stress" (43%), and "fear of financial strain" (30.5%). Higher levels of anxiety, stress, and pessimism were associated with higher levels of pain and lower quality of life. LIMITATIONS: The study is based on a small sample size. CONCLUSIONS: This study identified impacts of the financial crisis on chronic pain and quality of life, pointing to the need for measures to solve this problem. KEY WORDS: Pain, global financial crisis, quality of life, quality of health care, psychosocial factors.

Translation, Cultural Adaptation, and Validation of Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) and Self-Complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) Questionnaires into the Greek Language.

BACKGROUND: The LANSS and S-LANSS questionnaires represent two widely accepted and validated instruments used to assist the identification of neuropathic pain worldwide. OBJECTIVE: The aim of this study was to translate, culturally adapt, and validate the LANSS and S-LANSS questionnaires into the Greek language. METHODS: Forward and backward translations of both questionnaires were performed from the English to Greek language. The final versions were assessed by a committee of clinical experts, and they were then pilot-tested in 20 patients with chronic pain. Both questionnaires were validated in 200 patients with chronic pain (100 patients for each questionnaire), using as the "gold standard" the diagnosis of a clinical expert in pain management. Sensitivity and specificity of questionnaires were assessed, as well as the internal consistency (using Cronbach's alpha coefficient) and correlation with the "gold standard" diagnosis (using Pearson correlation coefficient). RESULTS: Sensitivity and specificity of the LANSS questionnaire were calculated to be 82.76% and 95.24%, while for the S-LANSS 86.21% and 95.24%, respectively. Positive predictive value for neuropathic pain was 96% for the LANSS and 96.15% for the S-LANSS. Cronbach's alpha was revealed to be acceptable for both questionnaires (0.65 for LANSS and 0.67 for the S-LANSS), while a significant correlation was observed compared to the "gold standard" diagnosis (rLANSS   = 0.79 και tSLANSS   = 0.77, respectively, P = 0.01). CONCLUSIONS: The LANSS and the S-LANSS diagnostic tools have been translated and validated into the Greek language and can be adequately used to assist the identification of neuropathic pain in everyday clinical practice.

Cerebral oximetry in cardiac anesthesia.

Cerebral oximetry based on near-infrared spectroscopy (NIRS) is increasingly used during the perioperative period of cardiovascular operations. It is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. Current literature indicates that it can stratify patients preoperatively according their risk. Intraoperatively, it provides continuous information about brain oxygenation and allows the use of brain as sentinel organ indexing overall organ perfusion and injury. This review focuses on the clinical validity and applicability of this monitor for cardiac surgical patients.

Effect of pre-emptive pregabalin on pain intensity and postoperative morphine consumption after laparoscopic cholecystectomy.

BACKGROUND: Postoperative pain is the dominant complaint and the most common cause of delayed discharge after laparoscopic cholecystectomy. The aim of this study is to evaluate the potential of preoperative administration of pregabalin to reduce postoperative pain and opioid consumption. METHODS: Fifty American Society of Anesthesiologists (ASA) I and II adult patients with symptomatic gallstone disease scheduled for elective laparoscopic cholecystectomy were randomized into two groups: group I patients (n = 25) were given 600 mg pregabalin per os divided in two doses, the night before surgery and 1 h preoperatively, respectively, while group II patients (n = 25) received a matching to pregabalin placebo at the same scheme. Postoperative pain, morphine consumption, and complications were compared between the two groups. RESULTS: Postoperative pain (static and dynamic assessment) was significantly less at 0, 1, 8, 16, and 24 h (p < 0.001) after the procedure for group I (pregabalin) compared with the placebo group. Postoperative patient-controlled morphine consumption during hospital stay was also significantly less in the pregabalin group compared with the placebo group. Side-effects were similar in both groups expect for dizziness, which was significantly higher (p < 0.0001) in the pregabalin group. CONCLUSIONS: Administration of 600 mg pregabalin per os, divided in two preoperative doses, significantly reduces postoperative pain as well as opioid consumption in patients undergoing laparoscopic cholecystectomy, at the cost of increased incidence of dizziness.

Impact of intraoperative hypotension on hospital stay in major abdominal surgery.

PURPOSE: Although the relationship between preoperative risk factors and outcomes has been extensively studied, the effect of intraoperative hemodynamic changes in a patient's postoperative course has been less well defined. METHODS: We designed a prospective observational study to assess the impact of several variables, and especially hypotension, on postoperative outcome. Patients considered eligible for the study, all more than 18 years old, were mentally stable patients scheduled for major abdominal surgery with an expected duration of more than 2 h. Total hypotension time (THT), with other variables that possibly influence the outcome, was analyzed using multivariate logistic regression analysis in 100 consecutive patients. RESULTS: Total hypotension time was isolated as a factor significantly associated with morbidity [odds ratio, 5.1 (1.95-13.35)] and significantly prolonged hospital stay [odds ratio, 4.56 (1.85-10.96)]. Patients who had prolonged THT presented more complications (50 vs. 30), especially of the cardiovascular, pulmonary, and gastrointestinal systems. These complications led to delayed hospital discharge in a significant number of patients (36 with THT vs. 17 others). Finally, duration of surgery was associated with postoperative complications [odds ratio, 3.1 (1.2-8.0)]. CONCLUSION: Persistent hypotension during elective major abdominal surgery is a significant risk factor for postoperative complications and may prolong hospitalization and affect patient outcomes. Anesthetic management for the avoidance of hypotension, as much as possible, during major abdominal surgery may positively affect outcomes.

Impact of pregabalin treatment on pain, pain-related sleep interference and general well-being in patients with neuropathic pain: a non-interventional, multicentre, post-marketing study.

BACKGROUND AND OBJECTIVES: Numerous controlled clinical trials have demonstrated the safety and efficacy of pregabalin in the treatment of neuropathic pain. The objectives of the present study were to assess the impact of pregabalin under real-world conditions on pain, pain-related sleep interference and general well-being, and to assess the tolerability and safety of pregabalin in patients diagnosed with neuropathic pain of central or peripheral origin. METHODS: This was a non-interventional, multicentre study in which pregabalin was administered for 8 weeks, at the therapeutic dosages of 150-600 mg/day, to patients with a diagnosis of neuropathic pain. Pain intensity and pain-related sleep interference were measured using 11-point numerical rating scales, while well-being was assessed by documenting how often emotions associated with anxiety or depression were felt over the past week. Patient and Clinician Global Impression of Change (PGIC and CGIC) were assessed at the final visit. RESULTS: In the 668 patients included in the full analysis set, there were significant (p < 0.0001) reductions in mean pain and pain-related sleep interference scores of 4.16 and 4.02, respectively. Indicators of general well-being showed improvement from baseline to final visit. The majority of patients were rated as 'much improved' (43.7% and 36.7%) or 'very much improved' (24.0% and 26.2%) on CGIC and PGIC scores, respectively. Discontinuation because of lack of efficacy occurred in 0.7% of 691 patients in the safety analysis set while discontinuation because of adverse events occurred in 5.1% of this population; 76.4% continued treatment after the study ended. CONCLUSION: Significant reductions in pain and pain-related sleep interference, combined with reductions in feelings of anxiety and depression, suggest that pregabalin under real-world conditions improves the overall health and well-being of patients with neuropathic pain.

Deep anaesthesia reduces postoperative analgesic requirements after major urological procedures.

BACKGROUND AND OBJECTIVE: There is evidence from previous studies that deeper anaesthetic levels reduce postoperative pain along with analgesic requirements. The aim of this study was to confirm this observation during major urological procedures under sevoflurane anaesthesia. METHODS: Seventy ASA I or II patients undergoing radical prostatectomy or nephrectomy were randomly allocated into two groups: the L-BIS group with BIS (bispectral index scale) values kept within a range of 20-30 and the H-BIS group with values within the range of 50-60. Sevoflurane was the main anaesthetic agent used, along with inhalation of nitrous oxide and continuous remifentanil infusion. Postoperative analgesia was achieved mainly through morphine and ketamine, which was continuously infused by pump, and intravenous parecoxib. Additional analgesics (paracetamol, parecoxib and morphine) were administered in persistent (continuous, lasting longer than predicted and requiring repeated doses of analgesics) postoperative pain. The number of patients who demanded additional analgesia during the first 24 h was recorded, as well as the number of administrations performed, along with visual analogue scale (VAS) scores at 8 and 24 h. RESULTS: Sixty patients completed the study, 30 in each group. VAS scores at 8 h were significantly higher in the H-BIS group, both at rest [1 (0-4) vs. 2 (0-8), P = 0.036] and on cough [1 (0-5) vs. 2 (2-9), P = 0.021], but at 24 h were similar between the two groups. Four patients in the L-BIS group and 17 patients in the H-BIS group demanded additional analgesia (P < 0.0009), although the patients in the L-BIS group needed significantly fewer additional doses of analgesics than those in the H-BIS group [0 (0-2) vs. 1 (0-5), P < 0.0008]. CONCLUSION: The results show that intraoperative deep anaesthetic levels during major urological procedures, achieved with high sevoflurane concentrations, lead to reduced postoperative analgesic requirements.

Dose-related shortening of ventricular tachycardia cycle length after administration of the KATP channel opener bimakalim in a 4-day-old chronic infarct anesthetized pig model.

Potassium channel openers are known to act on potassium ATP-dependent channels in cardiac tissue. Such agents may exacerbate acceleration of acute ischemia-induced ventricular repolarization and aggravate arrhythmias. To test whether activation of K( ATP) channels during the healing period of myocardial infarction (MI) can still influence the electrophysiologic properties and the type of inducible arrhythmias, we investigated the effects of bimakalim (BIM) on sustained ventricular tachycardia (VT) 4 days after ligation of the left anterior descending (LAD) coronary artery in pigs. Programmed stimulation was performed to elicit VT prior to and after intravenous (IV) BIM. Combination monophasic action potential (MAP)/PACING catheters were used to enable simultaneous ventricular MAP recording and pacing. Ventricular effective refractory period (ERP) and MAP duration determined at 50% and 90% repolarization were measured prior to and after BIM. After completion of baseline measurements, BIM was consecutively given at 0.5, 1, and 3 mg/kg bolus followed by 0.025, 0.05, and 0.1 mg/kg per minute maintenance infusion, respectively. From a total of 23 pigs subjected to LAD ligation, 4 animals succumbed to infarction and the remaining 19 animals were studied by programmed stimulation. Only animals that exhibited reproducible and hemodynamically stable monomorphic VTs during control stimulation were selected for evaluation (n = 14). After the first, second, and third dose of BIM, the mean VT rate was increased by 6%, 14% (P <. 01), and 47% (P < .001) compared to control values, respectively. Ventricular ERP and repolarization were significantly shortened only by the second and third dose of BIM. Of 14 pigs receiving the highest BIM dosage, 3 revealed polymorphic VTs degenerating into ventricular fibrillation (VF). Our data suggest that high BIM doses may lead to faster and more aggressive pacing-induced reentrant VTs after subacute MI. This is consistent with the drug-induced acceleration of ventricular repolarization with shortening of MAP duration and refractoriness.

Percutaneous nephrolithotomy under a multimodal analgesia regime.

OBJECTIVES: To evaluate the possibility of performing percutaneous nephrolithotomy (PCNL) under a multimodal analgesia regime. PATIENTS AND METHODS: During a period of 3 years, 51 patients requiring PCNL were enrolled in the study. All patients received a multimodal analgesic regime that included paracetamol, a COX(2) inhibitor, epidural morphine, and infiltration of the surgical field with local anesthetics. Percutaneous renal tract access was created with ultrasound guidance. All patients were informed about the possibility of experiencing short periods of discomfort or pain, and all patients completed a visual analog pain scale questionnaire postoperatively. RESULTS: All 51 patients completed the study, and the procedure was well tolerated. Intraoperative problems or postoperative complications were attributed mainly to the procedure itself (PCNL) rather than to the analgesic regimen administered. We observed no morphine-related side effects. Patients were transferred directly back to the ward immediately after the operation. The use of analgesics postoperatively was minimal. CONCLUSIONS: The use of our multimodal analgesia regime is a well-tolerated and safe alternative to general or regional anesthesia for patients undergoing PCNL.

Assessment of local atrial repolarization in a porcine acetylcholine model of atrial flutter and fibrillation.

OBJECTIVES: Progressive electrical alternans followed by conduction block and fibrillatory conduction have been suggested to precede disorganization of atrial flutter (Afl) to atrial fibrillation (AF). The purpose of the present study was to investigate patterns of local repolarization in the high and low right atrium to determine the site with pronounced propensity to action potential disorganization during Afl and AF. METHODS: Combination pacing/recording contact monophasic action potential (MAP) catheters were utilized to evaluate repolarization from the upper and low atrial endocardium in 16 pigs. To induce sustained atrial flutter (Afl) or fibrillation (AF), programmed atrial stimulation was carried out prior to and during intravenous acetylcholine (ACh) infusion at a dosage rate of 2.7 mg/min. Atrial repolarization was measured at 30, 50, and 90% of total MAP duration. RESULTS: Two main types of atrial MAPs were distinguished: MAPs originated from high atrial regions showing a prominent notch and longer duration and MAPs recorded from the lower atrium displaying a much slower slope of phase I repolarization and shorter duration. Control stimulation did not elicit any significant atrial tachyarrhythmias. After ACh all animals developed reproducibly induced sustained and non-sustained whole Afl or AF during programmed stimulation. A total of 40 sustained arrhythmia episodes were selected for evaluation: fourteen episodes of primary AF and 26 episodes of Afl. Whole Afl and AF in all animals were associated with MAPs of almost regular morphology in lower parts of atrium and disorganized activation in higher atrial regions. ACh significantly reduced (P < 0.001) both high and low atrial effective refractory periods as well as MAP duration determined at 30, 50, and 90% repolarization. CONCLUSIONS: ACh facilitated the induction of Afl more than AF in this experimental model. MAPs recorded from high atrial regions revealed discordant repolarization during Afl or AF, whereas low atrial MAPs maintained their baseline regular morphology. These findings may help expand knowledge about mechanisms underlying instability and perpetuation of these arrhythmias.

Spinal vs general anesthesia for laparoscopic cholecystectomy: interim analysis of a controlled randomized trial.

OBJECTIVE: To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients. DESIGN: Controlled randomized trial. SETTING: University hospital. PATIENTS: One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia. METHODS: Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups. RESULTS: All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up. CONCLUSIONS: Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Laparoscopic ventral hernia repair under spinal anesthesia: a feasibility study.

BACKGROUND: Regional anesthesia has not been used as the sole anesthetic procedure in laparoscopic ventral hernia repair due to the fear of potential adverse effects of the pneumoperitoneum. However, there are recent reports on the feasibility of performing laparoscopic procedures, such as cholecystectomy, in fit patients, under spinal anesthesia alone. The current study aimed to detect the feasibility of performing laparoscopic ventral hernia repair under spinal anesthesia. METHODS: Twenty-five American Society of Anesthesiologists (ASA) I or II patients underwent laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum under spinal anesthesia. In 9 cases the hernia was umbilical/para-umbilical, in 5 cases epigastric, and in 11 cases incisional. Intraoperative incidents, complications, postoperative pain, and recovery in general, as well as patient satisfaction at follow-up examination, were prospectively recorded. RESULTS: All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score at 4 hours postoperatively was .5 (range 0-5), at 8 hours 1.5 (range 0-6), and at 24 hours 1.5 (range 0-4). Most patients were discharged 24 hours after the operation; the median hospital stay was 1 day (range 1-3 days). At 2-weeks follow-up, no late complications were detected and all patients reported being satisfied with the anesthetic procedure. CONCLUSION: Laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and smooth recovery.

A simplified technique of RFA (radiofrequency assisted) hepatectomy.

A new technique of dividing the hepatic parenchyma in liver resections is presented. Seven liver resections in six patients were carried out, using a modification of the Radiofrequency assisted hepatectomy technique. The transection zone of the liver was coagulated prior to the division of the parenchyma using a transformed cluster cool-tip Radionics electrode. The reported technique resulted in adequate hemostasis of the raw hepatic surface and minimal blood loss. The aforementioned method seems to be quick and safe especially for local hepatic resections or segmentectomies.

Effects of weight loss on QT interval in morbidly obese patients.

BACKGROUND: Obesity causes structural changes to the heart that may influence its function. Furthermore, morbid obesity is associated with an acquired prolongation of the QTc interval that may lead to potentially hazardous arrhythmias. The present study investigated the effect of body weight loss following vertical banded gastroplasty (VBG) on the QTc interval. METHODS: 17 morbidly obese patients, scheduled for elective VBG, were studied before the operation and 8-10 months postoperatively, when each patient had achieved a weight loss of >/= 25% of the preoperative body weight. RESULTS: 15 patients achieved significant body weight loss of >/= 25% within the first 8-10 postoperative months (P <0.001). This weight loss, corresponding to an excess weight loss of 48.7% and a mean body mass index (BMI) reduction from 49.7 kg/m2 to 36.6 kg/m2, was followed by significant shortening of the QTc interval from 428 msec to 393 msec (P <0.001). CONCLUSIONS: The significant postoperative weight loss following VBG was accompanied by shortening of the QTc interval. This effect is expected to reduce the incidence of fatal conditions associated with the long QT syndrome, such as malignant ventricular arrhythmias and sudden death, and therefore improve morbidity and mortality.