Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study.

BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Efficiency of the Robotic Platform in Improving the Rate of Sphincter Preservation in Patients With Mid and Low Rectal Cancer.

Background: The aim of this study was to investigate whether the robotic platform can have a positive impact on the rate of sphincter preservation in patients with rectal tumors, undergoing robotic total mesorectal excision (TME), in comparison with laparoscopic or open TME. We also analyzed and compared short-term outcomes. Methods: A prospectively collected robotic database was reviewed and compared with the trust and national data. Three groups were designed according to the surgical technique: open, laparoscopic and robotic. This includes all resections for mid and low rectal cancer which were performed with the robotic platform, over a period of 4 years, versus the trust data for the same period. Results: Two hundred ninety-seven patients with mid and low rectal cancers were analyzed. Demographics for the groups (gender, age, and body mass index) were similar but distance from anal verge was shorter in the robotic group (7 vs. 8.5 cm, P < 0.001). The percentage of abdominoperineal resection (APR) rate was significantly lower in the robotic group (13.5% vs. 39.6% vs. 52.4% for the open group, P < 0.001). Median length of stay, complication rate, and positive circumferential resection margin (CRM) rate for the robotic group were also statistically significantly lower than those for both laparoscopic and open groups. Conclusion: Robotic surgery for mid and low rectal cancer is safe and feasible, and could help surgeons perform ultra-low anterior resections, rather than APRs and save patients' sphincters. Positive CRM is low, which could lead to improved oncological outcomes.

En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach.

BACKGROUND: Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. METHODS: This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. RESULTS: During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. CONCLUSIONS: The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.

Reply to Akça, B.; Bilotta, F. Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on "Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333".

We would like to take this opportunity to thank Drs Akça and Bilotta for their interest and their insightful comments [...].

Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters.

INTRODUCTION: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS: In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 µg/kg or 12 µg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS: A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 µg/kg. Additionally, administration of LS at a dose of 12 µg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION: LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study.

BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUCbaseline 0.74 [0.71-0.77], ROC AUCbaseline+4METs 0.74 [0.71-0.77], ROC AUCbaseline+floors climbed 0.75 [0.71-0.78], AUCbaseline+fitnessvspeers 0.74 [0.71-0.77], and AUCbaseline+physical activity 0.75 [0.72-0.78]). CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03016936.

Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter.

Background and Goal of Study: Spinal anesthesia for cesarean section is frequently associated with a high incidence of hypotension, which may bring about untoward effects for both the mother and fetus. Recently, norepinephrine has emerged as a promising alternative in maintaining blood pressure in the obstetric setting. Fluid administration is another technique still widely used to prevent maternal hypotension. The optimal fluid strategy to prevent maternal hypotension has not been elucidated yet. It has been recently suggested that the main strategy in the prevention and management of hypotension should be the combination of vasoconstrictive medications and fluid administration. The aim of this randomized study was to compare the incidence of maternal hypotension in parturients receiving either colloid preload or crystalloid co-load in the setting of prophylactic norepinephrine infusion during elective cesarean section under combined spinal-epidural anesthesia. Materials and Methods: After ethics committee approval, 102 parturients with full-term singleton pregnancies were randomly allocated to either 6% hydroxyethyl starch 130/0.4 5 mL/kg before the onset of spinal anesthesia (colloid preload group) or Ringer's lactate solution 10 mL/kg concurrent with the subarachnoid injection (crystalloid co-load group). In both groups, norepinephrine 4 µg/min starting simultaneously with the administration of the subarachnoid solution was also administered. The primary outcome of the study was the incidence of maternal hypotension, defined as systolic arterial pressure (SAP) <80% of baseline. The incidence of severe hypotension (SAP < 80 mmHg), total dose of vasoconstrictive agents administered, as well as the acid-base status and Apgar score of the neonate and any incidence of maternal side effects were also recorded. Results: Data analysis was performed on 100 parturients: 51 in the colloid preload group and 49 in the crystalloid co-load group. No significant differences were demonstrated between the colloid preload group and the crystalloid co-load group in the incidence of hypotension (13.7% vs. 16.3%, p = 0.933) or the incidence of severe hypotension (0% vs. 4%, p = 0.238). The median (range) ephedrine dose was 0 (0-15) mg in the colloid preload group and 0 (0-10) mg in the crystalloid co-load group (p = 0.807). The incidence of bradycardia, reactive hypertension, requirement for modification of vasopressor infusion, time to the first occurrence of hypotension, and maternal hemodynamics did not differ between the two groups. There were no significant differences in other maternal side effects or neonatal outcomes between groups. Conclusions: The incidence of hypotension with a norepinephrine preventive infusion is low and comparable with both colloid preload and crystalloid co-load. Both fluid-loading techniques are appropriate in women undergoing cesarean delivery. It appears that the optimal regimen for prevention of maternal hypotension is a combined strategy of a prophylactic vasopressor such as norepinephrine and fluids.

The Effect of Ultrasound-guided Bilateral Erector Spinae Plane Block With and Without Dexmedetomidine on Intraoperative and Postoperative Pain in Laparoscopic Cholecystectomies: A Randomized, Controlled, Double-blind, Prospective Trial.

BACKGROUND: Laparoscopic cholecystectomy is the most common surgical procedure performed in the Western world. While it is performed with minimally invasive procedures, patients often complain of moderate to severe postoperative pain, and the role of the anesthesiologist for its effective management remains crucial. Modern anesthesiology practices have embraced trunk blocks which can contribute to perioperative, multimodal analgesia. There is emerging literature about the favorable effect of erector spinae plane block in the reduction of pain after laparoscopic cholecystectomy. OBJECTIVE: The aim of this study was to explore the efficacy of preoperative bilateral erector spinae plane block when dexmedetomidine is added in the local anesthetic mixture in patients undergoing elective laparoscopic cholecystectomy. STUDY DESIGN: This study is a double-blind, randomized, controlled, prospective study. SETTING: Georgios Papanikolaou General Hospital of Thessaloniki, Greece. METHODS: After Local Ethics Committee approval (No: 1146/7.10.2019, October 2019) and in accordance with the principles outlined in the Declaration of Helsinki, the study was submitted to clinicaltrials.gov with reference number: NCT04587973. Sixty patients were randomized into 3 equal groups. Erector spinae plane block was performed in Group C with normal saline (N/S) 0.9%, in Group DR with ropivacaine 0.375% and dexmedetomidine 1 mcg/kg, and in Group R with ropivacaine 0.375%. The perioperative opioid consumption, pain intensity, time of first mobilization, hospitalization days, and satisfaction score of patients were recorded. Statistical analysis was performed with ANOVA, Kruskal-Wallis and Spearman test, as appropriate. RESULTS: The perioperative opioid consumption was significantly lower in Groups R and DR as compared to Group C (P < 0.001). The median numerical rating scale (NRS) scores of patients at all time points were statistically different between Groups C and DR, as well as between groups C and R. Satisfaction score was significantly higher in Group DR as compared to Group C (P < 0.001), and mobilization time was significantly shorter in group DR in comparison to Group C as well as in Group R as compared to Group C (P = 0.015 and P = 0.035, respectively). Intraoperative remifentanil consumption was lower in Group DR in comparison to Group R (P < 0.001). There was no difference in postoperative nausea and vomiting and duration of hospital stay of patients. LIMITATIONS: The limitation of the study is the small sample size of the patients recruited, which may be the reason why no statistically significant differences were found in postoperative morphine consumption and postoperative NRS scores between Groups R and DR and in postoperative nausea and vomiting among the 3 groups. CONCLUSION: Erector spinae plane block performed either with ropivacaine or with a combination of ropivacaine and dexmedetomidine is a novel and safe method, which was found to be more effective compared to standard analgesia protocols in patients undergoing laparoscopic cholecystectomy and thus, it can improve the quality of perioperative analgesia.

Splenic Artery Ligation: An Ontable Bail-Out Strategy for Small-for-Size Remnants after Major Hepatectomy: A Retrospective Study.

It has been reported that the prevention of acute portal overpressure in small-for-size liver grafts leads to better postoperative outcomes. Accordingly, we aimed to investigate the feasibility of the technique of splenic artery ligation in a case series of thirteen patients subjected to major liver resections with evidence of small-for-size syndrome and whether the maneuver results in the reduction of portal venous pressure and flow. The technique was successful in ten patients, with splenic artery ligation alleviating portal hypertension significantly. Three patients required the performance of a portocaval shunt for the attenuation of portal hypertension. Portal inflow modulation via splenic artery ligation is a technically simple technique that can prove useful in the context of major hepatectomies as well as in liver transplantations and the early evaluation and modification of portal venous pressure post hepatectomy can be used as a practical tool to guide the effect of the intervention.

Effect of General Anesthesia Maintenance with Propofol or Sevoflurane on Fractional Exhaled Nitric Oxide and Eosinophil Blood Count: A Prospective, Single Blind, Randomized, Clinical Study on Patients Undergoing Thyroidectomy.

Background: Nitric oxide (NO) is considered a means of detecting airway hyperresponsiveness, since even non-asthmatic patients experiencing bronchospasm intraoperatively or postoperatively display higher levels of exhaled NO. It can also be used as a non-invasive biomarker of lung inflammation and injury. This prospective, single-blind, randomized study aimed to evaluate the impact of two different anesthesia maintenance techniques on fractional exhaled nitric oxide (FeΝO) in patients without respiratory disease undergoing total thyroidectomy under general anesthesia. Methods: Sixty patients without respiratory disease, atopy or known allergies undergoing total thyroidectomy were randomly allocated to receive either inhalational anesthesia maintenance with sevoflurane at a concentration that maintained Bispectral Index (BIS) values between 40 and 50 intraoperatively or intravenous anesthesia maintenance with propofol 1% targeting the same BIS values. FeΝO was measured immediately preoperatively (baseline), postoperatively in the Postanesthesia Care Unit and at 24 h post-extubation with a portable device. Other variables measured were eosinophil blood count preoperatively and postoperatively and respiratory parameters intraoperatively. Results: Patients in both groups presented lower than baseline values of FeΝO measurements postoperatively, which returned to baseline measurements at 24 h post-extubation. In the peripheral blood, a decrease in the percentage of eosinophils was demonstrated, which was significant only in the propofol group. Respiratory lung mechanics were better maintained in the propofol group as compared to the sevoflurane group. None of the patients suffered intraoperative bronchospasm. Conclusions: Both propofol and sevoflurane lead to the temporary inhibition of NO exhalation. They also seem to attenuate systemic hypersensitivity response by reducing the eosinophil count in the peripheral blood, with propofol displaying a more pronounced effect and ensuring a more favorable mechanical ventilation profile as compared to sevoflurane. The attenuation of NO exhalation by both agents may be one of the underlying mechanisms in the reduction in airway hyperreactivity. The clinical significance of this fluctuation remains to be studied in patients with respiratory disease.

Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch.

Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1-L2, L2-L3) EBPs and one thoracic (T11-T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients' persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail.

Bilateral palsy of the hypoglossal nerve following general anesthesia for emergency surgery. A case report.

INTRODUCTION AND IMPORTANCE: Hypoglossal nerve palsy is a rare condition usually associated with tumors, trauma, stroke or multiple sclerosis. It can be associated with other cranial nerve palsies while injury to this nerve typically affects a patient's articulation by causing lingual motility disturbance and swallowing difficulty. Bilateral isolated hypoglossal nerve palsy is an even more infrequent condition, which can occasionally be due to airway manipulation. CASE PRESENTATION: We describe a case of bilateral hypoglossal nerve damage following general anesthesia for emergency surgery, presenting with dysarthria, immobility of the tongue and dysphagia after extubation. The patient had a gradual recovery of all lost functions during the next four months. CLINICAL DISCUSSION: Bilateral hypoglossal nerve palsy is a very rare entity and tracheal tube malposition or prolonged but unnoticed tracheal cuff pressure especially in the face of low blood pressure, should be considered as possible causative mechanisms for this condition. This underlines the importance of careful positioning of the patient's head and neck during surgery as well as the meticulous and correct performance of routine maneuvers of airway management. CONCLUSION: Bilateral hypoglossal nerve palsy is a very rare entity. Diagnosis and management of twelfth nerve palsy require a multidisciplinary approach to achieve the best patient outcome.

Vena cava balloon occlusion for pulmonary embolism prevention during resection of giant uterus fibroids.

We report the case of a single 46-year-old woman presenting with huge uterine fibroids growing for the last 12 years, resulting in a recent common iliac vein thrombosis. Due to the high risk for pulmonary embolism, an occluding balloon was inserted through the right jugular vein before the abdominal incision and occluded the vena cava just inferior to the renal veins. The tumor was easily mobilized, and the vena cava bifurcation was exposed and controlled until the uterus with the masses was resected. We recommend this method for oncovascular surgeries involving deep vein thrombosis and vein thromboembolism.

Assessment of Dynamic Changes in Stressed Volume and Venous Return during Hyperdynamic Septic Shock.

The present work investigated the dynamic changes in stressed volume (Vs) and other determinants of venous return using a porcine model of hyperdynamic septic shock. Septicemia was induced in 10 anesthetized swine, and fluid challenges were started after the diagnosis of sepsis-induced arterial hypotension and/or tissue hypoperfusion. Norepinephrine infusion targeting a mean arterial pressure (MAP) of 65 mmHg was started after three consecutive fluid challenges. After septic shock was confirmed, norepinephrine infusion was discontinued, and the animals were left untreated until cardiac arrest occurred. Baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of septic shock. Mean circulatory filling pressure (Pmcf) analogue (Pmca), right atrial pressure, resistance to venous return, and efficiency of the heart decreased with time (p < 0.001 for all). Fluid challenges did not improve hemodynamics, but noradrenaline increased Vs from 107 mL to 257 mL (140%) and MAP from 45 mmHg to 66 mmHg (47%). Baseline Pmca and post-cardiac arrest Pmcf did not differ significantly (14.3 ± 1.23 mmHg vs. 14.75 ± 1.5 mmHg, p = 0.24), but the difference between pre-arrest Pmca and post-cardiac arrest Pmcf was statistically significant (9.5 ± 0.57 mmHg vs. 14.75 ± 1.5 mmHg, p < 0.001). In conclusion, the baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of hyperdynamic septic shock. Significant changes were also observed in other determinants of venous return. A new physiological intravascular volume existing at zero transmural distending pressure was identified, termed as the rest volume (Vr).

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration.

Background: Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome. Methods: The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed. Results: Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C). Conclusion: Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

A Survey of Regional Anesthesia Use in Greece and the Impact of a Structured Regional Anesthesia Course on Regional Techniques Knowledge and Practice.

BACKGROUND: Due to the growing interest in regional anesthesia (RA) techniques and the realization of the need for formalized education in them, the Greek Chapter of the European Society of Regional Anesthesia and Pain Therapy (ESRA-Hellas) has established a structured hands-on training course held annually since 2009, which is quite popular in the community of Greek anesthesiologists. The aim of the current survey was twofold: first, to provide an overview of the current practice of RA in Greece; secondly, to evaluate the effect the aforementioned training course has on participants' knowledge and attitude towards RA. METHODS: An electronic questionnaire was uploaded on SurveyMonkey and a link giving access to the questionnaire was forwarded via email to a mailing list of 825 practicing Greek anesthesiologists held in the electronic database of ESRA Hellas. The survey was totally anonymous and no identifying information was collected throughout. It contained questions relating to the anesthesiologists' demographic characteristics, their RA practice, and information pertaining to the RA training course. RESULTS: A total of 424 fully completed questionnaires were received, representing an overall response rate of 51.4%. Attendants of the course are more familiar than non-attendants with the performance of peripheral nerve blocks with neurostimulation and/or ultrasound guidance (p < 0.001). Attendants are also less likely to practice exclusively general anesthesia, more likely to use peripheral blocks for lower limb surgery, and more likely to consider taking the European Diploma of RA in comparison to non-attendants (p < 0.001, p = 0.018 and p = 0.002, respectively). Both cohorts consider the course of value and agree that the main reason to use regional techniques is to ensure optimal postoperative analgesia, while the main hindrance to RA practice is the lack of relevant education in the techniques, especially those under ultrasound guidance. Regarding improvement of the course, most participants suggested devoting ampler time in hands-on ultrasound practice and application. Conclusion: Greek anesthesiologists seek educational activities in the field of RA and the course seems to fulfil the majority of attendants' expectations. There will be further effort by the organizers to improve weaknesses of the current course and undertake further educational initiatives in the field of RA according to international recommendations.

Abdominal cystic lymphangioma mimicking ovarian mass: A case report and literature review.

Cystic lymphangiomas are uncommon benign lesions extremely rare in the adult population. Most cases are found in the neck and axillary regions; while <1% of patients present with cystic lymphangiomas in the mesentery, greater omentum and retroperitoneum. The present report describes a rare case of large omental lymphangioma mimicking ovarian mass. A 40-year-old G2P2 female patient presented without symptoms for routine gynecological examination. Transvaginal ultrasound examination revealed a cystic mass with a maximum diameter of 10 cm localized at the right parametrium space, suggestive of large cystic lesion of the right ovary. Further preoperative evaluation by magnetic resonance imaging indicated that the mass was either cystic lymphangioma or mesenteric cyst. Complete excision of the cyst without need for gastrectomy was performed via laparotomy under general anaesthesia. Histology revealed omental lymphangioma. Most abdominal lymphangiomas are initially asymptomatic. The role of synchronous imaging examinations, such as ultrasonography and magnetic resonance imaging, in diagnosis of these lesions is crucial. Full preoperative differential diagnosis evaluation in cases of large intraabdominal lesions is required in order to decide the appropriate surgical approach and management.

Effect of Triiodothyronine Administration on the Kidney During Haemorrhagic Shock and Resuscitation.

OBJECTIVE: Apoptosis, measured via caspase activity, can be used to assess renal tissue damage in haemorrhagic shock. We investigated whether Triiodothyronine could attenuate apoptosis and protect against haemorrhagic shock-induced renal injury. METHODS: Haemorrhagic shock was induced in swine until the mean arterial pressure (MAP) was 35-40 mmHg for 40 minutes. Animals were randomly assigned to a control group (n=5), Group-F (Fluid resuscitation, n=6), and Group-T3 (Fluid plus Triiodothyronine, n=6). The swine were resuscitated for 1 hour aiming to MAP restoration (±10% from baseline) and were followed up for another 360 minutes. Haemodynamic parameters, fluids, acid-base status, plasma urea nitrogen, creatinine levels and caspase activity in the kidney were measured. RESULTS: Haemodynamic parameters did not differ significantly amongst the three groups. Group-T3 required less normal saline (Group-T3: 1083±204 mL versus F: 2500±547 mL, p=0.001) and hydroxyethyl starch (Group-T3: 558±102 mL versus F: 916±204 mL, p=0.004) during resuscitation. Additionally, Group-T3 swine experienced less acidosis following haemorrhage/resuscitation with a pH of 7.39 versus a pH of 7.26 in Group-F (p=0.004) at 360 minutes. Urea remained within normal limits in all groups, but creatinine levels were elevated at 6 hours in Group-F as compared to Group-T3 (p=0.019). Apoptosis, assessed by renal caspase-3 activity, was increased in Group-T3 (132±174 pmol minute-1 g-1) and reduced in Group-F (32±18 pmol minute-1 g-1) as compared to the control group, but without statistical significance (p=0.245 between Group-T3 and Group-F). CONCLUSION: Administration of Triiodothyronine in a swine model of haemorrhagic shock seems to interfere with renal cell apoptosis. The exact mechanism needs to be further investigated in future research.