Assessment of left ventricular performance during laparoscopy.

OBJECTIVES: Cardiovascular changes during laparoscopic surgery have been described in several studies. Pneumoperitoneum effects on cardiac performance instead have not been much investigated and are less known. The carbon dioxide insufflation necessary in order to perform laparoscopic procedures represents a higher force against which the myocardial fibers must shorten during ventricular contraction. Hypothesis of this study is that the intra-abdominal pressure at 12 mmHg could acutely affect the left ventricular wall stress and work. Aim of the study was to evaluate the impact of relationship pneumoperitoneum on the echocardiographic measures of left ventricular contractile function. PATIENTS AND METHODS: We studied 20 healthy, ASA I women, undergoing laparoscopic hysterectomy. Transthoracic echocardiography was performed preoperatively, after induction of anaesthesia, 15' after pneumoperitoneum, 15' after Trendelenburg positioning and 15' after the end of surgery. Left ventricular end-systolic wall stress, stroke work, left ventricular ejection time and mean velocity of fiber shortening were registered. RESULTS: Carbon dioxide insufflation caused a consistent increase in left ventricular end-systolic wall stress and left ventricular ejection time, while the mean velocity of fiber shortening decreased. The Trendelenburg position did not produce any other signficant effects. These changes were transient with a return to preinsufflation values at the last measurement. Pneumoperitoneum adversely affects left ventricular performance during laparoscopy, leading to an increase of left ventricular end-systolic wall stress and reducing the mean velocity of circumferential fiber shortening. These cardiac consequences appear to be reversible since all the echocardiographic parameters normalized at the end of surgery. CONCLUSIONS: Our results suggest that there is an adaptation of the cardiac systolic contractile status to the pressure overload during laparoscopy.

Dopamine infusion and fluid administration improve renal function during laparoscopic surgery.

BACKGROUND: Previous studies have documented the negative influence of pneumoperitoneum on cardiac and renal function during laparoscopy. In this respect, regard there is a lack of data regarding the use of an appropriate management of fluid therapy to decrease these side effects. The aim of this study was to investigate the cardiac and renal responses to the administration of different amounts of crystalloid solution, alone or in association with dopamine during laparoscopy. METHODS: Sixty ASA I patients undergoing laparoscopic surgery for endometriosis were randomly assigned to three groups. Group A was given saline solution at 5 mL/kg/h; group B received saline solution at 5 mL/kg/h and dopamine 3 mg/kg/min, and group C received saline solution at 10 mL/kg/h. Patients received A, B or C perioperatively. Renal function was evaluated by assessing total intraoperative diuresis and estimated glomerular filtration rate. Vasopressin plasmatic levels before and after surgery were measured. Transthoracic echocardiography was performed to estimate left ventricular filling pressure by using Tissue Doppler Imaging and registering the E/Ea ratio every hour after pneumoperitoneum. RESULTS: Total intraoperative diuresis was impaired in group A and significantly increased in group C (P<0.001). In group A estimated glomerular filtration rate significantly decreased after the end of surgery (P<0.003) and vasopressin significantly increased (P<0.001). The E/Ea ratio was significantly increased in group C (P<0.001). The infusion of saline solutions with the addition of dopamine slightly affected this parameter. CONCLUSION: A low rate of saline infusion could lead to an impaired renal function during laparoscopic surgery. This could be prevented by increasing the amount of saline solutions infused per hour or by adding a dopamine infusion.

Desflurane versus sevoflurane: a comparison on stress response.

BACKGROUND: Neurohumoral, immunologic and metabolic alteration characterize surgical procedures in relation with the intensity of injury, the total operating time and the anesthetic technique. We, therefore, compared the effects of desflurane versus sevoflurane anesthesia on intra and postoperative release of the stress hormones and inflammatory cytokines. METHODS: Fifty Caucasian women undergoing laparoscopic surgery for benign ovarian cysts were randomized to receive inhaled anesthesia with desflurane (DES group; N.=25) or sevoflurane (SEVO group; N.=25), with fentanyl bolus and remifentanil infusion. Plasma levels of noradrenaline, adrenaline, ACTH and cortisol were measured preoperatively (T1), 30 minutes after the beginning of surgery (T2), and 30 minutes, 2 and 4 hours after the end of surgery (T3, T4, T5 respectively). Interleukin 6 (IL-6), glucose and C-reactive protein (CRP) were measured at T1, T2,T3, T4, T5 and 12 hours after the end of surgery (T6). RESULTS: An increase of catecholamines during (T2) and immediately after surgery (T3) was observed in both groups. However, adrenaline and noradrenaline levels were significantly higher in the DES group compared to the SEVO group. Despite a drop of cortisol concentration was observed in both groups, only in the DES group there was a significant difference intraoperatively as compared to the baseline levels and to the SEVO group. While, the consequent increase of ACTH was significantly higher in the SEVO group at T2-T4. The preoperatory levels were restored at T5. Glucose, IL-6, CRP levels and postoperative pain did not show significant differences in timing within the same group and comparing DES vs SEVO group. CONCLUSION: In the present study we demonstrated that desflurane and sevoflurane produced a different stress response in the setting of laparoscopic surgery. The greater release of catecholamines during desflurane anesthesia could have adverse effects in patients with pre-existing cardiovascular disease. In low stress surgery desflurane, as compared to sevoflurane, was associated with a better control of intraoperative cortisol and ACTH response (T2). Moreover, the ACTH secretion resulted attenuated also postoperatively (T3-T4). Both gases did not influence the plasmatic levels of Il-6, CRP and glucose.

Influence of pneumoperitoneum on left ventricular filling pressures and NT-proBNP levels.

BACKGROUND: We recently demonstrated that pneumoperitoneum affects diastolic echocardiographic findings in healthy women scheduled for gynaecologic laparoscopy. No reports have been conducted in order to assess the echocardiographic consequences in hypertensive subjects during laparoscopic procedures. AIM: The aim of this study was to evaluate Left Ventricular filling pressures in hypertensive women with and without diastolic dysfunction, combining the tissue Doppler imaging technique and the plasmatic levels of amino terminal proBNP. MATERIALS AND METHODS: Doppler recordings of mitral inflow, tissue Doppler imaging of mitral annulus and N-terminal-proBNP plasmatic levels were obtained in 40 hypertensive women with or without diastolic dysfunction. Measurements were executed in awake patients (T0), after the induction of anesthesia (T1), 10 and 20 minutes after the creation of the pneumoperitoneum (T2 and T3, respectively) and at the end of the surgery (T4). Furthermore, we collected the last blood sample after 12 hours (T5). RESULTS: The E/Ea ratio for the evaluation of left ventricular filling pressures were higher in the diastolic dysfunction group than in the non diastolic dysfunction and significantly increased after pneumoperitoneum. Pneumoperitoneum increased the plasmatic levels of natriuretic peptide in both groups. At the end of the procedure we did not observe any further significant alteration. CONCLUSIONS: Pneumoperitoneum produces a consistent increase of ventricular filling pressures in a population of hypertensive patients with and without diastolic dysfunction. Moreover, there is a significant but transient rise in NT-proBNP after gas insufflation in both groups, most accentuated in the diastolic dysfunction group.

Efficacy of scheduled time ketorolac administration compared to continuous infusion for post-operative pain after abdominal surgery.

BACKGROUND: Ketorolac tromethanime is a non steroidal anti inflammatory drug and its efficacy on acute pain control after abdominal surgery has been well documented. It has a rapid onset and it can be given both for intra operative and for post operative pain management. AIM: In this study we aimed to evaluate if there were any differences in relieving post operative pain when Ketorolac was administered with continuous infusion or if it was given at prearranged times. PATIENTS AND METHODS: 80 ASA I patients, scheduled for major gynecological surgery, were randomly assigned to 2 groups: group A patients were connected after surgical incision with a 24h analgesic infusor (2 ml/h) containing morphine (0.02 mg/kg/h) and Ketorolac (90 mg). Group B patients were connected after surgical incision with a 24h analgesic infusor (2 ml/h) containing morphine (0.02 mg/kg/h) at first and Ketorolac was then given in bolus after surgical incision and then every 8 hours for the first 24 hours. Post-operative pain scores were assessed using the Visual Analogue Scale (VAS) every 8 hours for 24 h. For a VAS value greater than 6, patients received Tramadol 100 mg. RESULTS: Post-operative pain scores showed a better pain relief for patients in the group B. Furthermore, the requirements of rescue analgesic were less in the group B [Tramadol was used for only 8 patients] than in the group A [Tramadol was used for 31 patients]. No adverse effects were registered in both groups. CONCLUSIONS: For post-operative pain Ketorolac administration at prearranged times, every 8 hours, offers greater benefits in respect to its continuous infusion.

[Role of a mini-invasive approach in the diagnosis and treatment of tubo-peritoneal infertility as an altenative to IVF]. / Il ruolo di un approccio chirurgico mini-invasivo nello diagnosi e trattamento della sterilità tubo-peritoneale in alternativa alla FIVET.

AIM: Tubal factor infertility accounts for approximately 25-35% of cases of female infertility. Identifiable causes of tubal infertility are postinfectious tubal damage, postsurgical adhesion formation, and endometriosis-related adhesions. Aim of this study was to evaluate the results of a diagnostic/therapeutic minimally invasive approach in patients with suspect or ascertained mechanical infertility in terms of obtained pregnancies. METHODS: The study enrolled 143 patients who underwent diagnostic or operative laparoscopy, with chromopertubation, peritoneal or endometrial culture, salpingoscopy when indicated and diagnostic or operative hysteroscopy. Nine patients with submucous-intramural or multiple intramural fibroids underwent miomectomy by minilaparotomy following hysteroscopy and chromopertubation. Patients were contacted periodically by telephone to monitor the onset and outcome of pregnancy. The mean length of follow- up was 49 months (range: 11 to 118 months). RESULTS: Of the 152 patients considered in the study, 61 became pregnant (40%). Twenty-three pregnancies resulted in miscarriage, two in tubal pregnancy and one patient aborted after a diagnosis of Down syndrome. In total, 32% of the patients achieved a term pregnancy. CONCLUSION: The diagnostic/therapeutic mini-invasive approach allows women to become pregnant naturally and it is, therefore, an option for couples with ethical and religious concerns. The percentage of pregnancies is higher than after in-vitro fertilization. When efficacious, this approach allows additional spontaneous conceptions without renewed therapy and the course of pregnancy and the type of delivery will not differ from those in a normal population.

Leptin and perioperative neuroendocrine stress response with two different anaesthetic techniques.

BACKGROUND: Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy). METHODS: We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A=9) or sevoflurane anaesthesia (group B=9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4). RESULTS: The comparative analysis between the groups shows significantly higher values of NE (P<0.001 at time 1 and P<0.01 at time 3), E (P<0.001 at times 1 and 2; P<0.01 at time 3 and P<0.05 at time 4), ACTH (P<0.001 at times 1 and 2; P<0.05 at time 3) and cortisol (P<0.001 at times 1 and 2; P<0.01 at time 3; P<0.05 at time 4) in group B. The serum values of leptin were not significantly different between the two groups. CONCLUSION: The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E.

Prevalence of Neospora caninum and Toxoplasma gondii in sheep and dogs from Guarapuava farms, Paraná State, Brazil.

Sheep and dog blood samples were collected from nine farms in the county of Guarapuava, Paraná, Brazil. The indirect fluorescent antibody test (IFAT) was used to detect Neospora caninum and Toxoplasma gondii antibodies. Herein, serum samples from 305 sheep were evaluated, being 29 (9.5%) and 157 (51.5%) seropositives to N. caninum and T. gondii, respectively. Seven (29.1%) and five (20.8%) out of 24 dogs were seropositives to N. caninum and T. gondii, respectively. There were no differences among the sheep serology for N. caninum and reproductive problems, management and animal feeding variables, neurological problems and presence of other animals species on the farm (P>or=0.05). The simultaneous frequency of antibodies between N. caninum and T. gondii was 5.2% in the herds. Age, breed, farm size, semi-intensive activity, mineral salt supplementation, water origin, stage of the pregnancy when reproduction problems occurred, neurological problems in lambs, presence of rodents in the food room and pasture cat access were identified as associated factors for the occurrence of toxoplasmosis in sheep (P<0.05). There were no differences among the seropositivity in dogs for N. caninum and T. gondii and breed, age and sex (P>or=0.05). The present work is the first report on serum prevalence of N. caninum in sheep from the state of Paraná, Brazil.

Detection of Toxoplasma gondii by PCR and mouse bioassay in commercial cuts of pork from experimentally infected pigs

The distribution of T. gondii in commercial cuts of pork (ham, tenderloin, spareribs and arm picnic) by PCR and bioassay from experimentally infected pigs, was evaluated. Eighteen mixed breed pigs were divided into two groups (G). The G1 animals (n=10) were infected with 4 x10(4) oocysts of the T. gondii VEG strain and the G2 animals (n=8) were used as control. Pigs of both groups were slaughtered at 59th day after infection, and meat samples were collected for bioassay and PCR. All animals from G1 were positive by at least one or both tests, and all control animals were negative. T. gondii was identified in pork by mouse bioassay and PCR in 27/40 (67.5 percent) and in 9/40 (22.5 percent) of the evaluated samples, respectively. There were no statistical differences in the distribution of tissue cysts from commercial cuts of pork by bioassay (P>0.05). However, statistical differences were observed when mouse bioassay and PCR were compared (P<0.01).

Avaliou-se a presença de T. gondii em cortes comerciais de carne suína (pernil, lombo, costela e paleta), por meio do bioensaio e PCR, em animais experimentalmente inoculados. Dois grupos (G) foram formados. Os animais do G1 (n=10) foram inoculados com 4 x10(4) oocistos da cepa VEG e os do G2 (n=8) permaneceram como grupo-controle, não inoculado. Todos os animais foram abatidos no dia 59 após a infecção, quando foram colhidas as amostras de carne para a realização das provas de bioensaio e da PCR. Todos os suínos do G1 apresentaram-se positivos a pelo menos um dos testes de diagnóstico ou a ambos, e os do grupo-controle permaneceram negativos. Não houve diferenças significativas em relação aos tipos de cortes comerciais e à presença do parasita no bioensaio (P>0,05). O bioensaio foi capaz de detectar T. gondii em 27/40 (67,5 por cento) amostras e a PCR em 9/40 (22,5 por cento). O estudo mostrou diferença entre o bioensaio e a PCR (P<0,01).

Dairy cow abortion associated with Neospora caninum and other infectious agents

Trinta e cinco vacas de rebanhos leiteiros da região Norte do estado do Paraná, com histórico de abortamento, foram pesquisadas sorologicamente para verificar a presença de anticorpos contra Neospora caninum, Toxoplasma gondii, Leptospira spp., Brucella abortus, BHV-1 e BVDV. Vinte e uma vacas apresentaram títulos sorológicos compatíveis com infecção. Todas elas, soropositivas para N. caninum, foram também soropositivas para outros agentes infecciosos, sugerindo a possibilidade de associação desses agentes nos problemas reprodutivos de bovinos, no estado do Paraná.

Systematic pelvic and aortic lymphadenectomy in elderly gynecologic oncologic patients.

BACKGROUND: Retroperitoneal lymph node dissection is a fundamental step in the surgical management of patients with pelvic gynecologic malignancies, but its applicability to geriatric patients is controversial. The objective of this study was to evaluate whether pelvic and aortic lymphadenectomy in elderly patients with gynecologic malignancies can be a safe procedure in terms of morbidity and mortality. METHODS: In a retrospective case-control study, the authors compared morbidity, mortality, and surgical data in a series of elderly patients (age > 70 years) with endometrial and ovarian carcinoma who underwent surgery. Patients were divided into two groups: Cases were 36 elderly patients who underwent surgery and pelvic and/or aortic lymphadenectomy and were matched with 72 controls, who were patients who underwent surgery without lymphadenectomy. RESULTS: Cases showed a significantly longer median operative time than controls (median, 162 minutes [range, 85-330 minutes] vs. median, 100 minutes [range 20-310 minutes], respectively; P = 0.003). No significant difference between the two groups in terms of blood loss, blood transfusions, intraoperative complications, duration of ileus, reintervention required, or postoperative hospital stay were observed. One patient in the control group died. The type and frequency of severe postoperative complications in the two groups were not substantially different. CONCLUSIONS: Pelvic and aortic lymphadenectomy was performed safely in elderly patients age > or = 70 years with endometrial and ovarian carcinoma without an increase in morbidity and mortality. Advanced chronologic age alone should not be considered a contraindication to full surgical treatment in these patients.

Current practical application of office endoscopy.

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.

Stress responses to endoscopic surgery.

Growing evidence in the literature suggests that laparoscopic surgery should be performed instead of laparotomy for the treatment of pelvic benign diseases whenever feasible, as it results in a lower stress response on the part of the patient and possibly a shorter recovery time.

Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy.

STUDY OBJECTIVE: To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy. DESIGN: Prospective study. SETTING: A tertiary care university hospital. PATIENTS: Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis. INTERVENTIONS: Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH. MEASUREMENTS AND MAIN RESULTS: The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached. CONCLUSIONS: Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

[Behavior of GH and prolactin during enflurane anesthesia and neuroleptoanesthesia in man]. / Comportamento del GH e della prolattina durante anestesia con enfluorano e neuroleptoanestesia nell'uomo.

The present study was designed to investigate the effects of neuraleptanesthesia (NLA) and enflurane (Ethane) anesthesia on plasma levels of growth hormone (GH) and prolactin (PRL) in man. A total of 18 patients aged between 20 and 65 years scheduled for elective open-heart surgery were divided in two groups. In the first group (9 patients) general anaesthesia was induced with sodium thiopental (TPS) (3-5 mg/kg) and was maintained with enflurane administered with an inspired concentration of 1.5% in nitrous oxide (2 litres/min) and oxygen (2 litres/min). In the second group (9 patients) anaesthesia was induced with dihydrobenzopyridol (BPS) (0.1-0.2 mg/kg), fentanyl (5-8 gamma/kg) and TPS (3-5 mg/kg) and was maintained with fentanyl (0,65 mg in average). The patients had neither hepatic, renal or endocrine disease nor did they have a history of steroid therapy. All subjects received atropine (0.01 mg/kg) and diazepam (0.2 mg/kg) i.m. 2 hours before induction of anaesthesia. Blood samples for GH and PRL was collected before induction of anaesthesia (0) and at 30, 60, 90 and 120 minutes after induction: the 90' sample was taken immediately after sternal incision. The sampling was stopped at the start of the cardiopulmonary by-pass. A significative reduction of GH at 60' and of PRL at 30' was observed in both groups. Surgical stress at 90' does not evoke a significant increase of PRL and GH levels in both groups. In conclusion NLA and enflurane induced a decrease of GH and PRL plasma levels; in both groups the anaesthetic agents, at the dosage used during anaesthesia, blocked the response of these hormones to the surgical stress likely due to a block of the hypothalamic-pituitary response.