Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study.

OBJECTIVE: To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy. METHODS: We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates. RESULTS: Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53-68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients' demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3-5 vs 4-5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001). CONCLUSION: In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.

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 [...].

Enhanced Recovery After Surgery Protocols in Obese Gynecological Oncology Patients: A Single-Center Experience.

Objective The aim of this study is to present our experience and evaluate the safety and outcomes of the implementation of Enhanced Recovery After Surgery (ERAS) protocols in obese patients who underwent surgery for suspected or confirmed gynecological malignancies. Method From January 2020 to September 2021, 217 patients underwent laparotomy for a confirmed or suspected gynecological malignancy following a 19-element ERAS pathway. The patients were divided into two groups: obese (BMI ≥ 30 kg/m2, n = 104) and non-obese (BMI < 30, n = 113). Both groups were treated with a 19-element ERAS protocol. Results After dividing the 217 patients into two groups, significantly more comorbidities were observed in the obese group (diabetes mellitus: 23% vs. 8%, p = 0.004; ASA score grade 3: 25.0% vs. 6.2%, p < 0.001), as well as higher rates of endometrial cancer (51.9% vs. 17.7%, p < 0.001) compared to the non-obese group. The overall ERAS compliance rates when matched element by element were similar. Postoperatively, complication rates of all grades were significantly higher in the obese group (46.1% vs. 27.4%, p < 0.001) without differences in the length of stay, readmission, and reoperation rates. Conclusion In this retrospective study, we showed that obese gynecological oncology patients can be safely managed with ERAS protocols perioperatively while potentially minimizing the adverse outcomes in these otherwise high-risk patients.

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.

Peripartum Ηysterectomy: A Four-Year Obstetric and Anesthetic Experience in a Tertiary Referral Hospital in Greece.

Background Although peripartum hysterectomy (PH) is a life-saving procedure in cases of abnormal placentation and postpartum hemorrhage, it can be associated with major obstetric and anesthetic complications. This retrospective study aimed to evaluate the incidence, etiology, perioperative anesthetic and obstetric management, complications, and fetal outcomes in women undergoing PH in a single tertiary referral hospital in Greece. Methodology This was a retrospective analysis of medical records of women who underwent emergency or elective PH in our hospital between January 2015 and December 2018. Results During the study period, 69 women who underwent a PH were identified. The incidence rate of elective and emergency PH was 4 and 1.2 per 1,000 deliveries, respectively. The main indication for PH was abnormal placentation (81.2%), followed by uterine atony (13%). Conversion to general anesthesia (GA) was performed in 21 (30.4%) cases. Conclusions This study showed a high prevalence of PH in our hospital compared to high-income countries. A neuraxial-only technique may be a safe alternative in individual cases of abnormal placentation. Conversion to GA can be reserved for complex surgical cases when massive hemorrhage is anticipated and, if possible, after the neonate has been delivered.

Prevalence of postpartum depression and antenatal anxiety symptoms during COVID-19 pandemic: An observational prospective cohort study in Greece.

INTRODUCTION: A significant proportion of pregnant women and women in the early postpartum period suffer from mental health problems. The COVID-19 pandemic represents a unique stressor during this period and many studies across the world have shown elevated rates of postpartum depression (PPD). METHODS: In this multicenter two-phase observational prospective cohort study, we aim to assess the prevalence of anxiety prior to labor (Generalized Anxiety Disorder-7), as well as PPD at 6-8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: Of the 330 women analyzed, 13.2% reported symptoms of depression using EPDS cut-off score ≥13. High antenatal levels of anxiety (24.8% scored ≥10 in GAD-7) were documented. A significant proportion of postpartum women reported a decrease in willingness to attend antenatal education courses (36%) and fewer antenatal visits to their obstetrician (34%) due to pandemic. Higher antenatal anxiety increased the odds of being depressed at 6-8 weeks postpartum (EPDS ≥13). CONCLUSIONS: Compared to reported prevalence of PPD from previous studies before the COVID-19 era in Greece, we did not find elevated rates during the first wave of the pandemic. High anxiety levels were observed indicating that there is a need for close monitoring in pregnancy during the pandemic and anxiety screening to identify women who need support in the pandemic era. A well-planned maternity program should be employed by all the associated care providers to maintain the proper antenatal care adjusted to the pandemic strains as well as a follow-up after labor.

The Use of Vigileo® Monitor in a Parturient With Severe Mitral Valve Stenosis and Severe Pulmonary Hypertension Undergoing Cesarean Section Under General Anesthesia: A Case Report and Literature Review.

We report a case of a 35-year-old pregnant female of Afghan origin who was admitted to the intensive care unit (ICU) because of pulmonary edema development when she was in the 30th week of gestation. During the bedside examination, the transthoracic echocardiogram (TTE) revealed severe mitral valve stenosis and pulmonary hypertension. The patient went into treatment with metoprolol for the control of tachycardia and furosemide for the prevention of fluid overload. During the 32nd week of gestation, the medical council decided on a cesarean section (CS) to be carried out under general anesthesia. The anesthesiologists decided to use the Vigileo monitor (Edwards Lifesciences, Irvine, CA, USA) as it is vitally important to approach fluid administration as fluid management is challenging concerning the obstetric patient. Vigileo monitoring is based on the invasive measurement of cardiac output (CO), cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV). Fluid resuscitation based on hemodynamic parameters is a key component of patient care, especially in scenarios such as cardiovascular disease. This is the first case report where a Vigileo monitor was applied to a patient with severe mitral valve stenosis and severe pulmonary hypertension undergoing a cesarean section, which was accomplished without any complications. The patient was discharged from the hospital on the 12th postoperative day, hemodynamically stable. Each immigrant woman, regardless of her financial, social, cultural, or any other situation, has the fundamental right to receive complete perinatal healthcare. Nevertheless, the most recent statistical data show that those women's access to public healthcare is insufficient, leading to high rates of maternal mortality. The international medical community has to adapt to the new multicultural environment, and health services must be provided to this vulnerable population with the appropriate level of safety.

Role of Critical Care Units in the management of obstetric patients (Review).

Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recommended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives.

Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?

AIM: To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures. METHODS: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function. RESULTS: One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group. CONCLUSION: Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned. CLINICAL TRIAL REGISTRATION: ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).

Prevention of hypotension during elective cesarean section with a fixed-rate norepinephrine infusion versus a fixed-rate phenylephrine infusion. Α double-blinded randomized controlled trial.

BACKGROUND: Spinal anesthesia for cesarean section can be complicated by hypotension, with untoward effects for both the mother and fetus. Frequently used phenylephrine can lead to baroreceptor-mediated reflex bradycardia. The aim of the present study was to compare a fixed-rate prophylactic norepinephrine infusion to a fixed-rate prophylactic phenylephrine infusion during elective cesarean section under combined spinal-epidural anesthesia. MATERIALS AND METHODS: Eighty-two parturients were randomized to either norepinephrine 4 µg/min or phenylephrine 50 µg/min fixed-rate infusions, starting simultaneously with the administration of the subarachnoid solution. The primary endpoint was the incidence of maternal bradycardia. Maternal hemodynamics at specific timepoints, the incidence of hypotension or hypertension, the requirement for ephedrine or atropine bolus administration as well as the acid-base status and Apgar score of the neonate were recorded. RESULTS: The incidence of bradycardia as well as the requirement for atropine administration was lower in the norepinephrine group (4.8% vs. 31.7%, p = 0.004 and 2.4% vs. 24.3%, p = 0.01, respectively). Fetal pH, and fetal blood glucose concentration were higher in the norepinephrine group (p = 0.027 and 0.019, respectively). No difference in the occurrence of hypotension, hypertension, in the requirement for bolus vasoconstrictive medication or in Apgar scores was demonstrated. CONCLUSIONS: A fixed-rate infusion of norepinephrine is as effective in the management of hypotension during regional anesthesia for cesarean section as a fixed-rate infusion of phenylephrine, with the avoidance of phenylephrine-induced bradycardia. The more favourable neonatal acid-base profile of noradrenaline might be due to better maintenance of placental blood flow in the noradrenaline group due to its beta action, while the higher fetal glucose concentration in the same group might result from a catecholamine-stimulated glucose metabolism increase and a ß-receptor mediated insulin decrease.

Vaginal hysterectomy with anterior and posterior repair for pelvic organ prolapse under local anesthesia: results of a pilot study.

INTRODUCTION AND HYPOTHESIS: Vaginal hysterectomy (VH) and pelvic floor repair (PFR) for the surgical management of pelvic organ prolapse (POP) are usually performed under regional anesthesia. The aim of this study is to evaluate the feasibility of performing VH and PFR under local anesthesia and to compare postoperative pain and patient recovery parameters with patients undergoing the same surgical procedure under regional anesthesia. METHODS: This was a single-center prospective cohort study of women with advanced POP. The standard care group consisted of 20 patients who underwent VH and PFR under a combined spinal-epidural (CSE) block, whereas the local anesthesia group consisted of 20 patients who underwent VH and PFR under local anesthesia and intravenous sedation. Primary outcomes included the intensity of postoperative pain and the percentage of patients with moderate/severe pain. Secondary outcomes included percentage of patients who used opioids, incidence of nausea/vomiting, level of sedation, and patient satisfaction rate. RESULTS: The median pain intensity at rest was significantly lower in the local anesthesia group at 2 h, 4 h, and 8 h postoperatively (median values: 0 vs 1.9, 0 vs 4.1, and 1 vs 2.7 respectively). The percentage of patients needing opioids was significantly lower for the local anesthesia group (35% vs 95%, p = 0.002). The proportion of patients presenting nausea and vomiting symptoms in the two groups was similar. CONCLUSIONS: Local anesthesia for patients undergoing VH and PFR has been shown to be a viable alternative to regional anesthesia, offering reduced postoperative pain and less opioid use for the first 8 h.

Cancer pain who cares? International and national patterns of evidence-based global guidelines recommendations for physicians on the Web (2011 vs. 2018).

PURPOSE: Although pain is a common event during treatment of cancer, its assessment and management remains suboptimal in everyday clinical practice at global level. METHODS: Considering both the important role of internet in daily life and that clinical guidelines are important for translating evidence in clinical practice, we performed a prospective study to scrutinize the magnitude of updated evidence-based cancer-pain guideline recommendation for physicians on the web. Changes over-time at a global level were scrutinized at two time points: 2011 for baseline and 2018 at first follow-up. Both anesthesiology and oncology societies were analyzed. RESULTS: In 2011 we scrutinized 181,00 WebPages and 370 eligible societies were identified; 364 of these were eligible for analyses both in 2011 and 2018. The magnitude of cancer pain updated and evidence-based guideline recommendations on the web for health care providers was extremely low at global level and at any time point considered: 1.1% (4/364) in 2011 and 4.7% (17/364) in 2018. Continental and intercontinental patterns, National's highest developmental index, oncology tradition and economic-geographic areas were not found to influence cancer pain web-guideline provision. In 2018, pain & supportive care societies provided the highest rate of updated evidence-based cancer-pain guidelines for clinicians. Only 3/25 medical oncology societies and 1/34 radiation oncology societies, provided own or e-link (to other societies') evidence-based guidelines in their websites. CONCLUSIONS: Major medical oncology and radiation oncology societies - at global level - fail to produce updated cancer pain recommendations for their physicians, with most of these providing no or inconsistent or outdated guidelines.

Management of a Pregnant Patient With Central Poststroke Pain Syndrome Ultimately Having a Cesarean Delivery: A Case Report.

Cerebrovascular events, along with the early presentation of central pain, during pregnancy, are uncommon. We report a case of a parturient with intense central poststroke pain after an ischemic cerebrovascular incident at 15 weeks of gestation, attributed to cerebral venous thrombosis. After a multidisciplinary team consultation, she was scheduled for cesarean delivery at 35 weeks of gestation, under combined spinal-epidural anesthesia. Due to severe left-sided neurological deficits and ipsilateral intense neuropathic pain, the neuraxial technique was successfully performed using the paramedian approach.

Abdominal Radical Trachelectomy for Early-Stage Cervical Cancer During Pregnancy: A Provocative Surgical Approach. Overview of the Literature and a Single-Institute Experience.

OBJECTIVE: Treatment of pregnancy complication due to malignancy of the cervix constitutes a great clinical challenge between optimal maternal therapy and fetal viability. Radical trachelectomy in early-stage cervical cancer during pregnancy instead of radical hysterectomy presents an alternative approach that can offer a satisfactory outcome for the mother and fetus. MATERIALS AND METHODS-RESULTS: A literature search of articles in English has been performed. Until now, 28 women with cervical cancer, including 2 who were managed and treated in our institute, who underwent a radical trachelectomy during pregnancy have been reported. We overviewed a total of 13 abdominal trachelectomies, 13 vaginal trachelectomies, and 2 laparoscopic trachelectomies. CONCLUSIONS: Radical trachelectomy can widen the therapeutic approach of early-stage cervical cancer in pregnant women who wish to preserve their pregnancy, providing a possibility of receiving the proper treatment with no delay.