Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic

Background: laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid. Methods: international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed. Results: a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients. Conclusions: elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

Peridural Anesthesia and Cancer-Related Survival after Surgery for Pancreatic Cancer—A Retrospective Cohort Study

Background: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. Methods: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox’s proportional hazard regression model. Results: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio [HR] 0.884, 95% confidence interval [CI] 0.398–1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144–1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. Conclusion: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma.

Placenta Accreta: Management by Peridural Anesthesia

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Sensory Stimulation of Oxytocin Release Is Associated With Stress Management and Maternal Care

It has been shown that various types of stress initiate different physiological and neuroendocrine disorders. Oxytocin (OT) is mainly produced in the supraoptic nucleus (SON) and paraventricular nucleus (PVN) of the hypothalamus. Hypothalamic OT has antistress effects and attenuates the hypothalamic–pituitary–adrenal (HPA) axis. One mechanism behind the antistress effects of OT is mediated through the inhibition from GABAA receptors on corticotropin-releasing factor (CRF) expression at the PVN. Various manual therapies such as acupuncture, transcutaneous electrical nerve stimulation (TENS), and massage initiate the stimulation of somatosensory neurons of the body. It is well-known that TENS simulates OT expression, while it inhibits CRF expression at the PVN following chronic stress loading in rodents. Upregulation of OT expression at the hypothalamus is activated by the somatosensory stimulation, which is mediated via the spinothalamic pathway (the connection between the spinal cord and hypothalamus). Thus, somatosensory stimulation is beneficial in treating stress-associated symptoms. Hypothalamic OT is associated with the social behaviors, including maternal care and affiliation. Childhood neglect and/or child abuse are severely responsible for deleterious long-term effects on the cognitive/social activity and behavioral development. At parturition, a profound amount of OT is released into the systemic circulation in response to vaginal and cervical stimulation caused by the body of fetus, which induces the onset of maternal behavior. Peridural anesthesia effectively impairs the sensitivity to vaginal and cervical stimulation at parturition. OT levels in cerebrospinal fluid is significantly reduced following peridural anesthesia. The vaginal delivery mothers had significantly more OT pulses than the caesarian section (CS) mothers. Due to low levels of endogenous OT, maternal behavior could be interrupted by epidural anesthesia and CS at parturition because of the reduction of the usual sensory input from the genitalia.

Diagnosis and treatment of destructive forms of acute pancreatitis

Purpose of the study. The study of the diagnosis and treatment of destructive forms of acute pancreatitis and the identification of possible ways to optimize them. Materials and methods. Destructive forms of acute pancreatitis were found in 16,8%. The algorithm for treating acute destructive pancreatitis consisted in artificial ventilation of the lungs, adequate infusion therapy, peridural anesthesia, setting up a nasoenteric probe, stimulating the bowels, correcting hemodynamics, intra- and extracorporal detoxification, antisecretory, anti-bacterial, hepatoprotective, cerebroprotective, antioxidant therapy, directed immune correction, use of anti-enzyme drugs, suppression of the release of mediators inflammation, external secretory activity of the pancreas. Medical video laparoscopy and puncture interventions under the control of ultrasound were used as the first stage of surgical treatment. The indications for traditional surgical interventions are large areas of aseptic destruction, unlimited infected pancreatic necrosis, infection of necrotic areas with complete cell sequestration, abscesses with large sequesters, abdominal phlegmon, signs of progressive multiple organ failure and the development of arousal hemorrhage, perforation of cystic formations in the abdominal cavity, perforation of a hollow organ, purulent peritonitis. Results. The developed therapeutic tactics allowed, in destructive forms of acute pancreatitis, to achieve a reduction in overall mortality to 23,4%. Conclusion. Diagnostic and treatment tactics for destructive forms of acute pancreatitis should be standardized depending on the timing, severity of the disease, localization and prevalence of the destructive process, systemic and local complications. Keywords: acute, destructive, pancreatitis, diagnosis, treatment.