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We report a rare case of difficult intubation because of trachea deformation after therapy for diphtheria and subsequent tracheostomy at childhood. The patient was admitted to be subjected to a Bentall procedure, because of ascending aorta dilatation. With a detailed preanesthetic assessment and simulation for intubation by using three-dimensional technology, he was successfully intubated and the operation was accomplished uneventfully. 3D-printed models of the difficult airway enhance imaging of difficult anatomy, assist in simulation and management of potentially problematic intubation, and can be a valuable tool when dealing with airways with potential anatomical malformations. [ABSTRACT FROM AUTHOR]

Background: Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in patients suffering from obstructive jaundice before surgery. The severity of jaundice that mandates PBD has yet to be defined. Our aim was to investigate whether PBD is truly justified in severely jaundiced patients before pancreaticoduodenectomy. The parameters evaluated were overall morbidity, length of hospital stay, and total in-hospital mortality. Methods: From January 2000 to December 2012, a total of 240 patients underwent pancreaticoduodenectomy for periampullary tumors. Group A comprised 76 patients with preoperative serum bilirubin ≥15 mg/dl who did not undergo PBD before surgery. Group B comprised another 76 patients, matched for age and tumor localization (papillary vs. pancreatic head) who underwent PBD 2-4 weeks before pancreaticoduodenectomy and were identified from the same database. Results: Less operative time was required in the 'no PBD' group compared with the 'PBD' group (210 vs. 240 min). Total intraoperative blood loss and blood transfusions were also significantly less in the 'no PBD' group. There was no difference detected in the rate of pancreatic fistula or biliary fistula formation. Group A patients demonstrated significantly lower morbidity than group B (24 vs. 36 %, respectively) and therefore required briefer hospitalization (11 vs. 16 days). Mild infectious complications appear to be the main factor that enhanced morbidity in the PBD group. However, total in-hospital mortality was not significantly different between the two groups. Conclusions: Even severe jaundice should not be considered as an indication for PBD before pancreaticoduodenectomy, as PBD increases infections and postoperative morbidity, therefore delaying definite treatment. [ABSTRACT FROM AUTHOR]

Objectives Gender may be associated with postoperative pain. This study aimed to assess pain intensity and postoperative analgesic requirements in female and male patients scheduled for major abdominal surgery. Methods Sixty-five patients, 31 men and 34 women, scheduled for major abdominal surgery were recruited. Anesthesia and intraoperative analgesics were standardized in all patients. Postoperatively, all patients had access to a 60 mL PCA pump containing 1 mg/ mL morphine and 50 μg/ mL droperidol. Morphine consumption and VAS scores at rest and after cough were recorded 2, 4, 8, 24, and 48 hours postoperatively. Results Of the 65 patients recruited for the study, 30 women and 30 men aged 65 ± 8.9 and 66 ± 9.0 years, respectively, were included in the analysis. Morphine consumption was examined 2, 4, 8, 24, and 48 hours after surgery and did not differ in women vs. men (mean ± standard deviation, 4.4 ± 3.2 vs. 5 ± 4.8, 7.2 ± 4.8 vs. 8.7 ± 6.9, 10.4 ± 7.1, vs. 12.5 ± 8.5, 22.9 ± 11.6 vs. 25.6 ± 14.5, and 36.2 ± 15.7 vs. 39.7 ± 21.7 mg, P = 0.384). Cumulative morphine consumption was not significantly different in women vs. men when normalized for body mass index (mean ± standard deviation, 0.17 ± 0.13, 0.28 ± 0.20, 0.40 ± 0.30, 0.88 ± 0.46, and 1.38 ± 0.59 mg/kg/m2 in women and 0.18 ± 0.18, 0.31 ± 0.25, 0.46 ± 0.32, 0.95 ± 0.54, and 1.47 ± 0.81 mg/kg/m2 in men at 2, 4, 8, 24, and 48 hours postoperatively ( P = 0.567). Both genders exhibited similar VAS pain scores (mm) at rest and after cough ( P = 0.476, P = 0.378, respectively). Conclusions Postoperative morphine requirements did not differ between female and male patients undergoing major abdominal surgery. Pain intensity reported at rest and after cough did not differ between the 2 groups. [ABSTRACT FROM AUTHOR]

Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7 gdL-1 or 9.9 g dL-1, respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFα. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 ± 29.07 vs. 15.83 ± 13.22 pg mL-1, P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r² = 0.38, P = 0.032, r² = 0.52, P = 0.007, and r² = 0.68, P < 0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525. [ABSTRACT FROM AUTHOR]

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates. [ABSTRACT FROM AUTHOR]

Background: Treatment of peripherally located liver tumors with diaphragmatic invasion is technically demanding but does not preclude resection for cure. The aim of the present study was to compare patients undergoing combined liver and diaphragmatic resection with those submitted to hepatectomy alone so as to evaluate the safety, effectiveness, and value of this complex surgical procedure. Methods: From January 2000 to September 2011, 36 consecutive patients underwent en bloc liver-diaphragm resection (group A). These were individually matched for age, gender, tumor size, pathology, and co-morbitidies with 36 patients who underwent hepatectomy alone during the same time (group B). Operative time, warm ischemia time, blood loss, required transfusions, postoperative complications, and long-term survival were evaluated. Results: Mean operative time was significantly longer in group A than in group B (165 vs 142 min; P = 0.004). The two groups were comparable regarding warm ischemia time, intraoperative blood loss, required transfusions, and postoperative laboratory value fluctuations. Some 33 % of group A patients developed complications postoperatively as opposed to 23 % of group B patients ( P = 0.03). The mortality rate was 2.8 % in group A compared to 0 % in group B. Postoperative follow-up demonstrated 60 % 1-year survival for group A patients as opposed to 80 % 1-year survival for group B patients, a difference that is practically eliminated the longer the follow-up period is extended (35 vs 40 % 3-year survival and 33 vs 37 % 5-year survival for group A and group B patients, respectively). Conclusions: En bloc diaphragmatic and liver resection is a challenging but safe surgical procedure that is fully justified when diaphragmatic infiltration cannot be ruled out and the patient is considered fit enough to undergo surgery. [ABSTRACT FROM AUTHOR]

Background: There is evidence that small-for-size liver grafts are more vulnerable to ischemia/reperfusion injury after liver transplantation. We hypothesized that ischemic injury is more pronounced in small liver remnants after major hepatectomies. Methods: Fifteen patients underwent extended hepatectomy with remnant liver mass less than 30 % of standard liver weight (study group). These patients were matched with patients who underwent minor liver resection, with liver remnants equal to or more than 70 % of standard liver weight (control group). Ischemia/reperfusion injury was assessed by tissue caspase-3 activity postoperatively as well as peak aspartate aminotransferase (AST) values and a-glutathione S-transferase (α-GST) levels adjusted for remnant liver weight. In addition, caspase-3 activity and adjusted serum markers of hepatocyte injury were correlated with the degree of postoperative portal hypertension. Results: Caspase-3 activity was higher in patients with small liver remnants (22.66 ± 6.57 vs. 12.60 ± 4.06 count per high-power field, p < 0.001). Serum markers of hepatocyte injury, when adjusted per gram of liver remnant, were found to be higher in the study group than in the control group (AST: 1.26 ± 0.25 vs. 0.54 ± 0.11 IU g, p < 0.001; α-GST: 0.14 ± 0.02 vs. 0.08 ± 0.01 IU g, p < 0.001). Tissue caspase-3 expression in the small liver remnant group correlated with both AST and α-GST levels adjusted per gram of liver remnant ( r = 0.51, p = 0.005 and r = 0.71, p < 0.001, respectively). Significant correlations between postoperative portal hypertension and the same markers as well as caspase-3 activity were also demonstrated. Conclusion: Liver remnants less than 30 % of standard liver weight are much more susceptible to ischemia/reperfusion injury than controls twice the size. Adjustment of serum markers of hepatocyte injury to the liver remnant weight depicts injury more accurately. [ABSTRACT FROM AUTHOR]

Background. Hazards of liver surgery have been attenuated by the evolution in methods of hepatic vascular control and the anesthetic management. In this paper, the anesthetic considerations during hepatic vascular occlusion techniques were reviewed. Methods. A Medline literature search using the terms "anesthetic," "anesthesia," "liver," "hepatectomy," "inflow," "outflow occlusion," "Pringle," "hemodynamic," "air embolism," "blood loss," "transfusion," "ischemia-reperfusion," "preconditioning," was performed. Results. Task-orientated anesthetic management, according to the performed method of hepatic vascular occlusion, ameliorates the surgical outcome and improves the morbidity and mortality rates, following liver surgery. Conclusions. Hepatic vascular occlusion techniques share common anesthetic considerations in terms of preoperative assessment, monitoring, induction, and maintenance of anesthesia. On the other hand, the hemodynamic management, the prevention of vascular air embolism, blood transfusion, and liver injury are plausible when the anesthetic plan is scheduled according to the method of hepatic vascular occlusion performed. [ABSTRACT FROM AUTHOR]

Extensive experimental studies and a few clinical series have shown that ischemic preconditioning (IPC) attenuates oxidative ischemia/reperfusion (I/R) injuries in liver resections performed under inflow vascular control. Selective hepatic vascular exclusion (SHVE) employed during hepatectomies completely deprives the liver of blood flow, as it entails simultaneous clamping of the portal triad and the main hepatic veins. The aim of the present study was to identify whether IPC can also protect hepatocytes during liver resections performed under SHVE. Patients undergoing major liver resection were randomly assigned to have either only SHVE (control group, n = 43) or SHVE combined with IPC—10 min of ischemia followed by 15 min of reperfusion before SHVE was applied (IPC group, n = 41). The two groups were comparable with regard to age, liver resection volume, blood loss and transfusions, warm ischemic time, and total operative time. In liver remnant biopsies obtained 60 min post-reperfusion, IPC patients had significantly fewer cells stained positive by TUNEL compared to controls (19% ± 8% versus 45% ± 12%; p < 0.05). Also IPC patients had attenuated hepatocyte necrosis, systemic inflammatory response, and oxidative stress as manifested by lower postoperative peak values of aspartate transaminase, interleukin-6, interleukin-8, and malondialdehyde compared to controls. Morbidity was similar for the two groups, as were duration of intensive care unit stay and extent of total hospital stay. In major hepatectomies performed under SHVE, ischemic preconditioning appears to attenuate apoptotic response of the liver remnant, possibly through alteration of inflammatory and oxidative pathways. [ABSTRACT FROM AUTHOR]

Ischemic preconditioning (IPC) and intermittent vascular control (IVC) have been shown to reduce the number of ischemia/reperfusion injuries during liver resections with the Pringle maneuver. Our study aimed to compare the beneficial effect of these two modalities in relation to the duration of normothermic liver ischemia. A group of 24 Landrace pigs with a mean body weight of 25 to 30 kg were subjected to extended liver resection of more than 65%. Although, 12 animals underwent IPC (10 minutes of ischemia and 10 minutes of reperfusion), and subsequently the Pringle maneuver was applied for 90 minutes (n = 6) or 120 minutes (n = 6). Another 12 animals underwent liver resection by IVC (20 minutes of ischemia alternated with 5 minutes of reperfusion) for 60 minutes (n = 6) or 120 minutes (n = 6) of inflow vascular control. At 90 minutes of liver ischemia, the IPC group demonstrated lower levels of asporate aminotransferase (AST) (173 ± 53 vs. 265 ± 106 IU; p = 0.022) and higher liver tissue cAMP (200 ± 1.03 vs. 5.33 ± 2.25 μmol/L; p = 0.022) and higher liver tissue cAMP group. However, no pathologic differences were observed between the two groups. By contrast, at 120 minutes of liver ischemia, IVC proved to be more beneficial, reflected by lower levels of AST (448 ± 135 vs. 857 ± 268 IU; p = 0.006) and MDA (8.33 ± 1.75 vs. 12.7 ± 4.31 μmol/L; (p = 0.045), a higher cAMP level (127 ± 10 vs. 97 ± 31 pml/g wer wt p = 0.045), and eventually less cellular necrosis (necrosis score 1.66 ± 0.51 vs. 2.85 ± 1.16; p = 0.04) compared to the IPC group. It appears that IPC should be employed when liver ischemia is anticipated to last less than 90 minutes, followed by IVC when the liver ischemia is expected to last 120 minutes. [ABSTRACT FROM AUTHOR]

A correction to the article "Preoperative Biliary Drainage of Severely Jaundiced Patients Increases Morbidity of Pancreaticoduodenectomy: Results of a Case-Control Study" by Nikolaos Arkadopoulos and colleagues, published online on November 8, 2014, is presented.

The article reviews the book "Anaesthesia and the Foetus," edited by Yuheda Ginosar, Felicity Reynolds, Stephen H. Halpern, and Carl Weiner.