Early Oral Feeding Versus Traditional Postoperative Care After Abdominal Emergency Surgery: A Randomized Controlled Trial

Background

Early oral feeding (EOF) has been demonstrated to be safe and beneficial after abdominal elective surgery. The aim of this randomized controlled trial is to assess the safety and benefits of EOF compared to traditional postoperative care (TPC) after abdominal emergency surgery.

Methods

Patients assigned to the EOF group commenced a soft diet within 24 h after surgery. In the TPC group, a liquid diet was commenced upon passage of flatus or stool and then advanced to soft food. The primary endpoint was the complication rate. Secondary endpoints were severity of complications, mortality, gastrointestinal leaks, surgical-site infection, reoperation, diet intolerance, time to first flatus and stool, amount of food intake, postoperative discomfort, hospital stay, weight loss at the 15th postoperative day and incisional hernias.

Results

A total of 295 patients assigned to EOF (n = 148) or TPC (n = 147) were analyzed. No significant differences were seen in the complications rates (EOF 45.3 % vs. TPC 37.4 %; p = 0.1). There was a significantly higher rate of vomiting with EOF (EOF 13.5 % vs. TPC 6.1 %; p = 0.03), with no differences in nasogastric tube reinsertion. EOF patients’ food intake was proportionally lower for the first three meals than that of TPC patients (p < 0.01). Postoperative discomfort survey revealed more hunger in the TPC group (p < 0.01). There were no differences in postoperative ileus or length of hospital stay.

Conclusions

EOF was safe after abdominal emergency surgery. EOF was associated with more vomiting (treated easily and without patient discomfort) and less hunger than with TPC. No other EOF-related benefits could be demonstrated during this trial.     

Randomized Clinical Trial Comparing Blunt Tapered and Standard Needles in Closing Abdominal Fascia

Glove perforation frequently occurs during the course of surgical procedures, introducing risks for both surgeons and patients. The aim of this study was to compare the use of blunt tapered and “sharp” needles during abdominal wall closure with respect to the incidence of glove perforation and the convenience of needle handling. A series of 200 patients undergoing laparotomy in a 6-month period for general surgical disorders were randomized to two groups; in one, the abdominal fascia was closed with a blunt tapered needle; in the other, a sharp needle was used. The main outcome measures were glove perforation and convenience of handling the needle. Univariate and multivariate analyses were performed. In all, 56 glove perforations occurred during 40 (20%) surgical procedures.Perforation rates differed significantly: 12% for the blunt (n = 100) tapered needle and 28% (n = 100) for the sharp needle (p = 0.003). Only in 12 cases (21%) was the glove perforation detected at surgery. The type of needle (odds ratio 0.35, p = 0.006) and time taken to close the fascia (odds ratio 1.001, p = 0.05) significantly affected the risk of glove perforation. At multivariate logistic regression analysis the type of needle (odds ratio 0.23, p = 0.004) and the visual analog linear scale (VAS) for ease of needle handling (odds ratio 1.18, p = 0.019) were important predictive factors for glove perforation. With the blunt tapered needle, the VAS was significantly (p = 0.0003) higher at primary laparotomy than at relaparotomy. Use of the blunt tapered needle reduces the incidence of glove perforation. Laborious closure predicts glove perforation. Blunt tapered needles are less convenient in closing a scarred abdominal fascia.     

Epidural Bupivacaine-Morphine Analgesia versus Patient-controlled Analgesia following Abdominal Aortic Surgery: Analgesic, Respiratory, and Myocardial Effects

Background: The efficacy and effects of epidural analgesia compared with patient-controlled analgesia (PCA) have not been reported in patients undergoing major vascular surgery. We compared the effects of epidural bupivacaine-morphine with those of intravenous PCA morphine after elective infrarenal aortic surgery.

Methods: Forty patients classified as American Society of Anesthesiologists physical status 2 or 3 received general anesthesia plus postoperative PCA using morphine sulfate (group PCA; n = 21) or general anesthesia plus perioperative epidural morphine - bupivacaine (group EPI; n = 19) during a period of 48 h. During operation, EPI patients received 0.05 mg/kg epidural morphine and 5 ml 0.25% bupivacaine followed by an infusion of 0.125% bupivacaine with 0.1% morphine (0.1 mg/ml); group PCA received 0.1 mg/kg intravenous morphine sulfate. Continuous electrocardiographic monitoring (V4 and V5 leads) was performed from the night before surgery until 48 h afterward. Respiratory inductive plethysmographic data were recorded after tracheal extubation. Visual analog pain scores at rest and after movement were performed every 4 h after extubation.

Results: Nurse-administered intravenous morphine and time to tracheal extubation were less in group EPI, as were visual analog pain scores at rest and after movement from 20 to 48 h. Complications and the duration of intensive care unit and hospital stay were comparable. There was a similar, low incidence of postoperative apneas, slow respiratory rates, desaturation, and S-T segment depression.     

The Effect of Anesthesia on Intraoperative and Postoperative Bleeding during Abdominal Prostatectomies: A Comparison of Neurolept Anesthesia, Halothane Anesthesia and Epidural Anesthesia

Intraoperative blood loss was measured during abdominal prostatectomies in 213 patients anesthetized with neurolept anesthesia, halothane anesthesia and epidural anesthesia. In 55 of these patients, postoperative bleeding was also measured. The average intraoperative blood loss with neurolept anesthesia was 8.2 ± 5 ml/min, with halothane anesthesia 6.6 ± 6.3 ml/min and with epidural anesthesia 3.8 ± 2.3 ml/min. The difference of blood loss in the epidural group and in the groups receiving general anesthesia is highly significant.
Average systolic and diastolic blood pressures were lower during operation in the epidural group than in the other two groups. Statistical analyses failed, however, to show a significant correlation between blood pressures and blood loss in the individual patient. Thus, the ultimate explanation for the diminished bleeding associated with epidural anesthesia is not definitely ascertained. The average postoperative bleeding was not significantly different among the three anesthetic groups.     

Effect of Postoperative Epidural Analgesia on Rehabilitation and Pain after Hip Fracture Surgery: A Randomized, Double-blind, Placebo-controlled Trial

Background: Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery.

Methods: Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 [mu]g/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy.

Results: Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups.     

布托啡诺用于瑞芬太尼麻醉妇科腹腔镜手术后镇痛的观察

目的观察布托啡诺在防治瑞芬太尼麻醉妇科腹腔镜手术后疼痛的有效性。方法 60例择期妇科腹腔镜手术,按手术先后顺序分为B1、B2、S 3组。气管插管以微量泵持续输注丙泊酚和瑞芬太尼行全凭静脉麻醉。术毕前30 min B1、B2组分别静滴布托啡诺0.01 mg/kg、0.02 mg/kg,S组静滴舒芬太尼0.2μg/kg。记录拔管时、拔管后30 min、1 h、2 h Ramsay镇静评分(Ramsay sedation score,RSS)和疼痛视觉模拟评分(visual analogue scale,VAS)。记录拔管时间及术前、拔管时、拔管后30 min、1 h、2 h MAP、HR、RR,观察术后不良反应发生情况。结果 B1组拔管时和拔管后30 min,HR显著高于B2组(q=8.311,P0.05;q=5.263,P0.05)和S组(q=8.957,P0.05;q=6.073,P0.05)。拔管后30 min,B1组MAP显著低于B2、S 2组(q=3.959,P0.05;q=3.393,P0.05)。S组4例发生呼吸抑制,明显多于B1、B2组(χ2=17.549,P=0.000;χ2=21.232,P=0.000)。3组恶心呕吐、寒战的发生率无显著差异(P0.05)。VAS评分B1组拔管时、拔管后30 min显著高于B2(q=4.228,P0.05;q=3.648,P0.05)、S组(q=4.363,P0.05;q=4.115,P0.05),但B2、S组各时点VAS评分无统计学差异(P0.05)。B2组各时点RSS评分显著高于S组(q=5.973,8.030,9.251,9.339,P0.05),但B1组各时点RSS评分与S组无统计学差异(P0.05)。结论布托啡诺0.02 mg/kg能够安全有效地用于瑞芬太尼麻醉妇科腹腔镜术后镇痛。     

A Multicenter, Randomized, Controlled Trial Comparing Bupivacaine with Ropivacaine for Labor Analgesia

Background: A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl.

Methods: This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 [mu]g/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 [mu]g/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes.

Results: There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients;P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively;P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively;P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean +/- SD: 76 +/- 23 vs. 72 +/- 23, respectively;P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean +/- SD: 71 +/- 25 vs. 66 +/- 26, respectively;P = 0.037).     

Abdominal Aortic Surgery and Horseshoe Kidney

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.     

Autologous Versus Allogeneic Transfusion in Aortic Surgery: A Multicenter Randomized Clinical Trial

OBJECTIVE: To evaluate the efficacy of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS) in blood-conservation strategies for infrarenal aortic surgery. SUMMARY BACKGROUND DATA: Recent concerns over the risks of transfusion-related infection have resulted in sharp rises in the cost of blood preparations. Autologous transfusion may be a safe alternative to allogeneic transfusion, which has been associated with immune modulation and postoperative infection. METHODS: This multicenter prospective randomized trial compared standard transfusion practice with autologous transfusion combining ANH with ICS in 145 patients undergoing elective aortic surgery. The primary outcome measures were the proportion of patients requiring allogeneic blood and the volume of allogeneic transfusion. The secondary outcome measures were the frequency of complications, including postoperative infection, and postoperative hospital stay. RESULTS: The combination of ANH and ICS reduced the volume of allogeneic blood transfused from a median of two units to zero units. The proportion of patients transfused was 56% in allogeneic and 43% in autologous. There were no significant differences in complications or length of hospital stay. CONCLUSIONS: Both ANH and ICS were safe and reduced the allogeneic blood requirement in patients undergoing elective infrarenal aortic surgery.     

全膝关节置换术后股神经阻滞自控镇痛的随机对照研究

目的比较患者自控与恒速输注2种给药方案对全膝关节置换术后患者股神经阻滞镇痛的效果。方法 2010年3月～11月选择60例单侧全膝关节置换术,椎管内麻醉前在超声及神经刺激器引导下置入连续股神经阻滞导管,将阻滞效果完全的患者按随机数字表随机分为2组：恒速输注组（CI组）和患者自控镇痛组（PCA组）。CI组经导管持续输注0.2%罗哌卡因5 ml/h,PCA组输注0.2%罗哌卡因背景量5 ml/h,单次注射5 ml/次,锁定时间60 min。记录2组患者静息痛及运动状态下疼痛评分、满意率以及不良反应发生情况。结果 3例在首次给药后30 min内没有达到完全阻滞而被排除。术后1～3 d静息及主动锻炼时疼痛评分2组无显著性差异（P〉0.05）。术后1～3 d被动锻炼时疼痛评分PCA组（4.7±1.3,4.5±1.0,4.5±1.0）显著低于CI组（6.5±1.6,6.1±1.6,5.9±1.6）（P〈0.05）。患者满意度PCA组显著高于CI组[8（6～10）vs.7（4～9）]（Z=16.957,P=0.031）。2组患者均无耳鸣、口周麻木、眩晕等局麻药中毒症状同,均无因下肢无力而跌倒,无导管脱出。结论与恒速输注相比,患者自控股神经阻滞能够提高术后康复运动时的镇痛效果。     

Intraoperative Epidural Analgesia Prevents the Early Proinflammatory Response to Surgical Trauma. Results from a Prospective Randomized Clinical Trial of Intraoperative Epidural Versus General Analgesia

Background  

The intraoperative epidural analgesia (EA) has the potential to reduce stress response to surgical trauma which induces a transient immunoactivation that has a negative impact on the outcome. This study investigates the effect of intraoperative EA versus intravenous analgesia (IA) on the immune function.