A prospective randomized single-blind trial comparing ultrasonic scalpel tonsillectomy with tonsillectomy by blunt dissection in a pediatric age group.

OBJECTIVE: To determine if there was a difference in postoperative pain and dietary intake when comparing ultrasonic scalpel (US) with blunt dissection tonsillectomy (BD) in children. STUDY DESIGN AND SETTING: A prospective single-blind randomized controlled trial comparing US and BD tonsillectomy in children aged between 5 and 13 years who undergo tonsillectomy for recurrent acute tonsillitis in a specialized pediatric hospital. RESULTS: One hundred and twenty-two children were enrolled. Ninety-three (76%) patients completed dietary and pain scales. Pain was significantly greater in the US group on postoperative days 1 and 3 (P = 0.0466, P = 0.0084) and overall (P = 0.0003). Dietary intake scores were significantly better in the US group on days 1, 5, 7, and 9, however, these scores were inconsistent with dietary intake scores declining in both groups throughout the study. Blood loss was statistically significantly greater in the BD group (33.1 ml vs 3.0 ml, P < 0.0001). There were no significant differences for all other observed outcomes. CONCLUSIONS: US tonsillectomy causes significantly more pain overall and on postoperative days 1 and 3 when compared to BD tonsillectomy. US tonsillectomy causes less intraoperative blood loss, the clinical significance of which is questionable. SIGNIFICANCE: US tonsillectomy appears to cause more postoperative pain than BD tonsillectomy in children aged 5 to 13 years undergoing tonsillectomy for recurrent acute tonsillitis.     

Hot versus cold tonsillectomy: a systematic review of the literature.

OBJECTIVE: We systematically reviewed the literature comparing monopolar electrocautery versus cold knife dissection tonsillectomy. METHODS: The MEDLINE database was searched using the key words "tonsillectomy," "hot," "cold," "sharp," "bleeding," and "cautery." Selection criteria included prospective trials comparing electrodissection versus cold knife dissection on posttonsillectomy pain and hemorrhage. Six of the 815 articles met the selection criteria. RESULTS: Pooled data for the paired studies showed significantly more patients with pain worse on the electrodissection side (148 of 293 = 51%) than the cold knife side (33 of 293 [11%]; P = 0.001) on postoperative days 4 to 10. There were significantly more analgesic doses after surgery with electrodissection (means 26.7 versus 19.2; P = 0.028) and higher pain scores for adults undergoing electrodissection (means, 2.6 versus 0.8; significance could not be determined). There were no differences in hemorrhage rates. CONCLUSIONS: Electrodissection increases pain in comparison to sharp dissection for tonsillectomy. Postoperative hemorrhage rates are not significantly different when comparing the 2 methods.     

Effect of pre- vs postoperative tonsillar infiltration with local anesthetics on postoperative pain after tonsillectomy

Background : Since pre-incisional peritonsillar infiltrations of local anesthetic solutions have been suggested to reduce postoperative pain after tonsillectomy, we compared the efficacy of either pre- or postoperative local anesthetic infiltration upon post-tonsillectomy pain. Methods : After the induction of general anesthesia, 68 consecutive healthy patients, ranging in age from 8 to 65 years, were randomly allocated to either receive peritonsillar infiltration with 0.25% bupivacaine (group 1) or normal saline (group 2) before incision. A third group (group 3) had their peritonsillar region infiltrated with 0.25% bupivacaine after the completion of surgery but before the patients were awakened from anesthesia. All the patients were treated in the same way in the postoperative period: NSAIDs were given intravenously to adults and rectally to children. Acetaminophen was given intravenously or rectally (children aged < 15 yr) if additional analgesic support was requested by the patient. Additional acetaminophen consumption was recorded daily. Pain scores were assessed on every patient with the use of a visual analogue scale (VAS) at rest, 1, 5, 9, 13, 17, 21 and 36 h after surgery, and also on swallowing during the first postoperative day. Results : Global VAS pain scores were lower in the groups treated with bupivacaine infiltration during the first 24 h after surgery (P < 0.05). Supplementary analgesic consumption was lower in group 3 than in group 2 during the 0–9 h interval immediately following surgery (P < 0.05). There were no statistically significant differences for any other parameters between the 3 groups. Conclusion : These results suggest that the timing of peritonsillar infiltration with bupivacaine is not of clinical importance and does not affect the quality of postoperative analgesia in patients undergoing tonsillectomy.     

Microscopic tonsillectomy: A double-blind randomized trial

OBJECTIVE: To evaluate microsurgical bipolar cautery tonsillectomy (TE_mic ) by comparing it with traditional blunt dissection tonsillectomy (TE_trad ).DESIGN: A double-blind prospective randomized trial with stratification in two age groups.PATIENTS: 200 consecutive patients undergoing tonsillectomy for tonsillar hypertrophy, or recurrent or chronic tonsillitis.OUTCOME MEASURES: Duration of surgery, intraoperative bleeding, daily postoperative pain and otalgia, postoperative bleeding episodes.METHODS: Duration of surgery and operative bleeding were evaluated by the anesthesiologist. The patients were instructed to record daily pain and otalgia. Final postoperative evaluation was done by a different physician, blinded to the surgical technique.RESULTS: Mean intraoperative bleeding was 12 ml for TE_mic and 36 ml for TE_trad ( p < 0.001). Mean duration of surgery was 37 minutes for TE_mic and 36 minutes for TE_trad (NS). Otalgia was present in 41% of TE_mic patients and 69% of TE_trad patients ( p < 0.001). Daily postoperative pain was lower in the TE_mic group than it was in the TE_trad group for the entire study period (10 days). Postoperative hemorrhage was present in three TE_mic patients (3%) and in eight TE_trad patients (8%), a difference that did not reach significance ( p > 0.1).CONCLUSION: Microsurgical bipolar cautery tonsillectomy compares favorably with traditional techniques in terms of intraoperative bleeding, postoperative pain, otalgia, and hemorrhage. This technique combines the hemostatic advantage of cautery dissection, the excellent visualization achieved by a microscope, and, with the use of a video, greatly improves the physician’s ability to teach how to perform a tonsillectomy. (Otolaryngol Head Neck Surg 1997;117:641-7.)     

A case of corrosive esophagitis with stenosis

A 41-year-old man was admitted to our hospital because of pharyngeal pain and vomiting after intentionally swallowing sodium hydroxide. Gradually esophageal stenosis took place. After 9 months from the taking poison the patient was operated. We tried blunt dissection of esophagus. But the procedure failed in because the wire of stripper was cut. So performed total esophageal resection under the right thoracotomy. The right side colon was used to re-construction through antero-sternal space that was anastmosed to cervical esophagus and stomach. The postoperative course was uneventful.     

Preoperative flurbiprofen for pain prevention after tonsillectomy in adults

STUDY OBJECTIVE: To investigate the analgesic efficacy of preoperative flurbiprofen on postoperative pain after tonsillectomy. DESIGN: Prospective, randomized, nonblinded, non-placebo-controlled study. SETTING: Municipal hospital. PATIENTS: Twenty-five ASA physical status I patients older than 20 years of age, who were scheduled for tonsillectomy. INTERVENTIONS: Patients were randomly allocated to two groups to receive preoperative intravenous (IV) 50 mg flurbiprofen (group F) or not (group C). Anesthesia was induced with IV propofol two mg/kg and maintained with nitrous oxide and sevoflurane. MEASUREMENTS: Pain scores at rest and at swallowing, intraoperative bleeding, vital signs during the postanesthetic period, interval until diclofenac sodium suppository rescue, and the total dose required for 12 hours postoperatively were all recorded. MAIN RESULTS: Pain scores at rest as well as those recorded after swallowing 30 minutes after tonsillectomy were significantly lower in group F than in group C. During the first postoperative 1.5 hours, significantly fewer patients in group F required rescue diclofenac suppository than did group C patients. However, total dose of required rescue during the postoperative 12 hours in group F did not significantly differ from that of group C. There were no significant differences in intraoperative bleeding or in any vital signs during the postanesthetic period either. CONCLUSION: Preoperative flurbiprofen suppressed immediate postoperative pain after tonsillectomy. The analgesic effect, however, disappeared in a few hours and was insufficient for overnight pain relief.     

Preemptive gabapentin reduces postoperative pain and opioid demand following thyroid surgery

PURPOSE: Gabapentin is reported to possess antihyperalgesic and antiallodynia properties. Recently, reports have indicated that gabapentin may have a place in the treatment of postoperative pain. In this study, we sought to determine whether preemptive use of gabapentin reduced postoperative pain and morphine demand following thyroidectomy. METHODS: In this prospective, randomized, double-blind clinical trial, we gave gabapentin 1200 mg or placebo two hours prior to induction of anesthesia to patients undergoing elective thyroidectomy. Post-thyroidectomy pain was assessed on a visual analogue scale at rest and during swallowing in the first 24 hr postoperatively. All patients received morphine 3 mg iv every five minutes until visual analogue scale scores were 4 or less at rest, and 6 or less with swallowing. Total morphine consumption for each patient was recorded from zero to 24 hr postoperatively. RESULTS: Thirty-seven patients in the gabapentin group and 35 patients in the placebo group completed the study. Overall, pain scores at rest and during swallowing in the gabapentin group were significantly lower when compared with the placebo group. Total postoperative morphine consumption in the gabapentin group was 15.2 +/- 7.6 mg (mean +/- SD) vs 29.5 +/- 9.9 mg in the placebo group (P < 0.001). No significant differences in side effects were observed between groups. CONCLUSIONS: Preoperative gabapentin decreased pain scores and postoperative morphine consumption in patients following thyroid surgery.     

Ketamine reduces swallowing-evoked pain after paediatric tonsillectomy

BACKGROUND: Ketamine efficacy as an analgesic adjuvant has been studied in several clinical settings with conflicting results. The aim of this study was to investigate the effect of ketamine on spontaneous and swallowing-evoked pain after tonsillectomy. METHODS: Fifty children were randomized to receive premedication with either ketamine 0.1 mg kg(-1) i.m. or placebo given 20 min before induction of a standard general anaesthesia. All children received rectal diclofenac 2 mg kg(-1) and fentanyl 1 micro g kg(-1) i.v. before surgery. RESULTS: The ketamine group showed significantly lower pain scores both at rest and on swallowing, with less total paracetamol consumption (P < 0.05) during the 24 h after surgery. Significantly more patients required postoperative morphine titration in the control group (P < 0.05). The time to the first oral intake, and duration of i.v. hydration, were significantly shorter and the quality of oral intake was significantly better in the ketamine group (P < 0.05). There were no differences in the incidence of vomiting or dreaming between the groups. CONCLUSION: Premedication with a small dose of ketamine reduces swallowing-evoked pain after tonsillectomy in children who received an analgesic regimen combining an opioid and a NSAID.     

Preoperative peritonsillar infiltration of dexamethasone and levobupivacaine reduces pediatric post-tonsillectomy pain: a double-blind prospective randomized clinical trial

Background

Preoperative corticosteroids reduce post-tonsillectomy morbidities. The present study was performed to compare the effect of peritonsillar dexamethasone infiltration to intravenous injection together with peritonsillar levobupivacaine infiltration before tonsillectomy on postoperative pain in children.

Methods

One hundred twenty children, ASA I–II, aged 6–12 years, scheduled for adenotonsillectomy were enrolled in the study. They were randomized equally into two equal groups; 60 children each. Group A received peritonsillar infiltration with dexamethasone and levobupivacaine, and group B received i.v. dexamethasone and peritonsillar levobupivacaine infiltration. Rest and swallowing pain in the first postoperative day using a visual analogue scale, time to first rescue analgesia, cumulative paracetamol dose, vomiting, and adverse effects related to both interventions during the first postoperative day were recorded. Children care givers were asked to score pain using a verbal rating scale and to disclose complications as halitosis, headache, fever and otalgia during the first postoperative week.

Results

Time to first rescue analgesia was significantly longer in group A. Rest and swallowing pain in the first postoperative day, cumulative paracetamol dose, pain in the second and third postoperative days, and otalgia were significantly lower in group A. None of children developed postoperative bleeding, or complications related to dexamethasone or levobupivacaine infiltration. There was no significant difference in postoperative emesis, fever and halitosis between the groups.

Conclusion

Addition of dexamethasone to levobupivacaine for preoperative peritonsillar infiltration has better postoperative analgesic effects than i.v. dexamethasone combined with peritonsillar levobupivacaine infiltration in children.     

Postoperative Adhesion Formation in a Rabbit Model: Monopolar Electrosurgery Versus Ultrasonic Scalpel

Background and Objectives:

To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period.

Methods:

Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators.

Results:

There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30).

Conclusion:

Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.     

超声刀与电凝在腹腔镜结直肠癌手术中的疗效比较

目的 比较超声刀与电凝在腹腔镜结直肠癌手术中的安全性与有效性.方法 2002年5月至2006年12月间,82例结直肠癌患者行腹腔镜结直肠手术,手术中分别应用超声刀(44例)和电凝(38例),比较两组的手术时间、出血量、使用止血夹数及术后肠功能恢复时间、平均住院时间和术后并发症发生率.结果 超声刀组出血量明显少于电凝组(P＜0.05);超声刀组使用止血夹数(2.3枚/例)明显少于电凝组(5.1枚/例)(P＜0.05).而术后肠功能恢复时间和平均住院时间两组差异无统计学意义(P＞0.05).超声刀组并发症发生率2.3%,明显低于电凝组的10.5%,两组比较差异有统计学意义(P＜0.05).结论 超声刀在腹腔镜结直肠外科应用中出血量少、使用止血夹数少、术后并发症少,是安全可靠的止血工具.     

Inclusion of pethidine in lidocaine for infiltration improves analgesia following tonsillectomy in children

Background: Previous work has demonstrated that pethidine exerts local anaesthetic effects on peripheral nerves in vivo. We examined the effects of infiltration anaesthesia by a combination of pethidine and lidocaine on post-tonsillectomy pain and restlessness in children.
Methods: Eighty children were randomly allocated to receive peritonsillar infiltration postoperatively with 3 ml of lidocaine 2% (1.5 ml on each side) combined with either 0.1 ml pethidine, 10 mg · ml^-1, (pethidine group) or 0.1 ml normal saline (control group). Pain and behaviour were assessed at 1, 3, 6 and 12 h postoperatively and on the following morning by the patients and by a nurse blinded to previous treatment.
Results: Patients in the pethidine group had lower pain scores than those in the control group at rest as well as swallowing during the whole observation period ( P < 0.05). Paracetamol was given to 34/40 children in the control group and to 6/40 children in the pethidine group. The corresponding figures for pethidine administration were 6/40 and 0/40, respectively. Patients in the pethidine group displayed a more rapid return to calm wakefulness than those in the control group ( P <0.01).
Conclusions: Inclusion of a low dose of pethidine in lidocaine for tonsillar infiltration improves pain relief after tonsillectomy in children.     

A comparison of tonsillectomy with the harmonic scalpel versus electrocautery.

OBJECTIVE: We sought to test whether the use of the harmonic scalpel would cause less pain and more rapid recovery in tonsillectomy patients versus the use of electrocautery. DESIGN AND SETTING: In a private practice community hospital, we conducted a prospective nonrandomized comparison of 156 pediatric tonsillectomy cases. Local anesthetic infiltrations and steroids were used at the discretion of the surgeon. Outcome variables consisted primarily of immediate- and mid-term pain, pain medications required, time to eating, morbidities and charges. RESULTS: There were no differences between the groups on an intention-to-treat basis except for costs, which were higher in the harmonic scalpel group. When rescue use of electrocautery was required to control bleeding in the in the harmonic scalpel patients, more pain and longer times to taking food were noted. CONCLUSIONS: Used with discretion the harmonic scalpel is equivalent to electrocautery for tonsillectomy. SIGNIFICANCE: The harmonic scalpel does not provide a major benefit over more conventional methods of tonsillectomy.     

Swallowing before and after tonsillectomy as evaluated by surface electromyography.

OBJECTIVES: Surface electromyography (sEMG) was performed on adult patients (n = 40) following tonsillectomy to evaluate recovery by objective means. METHODS: Evaluated parameters included timing of swallowing and continuous drinking, electric amplitude and graphic patterns of masseter (MS), and measurement of infrahyoid (INF) and submental (SUB) muscles after tonsillectomy and comparison with normative database. RESULTS: The duration of drinking periods showed significant increase among patients; single-swallow durations remained normal. The electric activity of MS and INF muscles was significantly higher among the patients compared with normative database. It took one month until all the EMG data returned to normal. CONCLUSION: Tonsillectomy affects muscle activity during swallowing by involving additional muscles in deglutition. EMG is a simple reliable method for postoperative evaluation and might contribute to comparative analysis of different tonsillectomy techniques. EMG can be used during pre- and postoperative stages to monitor recovery and functional improvement of throat muscles and deglutition. SIGNIFICANCE: The reported sEMG method and obtained data might be further used: 1) As an additional tool for comparison of different methods of tonsillectomy (eg, cold vs hot dissection, laser surgery, etc); 2) For further development of objective postsurgical pain assessment; 3) As an additional tool for assessment and development of less traumatic surgical technique; and 4) For monitoring of recovery in difficult cases.     

Postoperative pain following coblation tonsillectomy: randomized clinical trial

BACKGROUND: Tonsillectomy is one of the commonest surgical procedures, with postoperative pain being an important source of morbidity. Coblation (cold ablation) is a new technique for tonsillectomy, promoted by claims of reduced postoperative pain levels. This study was designed to compare postoperative pain after tonsillectomy using coblation and tonsillectomy using the standard dissection techniques. METHODS: Twenty adult patients underwent tonsillectomy, each having one randomly selected tonsil removed by dissection and the other removed by coblation. For each side, subjective pain levels were recorded on a daily basis for 10 postoperative days, using a visual analogue scale. RESULTS: Coblation tonsillectomy was significantly less painful than dissection tonsillectomy on day 1 (P < 0.001), day 2 (P = 0.003) and day 3 (P = 0.018). For all subsequent postoperative days, there was no significant difference in pain levels between the techniques. CONCLUSION: Coblation tonsillectomy causes significantly less pain during the first three postoperative days, when compared with dissection tonsillectomy. No demonstrable benefit was shown on days 4-10. The beneficial effects of coblation on early postoperative pain make it a potentially attractive technique for day-case tonsillectomy in adults with recurrent or chronic tonsillitis.     

Parenteral ketoprofen for pain management after adenoidectomy: comparison of intravenous and intramuscular routes of administration

BACKGROUND: Different parenteral routes of administration of NSAIDs such as ketoprofen have not been properly compared in children. This study was designed to compare the analgesic efficacy of intravenous and intramuscular ketoprofen for pain management in children after day-case adenoidectomy. METHODS: A total of 120 children, aged 1-9 years, who were scheduled to undergo adenoidectomy, were randomized to receive ketoprofen 2 mg/kg either intravenously with intramuscular placebo (n = 40) or ketoprofen 2 mg/kg intramuscularly with intravenous placebo (n = 40), or both intravenous and intramuscular placebo (n = 40) at induction of anesthesia. The study design was prospective and double-blind with parallel groups. Pain was assessed at rest and during swallowing using the Maunuksela pain scale during 3 h after surgery, and fentanyl i.v. was given for rescue analgesia. RESULTS: Children in the Placebo group needed significantly more doses of fentanyl (72 doses) than either children in the intravenous group (47 doses) or children in the intramuscular group (51 doses) (P = 0.021). In addition, a higher proportion of children in the Placebo group than in the two ketoprofen groups (P = 0.03) demanded rescue analgesic. No difference in the need for rescue analgesia or in pain scores was found between the two ketoprofen groups. Children in the intravenous group had less pain than children in the Placebo group. The difference was significant during swallowing at 1 h after surgery (P = 0.046) and for the worst pain observed during swallowing for 3 h after surgery (P = 0.022). There were no differences between the three groups with respect to operation times, amount of perioperative bleeding, or rate or extent of adverse events. CONCLUSION: The efficacy of intravenous and intramuscular ketoprofen was similar, and they both differed from placebo.     

Sucralfate for posttonsillectomy analgesia

Pain is one of the most troublesome complications of tonsillectomy. The pain appears as throat pain, otalgia, or both, and continues until mucosal recovery on the tonsillar fossae is complete. Some surgical and hemostasis techniques may increase pain. Analgesics, antibiotics, steroids, and local and topical anesthetics are used to relieve posttonsillectomy pain, but none has the desired effectiveness. The pain reliever must not increase bleeding and must have minimal side effects. Sucralfate, a basic amino salt of sucrose octasulfate, binds to the matrix protein of a peptic ulcer and produces a protective barrier. Tonsillectomy leaves two large ulcerous wounds, and sucralfate may bind those wounds as it does peptic ulcers. In this controlled study, the efficacy of sucralfate on posttonsillectomy throat pain, otalgia, analgesic requirement, degree of strength, bleeding, body temperature, and mucosal recovery is investigated in 80 patients. Sucralfate is found to significantly reduce throat pain and analgesic requirement after surgery. (Otolaryngol Head Neck Surg 1998;119:700-4.)     

Dissektionstechniken in der Leberchirurgie

The first liver resection was performed in 1888. Since then a wide variety of dissection techniques have been introduced. The blunt dissection was replaced by novel methods, i.e. the CUSA technique and the Jet Cutter for major liver resections. These methods represent selective dissection techniques; whereas non-selective methods include the scalpel, scissors, linear stapling cutter, high-frequency coagulation, and the laser technique. The aim of this review article is the comparison of the different resection techniques in liver surgery, focussing on blood loss and resection time.     

Comparison between tonsillectomy with thermal welding and the conventional 'cold' tonsillectomy technique

Background: The aim of this study was the evaluation of length of the procedure, anaesthesia, the amount of the intraoperative fluid required, total blood loss and postoperative pain of the ‘thermal welding system tonsillectomy (TWS)’ compared with the conventional ‘cold dissection tonsillectomy’. Methods: Fifty patients aged between 3 and 28 years were included in this prospective controlled study. Extracapsular tonsillectomy with TWS was carried out on 25 patients and conventional ‘cold’ extracapsular dissection complete tonsillectomy was carried out on the other 25 patients. Haemostasis was achieved with packing and 3/0 chromic catgut suture is used to treat the persistently bleeding sites in the ‘cold’ tonsillectomy group. Intraoperatively, the duration of the procedure, anaesthesia, the amount of the required intraoperative fluid, the total blood loss and the number of sutures were documented for each patient. In the hospital, the postoperative amount of intravenous fluids, oral intake (timing of onset and amount), the duration and the total dose of analgesics were recorded. Daily assessment included the type of diet, the level of appetite, the total number of analgesics, the presence of fever, the time required to return to normal activity and the pain score (twice daily). Pain was measured by means of Faces Pain Scale and Visual Analogue Scale. Results: There was a statistically and clinically significant difference in the operating time in the intraoperative blood loss in favour of the conventional tonsillectomy group (P > 0.05). Although there was no statistically significant difference between the two groups for the postoperative evening pain scores (P > 0.05), there was a statistically significant difference for the morning pain scores (P < 0.05) in the first 2 days postoperatively (P > 0.05) and in the level of appetite in the first postoperative day (P > 0.05). The other outcome measures did not show any statistically significant difference. Conclusion: When we compared TWS with the conventional ‘cold’ dissection tonsillectomy, we found that TWS tonsillectomy offered an innovative new tonsillectomy method with significantly reduced blood loss and reduced surgical time and without any increase in the postoperative pain. It was a useful method for tonsillectomy.