Long-term results of bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis

BACKGROUND: The management of pain in patients with chronic pancreatitis is difficult. The aim of this prospective study was to evaluate the early and long-term pain relief provided by bilateral thoracoscopic splanchnicectomy. METHODS: From August 1995 to August 1999, 44 patients with chronic pancreatitis underwent bilateral thoracoscopic splanchnicectomy. Data were collected prospectively. Thirty-six patients required opioids. Pain intensity was registered before operation and at regular intervals after surgery by means of a visual analogue scale (VAS). Use of analgesics (opioids; non-steroidal anti-inflammatory drugs and acetaminophen; no analgesics or aminocetophen) was noted before and after splanchnicectomy. Median follow-up was 36 (range 12-60) months. RESULTS: The procedure was technically successful in 40 patients. Thirty-six patients had no complications. Eleven of 24 patients who have been followed up for 24 months or more had a significantly reduced VAS score at 2 years (median (range) 8.5 (7-10) versus 2.5 (0-5); P < 0.01). The cumulative rate of pain relief was 46 per cent 48 months after splanchnicectomy. CONCLUSION: Bilateral thoracoscopic splanchnicectomy alleviated pain in patients with chronic pancreatitis. It was associated with a low morbidity rate and no deaths. Pain eventually recurred in approximately 50 per cent.     

Management of chylothorax after thoracoscopic splanchnicectomy.

Thoracoscopic splanchnicectomy is a minimally invasive procedure used in the treatment of recalcitrant abdominal pain in patients with chronic pancreatitis or pancreatic carcinoma. Chylothorax, an uncommon complication of thoracoscopic splanchnicectomy, may lead to a protracted, costly hospital course of treatment usually consisting of central venous hyperalimentation, restricted oral intake, and tube thoracostomy. In our series of 25 patients who underwent thoracoscopic splanchnicectomy, 2 developed postoperative chylothorax. Both patients failed conservative management and ultimately underwent operative reintervention, at which time, leaking lymphatics were easily identified and closed using minimally invasive techniques. On the basis of this experience, we advocate early thoracoscopic reintervention in patients with chylothorax after thoracoscopic splanchnicectomy.     

Thoracoscopic splanchnicectomy for “small” duct chronic pancreatitis: Case selection by differential epidural analgesia

Management of patients with intractable pain from “small duct” chronic pancreatitis has been difficult, often resulting in narcotic addiction and/or malnutrition from major pancreatic resection. Recently, denervation of sympathetic pain afferents from the pancreas by surgical splanchnicectomy has shown promise in relieving pain while preserving residual pancreatic function. However, results from surgical splanchnicectomy have been mixed in large part because of patient selection. Differentiating actual pancreatic pain from “pancreatic” pain caused by drug-seeking behavior, psychogenic diseases, or various somatically innervated conditions is clinically challenging at best. Between 1992 and 1996, twenty-two patients with 20 prior pancreatic operations, “small duct” chronic pancreatitis, and “pancreatic” pain requiring narcotics were evaluated. Each underwent differential epidural analgesia (DEA) using the following standard techniques: placebo, low-dose (sympathetic), and high-dose (somatic) blocks. Pain perceptions were recorded before and after DEA using a visual analogue scale (VAS). Six demonstrated a greater than 50% decrease in VAS pain after placebo injection and were eliminated from further study. In the remaining 16 patients, pain relief only occurred with sympathetic or somatic blockade. Greater and lesser splanchnicectomy (surgical splanchnicectomy) was performed 27 times in these 16 patients (11 bilateral, 6 synchronous) (5 unilateral; 2 right and 3 left) using thoracoscopic techniques in 14 patients and open thoracotomy in two. No significant surgical or anesthetic complications were encountered. Surgical splanchnicectomy resulted in an overall significant reduction in preoperative VAS scores (8.25 to 4.18; P <0.05). Ten of 13 patients with DEA-predicted sympathetic pain experienced a greater than 50% decrease in VAS after surgical splanchnicectomy, but only two had complete relief. None of the three patients with DEA-predicted somatic pain were benefited by splanchnicectomy. During an average follow-up of 23.3 months, initial good results from surgical splanchnicectomy were maintained in 8 of 10 patients. The following conclusions were reached: (1) surgical splanchnicectomy is a safe, often effective technique for amelioration of intractable pain from “small duct” chronic pancreatitis and (2) DEA is a promising approach for identifying patients most likely to respond to surgical splanchnicectomy. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Continuing experience with palliative chemical splanchnicectomy.

Forty-one patients underwent open phenol splanchnicectomy for control of pain at the time of initial laparotomy for what was thought to be unresectable pancreatic carcinoma. Twenty-three patients underwent concomitant biliary and/or intestinal bypass procedures. In no patient was laparotomy performed only for the purpose of performing splanchnicectomy. The operative mortality was 15%. In no patient could the addition of splanchnicectomy be implicated as the cause of death. Eighty-eight per cent of patients experienced relief of pain postoperatively. The mean duration of pain control was 4.3 months. The mean postoperative survival was five months. No postoperative complications could be attributed to the addition of splanchnicectomy. Open phenol splanchnicectomy is a highly successful and safe ancillary procedure for control of pain and is recommended at the time of initial laparotomy in patients found to have advanced intra-abdominal neoplasm.     

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas

Background: Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. Methods: Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30–85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. Results: All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58 ± 22 min for unilateral left splanchnicectomy and 93.5 ± 15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8–10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2–5). Conclusions: We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short. Received: 23 December 1999/Accepted: 6 January 2000/Online publication: 12 July 2000     

Thoracoscopic splanchnicectomy for pain control in irresectable pancreatic cancer

AIM: Disabling pain for many patients with irresectable pancreatic cancer is poorly managed and can remain a significant problem until death. The aim of this study was to evaluate the safety and efficacy of thoracoscopic splanchnicectomy for pain control in patients with irresectable pancreatic cancer. PATIENTS AND METHODS: Thirteen patients suffering from intractable pain due to irresectable pancreatic cancer underwent 15 attempted thoracoscopic splanchnicectomy procedures. All patients were opiate dependent. Right-sided splanchnicectomy was performed for a dominantly right-sided pain, whereas a centralized, bilateral, or left-sided pain was managed by left splanchnicectomy. If pain recurred, patients were offered to have the procedure repeated on the contralateral side. RESULTS: Thoracoscopic splanchnicectomy procedure was a technical failure because of pleural adhesions in 1 patient. Fourteen (10 left- and 4 right-sided) thoracoscopic splanchnicectomies were successfully completed in 12 patients. Immediate pain relief was achieved in all 12 patients after unilateral thoracoscopic splanchnicectomy. Pain relief persisted until death in 8 patients and until the latest postoperative follow-up visit at 5 months in 1 patient. Two patients required a contralateral procedure for pain recurrence. A 3rd patient had a recurrent pain but refused contralateral intervention. Except for the latter, none of the patients required opioids. CONCLUSION: Thoracoscopic splanchnicectomy is a safe, simple, and effective minimally invasive procedure. It offers a substantial relief of pain in patients with unresectable pancreatic cancer.     

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目的　探讨经腹行左侧内脏大神经切断术对顽固性上腹痛的临床治疗效果。方法　 1998年 10月至2 0 0 0年 4月共为 37例难治性上腹及腰背痛病人经腹行左侧内脏大神经切断术 ,其中 32例为胰源性疾病 ,余 5例为邻近器官肿瘤。结果　手术前病人疼痛平均为 (9 47± 0 5 5 )分 ,术后平均为 (1 5 3± 1 0 6 )分 ,差异明显 (P <0 0 1)。病人术后住院期间全部无需止痛药物 ,术后随访无疼痛再发。结论　经腹行左侧内脏大神经切断术治疗难治性腹痛 ,疗效确切 ,操作简单 ,并发症少。对于上腹部腹膜后肿瘤引起的难治性疼痛也可以应用此术式治疗。     

Manipulation after total knee arthroplasty

BACKGROUND: Following total knee arthroplasty, some patients who fail to achieve >90 degrees of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty. METHODS: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of < or =90 degrees at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively. RESULTS: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102 degrees prior to total knee arthroplasty, 111 degrees following skin closure, and 70 degrees before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027). CONCLUSIONS: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.     

Hand-assisted laparoscopic vs the open (flank incision) approach to radical nephrectomy

OBJECTIVE: To compare the outcome in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open (flank) radical nephrectomy (ORN), as many series worldwide have confirmed the feasibility and advantages of LRN in managing renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively evaluated 44 patients who underwent radical nephrectomy for RCC from 1999 to 2001, 22 by HALRN and 22 by ORN, through an extraperitoneal 11th or 12th rib flank incision. Standard perioperative variables were assessed; a validated questionnaire was also sent to each patient after surgery, allowing them to report their overall satisfaction and the period needed for them to return to both routine and full activities. The outcomes of HALRN and ORN were compared using Wilcoxon rank-sum analysis. RESULTS: There was a statistically significant difference between HALRN and ORN in operative duration, length of hospital stay, total narcotic requirement, pain scores at 1 week and 1 month after surgery, and the time to resume routine and full activity, with all variables (except operative duration) lower in the HALRN group. There were no significant differences between the groups in pain at 1-3 days, estimated blood loss or overall satisfaction. CONCLUSION: Compared with ORN, HALRN is associated with lower narcotic requirement, pain scores, a shorter hospital stay and earlier resumption of routine and full activities. However, several obstacles remain, including increased operative duration and the increased equipment costs.     

Effect of combined erector-spinae plane blocks on the immediate postoperative neuronal and stress biomarkers after thoracoscopic radical resection for lung cancers

BackgroundThis study evaluates the impact of general anesthesia combined with erector spinae plane blocks (ESPB) on patients who underwent thoracoscopic radical resection (TRR) for lung cancer.MethodsThere involved a total of 108 patients undergoing TRR for lung cancers. Patients enrolled were equally allocated into experimental group (general anesthesia combined with ESPB) and control group (general anesthesia). The following parameters, including baseline characteristics, serum markers of neurological disorders, postoperative pain degree, dosage of narcotic, adverse events and early postoperative rehabilitation quality, were compared between the two groups.ResultsBased on Visual Analogue Scale, the postoperative pain degree was significantly lower in experimental group on 6h postoperative (P<0.001). And markedly lower results were observed in the levels of serum markers of neurological disorders in the experimental group one day after surgery (all P<0.05). Moreover, the dosage of narcotic and early postoperative rehabilitation quality based on QoR-40 scale were significantly lower in experimental group (all P<0.05).ConclusionAdding ESPB with general anesthesia reduce the postoperative pain up to 6 h, reduce the requirement of postoperative narcotic and help early postoperative rehabilitation quality.     

Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial.

OBJECTIVE: A prospective, randomized, double-blind study was completed comparing intraoperative chemical splanchnicectomy with 50% alcohol versus a placebo injection of saline in patients with histologically proven unresectable pancreatic cancer. METHODS: Standardized assessment of pain, mood, and disability due to pain was completed preoperatively and at 2-month intervals until death. Chemical splanchnicectomy with alcohol was performed in 65 patients, whereas 72 patients received the placebo. The two groups were similar with respect to age, sex, location, and stage of tumor, operation performed, the use of postoperative chemo- and radiation therapy, and initial assessment scores for pain, mood, and disability. RESULTS: No differences in hospital mortality or complications, return to oral intake, or length of hospital stay were observed. Mean pain scores were significantly lower in the alcohol group at 2-, 4-, and 6-month follow-up and at the final assessment (p < 0.05). To further determine the effect of chemical splanchnicectomy, patients were stratified into those with and without preoperative pain. In patients without preoperative pain, alcohol significantly reduced pain scores and delayed or prevented the subsequent onset of pain (p < 0.05). In patients with significant preoperative pain, alcohol significantly reduced existing pain (p < 0.05). Furthermore, patients with preexisting pain who received alcohol showed a significant improvement in survival when compared with controls (p < 0.0001). CONCLUSION: The results suggest that intraoperative chemical splanchnicectomy with alcohol significantly reduces or prevents pain in patients with unresectable pancreatic cancer.     

Nerve Blocks and Neuroablative Surgery for Chronic Pancreatitis

Surgical decompressive procedures for large-duct chronic pancreatitis have been notably successful in relieving pain. However, management of patients with intractable pain from small-duct chronic pancreatitis has been difficult, often resulting in narcotic addiction and/or malnutrition from major pancreatic resection. In view of the disappointing results from extensive pancreatic resections in these cases, denervation of pancreatic sympathetic pain afferents has been suggested as an alternative. Although denervation procedures have been attempted at multiple anatomical levels, results have unfortunately been mixed. The observed variability in results has been attributed to poor patient selection, incomplete understanding of neurophysiology of pancreatic pain, and perhaps inadequate knowledge of pancreatic neuroanatomy. At present, the preferred form of neural ablation is splanchnicectomy. However, a consistent and reliable method for identifying candidates for splanchnicectomy is critical, as it is clinically difficult to distinguish true pancreatic pain from other nociceptive conditions masquerading as pancreatic pain. Differential epidural anesthesia (DEA) is a promising, safe test for initial evaluation and patient selection, although it is not as precise as sometimes claimed. Patients responding to sympathetic block during DEA seem to be the best candidates for operative sympathetic ablation. At the moment, the optimal surgical approach to splanchnic ablation, which offers the least morbid technique, most favorable results, and an attractive risk–benefit ratio, is bilateral thoracoscopic splanchnicectomy. More experience and longer follow-up will be necessary to evaluate this approach.     

Perioperative rofecoxib plus local anesthetic field block diminishes pain and recovery time after outpatient inguinal hernia repair

In this study, we compared pain scores after inguinal herniorrhaphy in patients treated by preincisional local anesthetic field block (PL), or PL combined with perioperative rofecoxib, with controls who received standard care. Seventy-five patients having herniorrhaphy under general anesthesia were randomly assigned to receive a placebo pill preoperatively, and for 5 days postoperatively (CONT); preoperative bupivacaine field block and perioperative placebo (PL); preoperative field block plus rofecoxib, 50 mg preoperatively and for 5 days postoperatively (PLR). Bupivacaine infiltration in the wound at closure, IV fentanyl and acetaminophen/oxycodone were administered postoperatively to all. Discharge time, pain scores (0-10), analgesic use, and satisfaction scores (1-6) were compared using analysis of variance. PLR patients had lower maximum pain scores (worst pain) in the postanesthesia care unit (3.7 versus 5.3, P = 0.02) and at 24 h (5.3 versus 6.8, P = 0.03), were discharged 38 min sooner (P = 0.01), required 28% less oxycodone 0-24 h after discharge (P = 0.04), and reported higher satisfaction scores compared with CONT. Pain in PL was less than CONT for 30 min. There were no differences among the 3 groups after 24 h postoperatively. We conclude that perioperative rofecoxib with PL reduces in-hospital recovery time, decreases pain scores and opioid use, and improves satisfaction scores in the first 24 h after surgery.     

Randomized, controlled trial of bupivacaine injection to decrease pain after laparoscopic cholecystectomy.

OBJECTIVES: To determine if intraoperative instillation of bupivacaine would decrease early postoperative pain after laparoscopic cholecystectomy, if the patients would consequently require less narcotic postoperatively and if such patients would elect to be discharged on the day of operation if given the choice. DESIGN: Double-blind, randomized, controlled trial. SETTING: A tertiary care hospital in Hamilton, Ont. PATIENTS: Fifty patients underwent laparoscopic cholecystectomy. Day-surgery patients had the choice of staying overnight for discharge the following day. They were compared with a control group of 47 patients who had laparoscopic cholecystectomy but did not receive bupivacaine. INTERVENTION: Instillation of 20 mL of 0.5% bupivacaine with epinephrine into laparoscopic cholecystectomy port sites intraoperatively before closure. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores assessed 4 times postoperatively, the choice of patients to leave hospital the same day or to remain in the hospital overnight; the level of postoperative narcotic usage. MAIN RESULTS: Mean VAS pain scores (range 0 [no pain] to 5 [severe pain]) at less than 2 hours and at 6 hours after surgery were 2.9 and 2.9, respectively, in the bupivacaine group compared with 4.5 and 4.0, respectively, in the control group (p = 0.001 and 0.025). VAS scores at 10 hours postoperatively and the next morning did not differ between the groups. More patients in the bupivacaine group elected to go home on the day of surgery (p = 0.034). Narcotic usage was not significantly different. CONCLUSION: Instillation of bupivacaine into port sites should be standard practice for elective laparoscopic cholecystectomy.     

Intrapleural regional analgesia for pain management in cholecystectomy

Fifty patients undergoing cholecystectomy either electively or urgently were treated in the postoperative period with the intrapleural injection of 30 mL of 0.75% bupivacaine hydrochloride with epinephrine (1:200,000). The frequency of narcotic administration and the postoperative stay were compared with those of 50 historical controls. The group receiving intrapleural regional analgesia had significant, prolonged pain relief requiring minimal narcotic analgesics in the first 24 hours postoperatively and had a significantly shortened hospital stay. There were no complications related to catheter insertion or bupivacaine toxic effects. This technique is safe and effective in controlling perioperative pain.     

Pulmonary sequestration children: is the thoracoscopic approach a good option?

Background The thoracoscopic approach for pulmonary sequestration in children seems to be feasible and reproducible. To date, there have been no studies comparing the thoracoscopic approach with the conventional technique in this indication. Therefore, the aim of this study was to compare these two approachs.Methods We performed a retrospective study in patients treated surgically for a prenatal diagnosis of pulmonary sequestration between 2000 and 2003. Three or five ports were used, and single-lung ventilation was required. The clinical, operative, and postoperative data were compared with those for patients operated on during the same period via thoracotomy. For statistical purposes, the children who required conversion to the open proecedure were grouped with those who underwent thoracotomy. The following data were compared: age, and weight, operating time, duration of postoperative drainage via chest tube, duration of postoperative narcotic use, pain scores on the 1^st and 2^nd days after the procedure, and length of hospital stay. The Mann-Whitney test was used for statistical analysis.Results Five infants were operated on via a thoracoscopic approach. Two required conversion to an open procedure. There were four intralobar sequestrations (ILS) and one extralobar sequestration (ELS). The mean age at surgery was 6.2 months (range, 4–9). The mean operating time, excluding the patients who were converted to open, was 155 min (range, 120–190). In the thoracotomy group, there were one ELS and one ILS. Two groups were defined: the exclusively laparoscopy group (EL) (n = 3) and the thoracotomy and conversion group (TC) (n = 4). The duration of postoperative drainage, duration of postoperative narcotic use, and hospital stay seemed to be shorter in the group EL. These times, respectively, were 3.4 vs 2.75 days, 4.1 vs 3.3 days, and 7.5 vs 4.3 days = (p = 0.03). There were two complications in the TC group (one wound abcess and one pleural leak that required a chest tube).Conclusion The thoracoscopic approach for pulmonary sequestration is feasible. It seems to reduce the duration of postoperative drainage, postoperative narcotic use, hospital and stay. These results need to be confirmed by a prospective and more detailed study.     

Bilateral thoracoscopic splanchnicectomy with sympathectomy for managing abdominal pain in cancer patients

BACKGROUND: Simple interruption of splanchnic nerve can lead to incomplete transection of nerve fibers responsible for cancer-derived abdominal visceral because lots of neural communications exist. METHODS: From December 1999 to June 2005, a total of 21 cancer patients underwent bilateral thoracoscopic segmental resection of splanchnic nerve with sympathectomy for intractable abdominal pain based on the anatomic observation of 26 embalmed Korean cadaveric specimens in Yonsei University Medical Center, Seoul, Korea. All patients were preoperatively asked to rate the extent of their current pain by using the numeric rating scale (NRS), where 0 indicated no pain and 10 indicated intractable pain. The effectiveness of this thoracoscopic procedure was assessed based on the NRS reevaluated after surgery. RESULTS: NRS score was significantly reduced after thoracoscopic surgery (1.71 +/- 1.10 versus 8.52 +/- 1.08, paired t test, P < .0001). Sixteen patients (76.2%) could tolerate pain without or with reduced dose of analgesics. No mortality and morbidity were found in this study. CONCLUSION: This bilateral thoracoscopic splanchnicectomy with sympathectomy is safe, easy, and effective method in managing cancer-derived visceral abdominal pain.     

Efficacy of celecoxib for pain management after arthroscopic surgery of hip: a prospective randomized placebo-controlled study

The present work was conducted to examine whether celecoxib, a selective COX-2 inhibitor, 200 mg administered 1 h preoperatively to patients undergoing arthroscopic hip surgery reduces postoperative pain. Fifty-three patients undergoing arthroscopic hip surgery under spinal anesthesia were randomized to receive either 200 mg of celecoxib (Group I) or 200 mg of placebo (Group II) 1 h preoperatively. Narcotic use was monitored for 24 h, and time in recovery room was determined. Visual analog scale (VAS) scores and Short-Form 12 (SF-12), including a physical composite score (PCS) and a mental composite score (MCS), documented pain in recovery, 12 h postoperatively, and 24 h postoperatively. Moreover, time in recovery room was also investigated. We enrolled 27 patients in Group I and 26 patients in Group II. Groups were comparable for patient characteristics. No significant difference was detected in terms of VAS scores and SF-12 in recovery room. Statistically, patients in Group I showed significantly lower pain VAS scores at 12 and 24 h postoperatively. Patients taking celecoxib had significantly higher PCS at 12 and 24 h postoperatively. No difference occurred between groups for the MCS. Patients taking celecoxib also showed a significant reduction in postoperative narcotic consumption. The obtained results from the current study indicate that patients who took celecoxib 200 mg 1 h before arthroscopic hip surgery had a less painful and more rapid recovery. Celecoxib 200 mg as a single preoperative dose could be considered as part of a perioperative analgesic plan in arthroscopic hip surgery.     

Videoscopic heller myotomy as first-line therapy for severe achalasia.

To many nonsurgeons myotomy is considered an excessively invasive treatment for achalasia and has become a salvage procedure when esophageal dilation and botulinum toxin (botox) injections fail. We sought to examine our experience with videoscopic Heller myotomy to determine whether preoperative therapy predicts perioperative complications and long-term outcome. Videoscopic Heller myotomy was undertaken in 111 patients with achalasia between June 1992 and May 2000. Intraoperative endoscopy was used in all patients. Fundoplication was used selectively for patients with large hiatal hernias or as part of repair of esophageal perforation. Patients were asked to grade their dysphagia and reflux symptoms before and after myotomy on a scale of 0 (no symptoms) to 5 (severe symptoms). Patients were also asked to rate their outcome as excellent (no symptoms), good (greatly improved), fair (slightly improved), or poor (not improved) compared with their preoperative status. Patients were stratified on the basis of preoperative intervention (botox, pneumatic dilation, botox and pneumatic dilation, or no botox or dilation) and compared. Previous pneumatic dilation and/or botox injection had been undertaken before operation in 88 (79%) patients whereas 23 (21%) patients had no invasive preoperative therapy. The overall mean preoperative dysphagia score was 4.8+/-0.8 and mean preoperative reflux score was 3.3+/-2.1. Groups of patients undergoing preoperative interventions were similar to those patients not undergoing preoperative interventions in terms of preoperative symptoms, dysphagia scores, and reflux scores. Postoperative complications (13%) and perforations (8%) were slightly more common in patients who had undergone preoperative botox or dilation (P = not significant). Subjectively, operative myotomy was more difficult in patients who had preoperative botox or dilation. Patients had significant improvement in dysphagia, dysphagia score, reflux score, emesis/ regurgitation, and chest pain (P < 0.05) regardless of preoperative intervention. After myotomy patients who had never undergone botox or pneumatic dilation were less likely to have mild dysphagia compared with those with previous botox injections (30% vs 53%; P = 0.09), previous dilations (30% vs 54%; P = 0.09), or both (30% vs 59%; P = 0.04). As well, dysphagia scores were better if no preoperative therapy had been undertaken: botox 0.8+/-1.3, dilation 1.0+/-1.4, botox and dilation 1.0+/-1.3, and no therapy 0.3+/-0.7 (P < 0.05). Overall 97 per cent of patients stated that their symptoms were improved although more patients tended to have excellent or good outcomes if no preoperative intervention was undertaken (91%) compared with patients undergoing preoperative botox (86%), dilation (83%), or both (82%) (P = not significant). We conclude that videoscopic Heller myotomy is safe and efficacious particularly in patients who have not undergone previous endoscopic interventions. The difference in patients' outcomes based on preoperative therapy may be related to a less difficult operation in patients who forgo endoscopic therapy and elect to undergo early myotomy. Although videoscopic Heller myotomy provides good outcomes as a salvage procedure after failed dilations and/or botox injections for achalasia we advocate it as first-line therapy in reasonable operative candidates.