超声引导下幼儿骶管麻醉在小儿疝手术中的应用

目的探讨超声引导下幼儿骶管麻醉在小儿疝手术中的应用价值。 方法回顾性分析2016年1至12月,陆军特色医学中心行小儿疝手术的100例患儿的临床资料。根据麻醉方式不同,将其分为观察组（52例）与对照组（48例）。观察组患儿行超声引导下骶管麻醉,对照组患儿行阻力消失技术定位骶管穿刺,比较2组患儿的麻醉效果。 结果（1）观察组患儿穿刺时间、穿刺次数及术后苏醒时间、氯胺酮使用剂量、术毕离开手术室时间均明显低于对照组,差异均有统计学意义（P均<0.05）。（2）观察组患儿骶管阻滞成功率明显高于对照组,差异有统计学意义（P<0.05）。（3）观察组患儿术后镇痛效果明显优于对照组,差异有统计学意义（P<0.05）。（4）观察组患儿苏醒期躁动评分与术后（2、4、8 h）疼痛评分明显低于对照组,差异均有统计学意义（P均<0.05）。（5）气腹前,2组患儿心率、平均动脉压（mean artery pressure,MAP）、呼气末二氧化碳分压（end-tidal carbon dioxide partial pressure,PetCO₂）比较,差异无统计学意义（P>0.05）;气腹后,观察组心率、MAP、PetCO₂水平明显高于对照组,差异均有统计学意义（P均<0.05）。2组患儿治疗前后血压、血氧饱和度、pH值比较,差异均无统计学意义（P均>0.05）。（6）观察组不良反应发生情况明显低于对照组,差异有统计学意义（P<0.05）。 结论超声引导下幼儿骶管麻醉应用于小儿疝手术,定位准确,患儿苏醒时间短,镇痛效果好,并减少其苏醒期躁动,改善患儿血气与循环,安全有效。     

Megarectum after surgery for anorectal malformations

Purpose

Megarectum complicating surgery for anorectal malformation (ARM) has implications for long-term continence. Factors influencing continence and defecation include intact rectal reservoir, innervation/proprioception of the anorectal muscle complex, functioning anorectal inhibitory reflex (AIR), and intact perception at the anal margin. We studied outcomes after surgery for ARM with emphasis on megarectum; particularly as to whether altered rectal proprioception from anatomic sacrococcygeal anomalies affect incidence. We also assessed whether an abnormal AIR could trigger passive rectal dilatation without mechanical obstruction.

Methods

Eighty six infants (53 male) with ARM over 20 years were included. Demographics, surgical history, pathology, defecation patterns, imaging, manometry, and morbidity were analyzed. Incidence of sacrococcygeal malformations in children with and without megarectum was compared using Fisher exact test. Manometry results were evaluated for integrity of AIR and correlated to megarectum occurrence.

Results

There were 23 high/intermediate and 63 low ARMs. Fourteen (16%) developed a megarectum: 6 of 23 in high and 8 of 63 in low anomalies (P = .33). Twelve patients underwent megarectum resection at a median of 2.6 years (7 months to 10 years); 2 received bowel management protocols. Fifty-seven percent (8/14) of children with and 7% (5/72) without megarectum had sacrovertebral anomalies (P = .0001). Patients with preoperative manometry (n = 5) demonstrated an intact AIR. Colonic manometry demonstrated hyperactive colons (n = 2). Constipation was the predominant preoperative symptom; 3 patients suffered from incontinence after resection. All the specimens showed normal innervation and thickened muscularis on pathology.

Conclusions

Sacral anomalies, which are more prevalent in children who developed megarectum, may result in abnormal rectal proprioception contributing to this pathology. Innervation anomalies may coexist, although preoperative manometries showed normal AIRs. Rectal dysmotility may lead to stool retention with subsequent dilatation, and patients who underwent colonic manometry had diffuse colonic hypermotility. Further physiologic and cellular studies are needed to elucidate the causes of this significant complication after surgical ARM repair in the absence of obstruction.     

肛肠手术行骶管麻醉操作技巧的临床研究

目的探讨在肛肠手术中行骶管麻醉的操作技巧。方法对2022例肛肠手术患者采用骶管麻醉于手术中及术后的麻醉镇痛效果的临床资料作回顾性分析。结果有效1659例（82％）;显效202例（10％）;无效161例（8％）,并发症发生率低。结论骶管麻醉用于肛肠手术镇痛效果良好,且安全可靠,值得推广。     

Influence of anesthesia on the results of intraoperative diagnostic electromyostimulation in patients with anorectal malformation

Background and Purpose

Stimulation electromyography (sEMG) is useful in identifying the sphincter muscle (M) in patients with anorectal malformations (ARMs). This study evaluates the effect of anesthetic agents and M relaxants on sEMG findings.

Materials and Methods

Seventeen infants (10 boys and 7 girls) with a mean age of 6.3 months and mean body weight of 6.7 kg were included in a prospective randomized study. Anesthesia was induced by sevoflurane and opioids, and an epidural catheter was inserted caudally. Stimulation electromyography of levator ani M using 14 mA current was used, and latency and amplitude of the evoked compound M action potential (CMAP) were recorded. Patients were randomized into 2 groups. Group A received a local anesthetic epidurally, and sEMG was performed. Administration of the M relaxant and measurement of M response followed. In group B drug administration, sEMG and response measurement were performed after administration of M relaxant.

Results

Baseline CMAP was recorded in all patients. Average latency was 4.1 milliseconds, and average amplitude was 0.43 mV. In group A, the average latency was 4.0 milliseconds, and average amplitude was 0.65 mV. After administration of the M relaxant, the CMAP disappeared. In group B, no CMAP was observed immediately after administration of the M relaxant.

Conclusion

Administration of the inhalational anesthetic, opioids, and local anesthetic did not influence the M response of M fibers in the levator ani M on sEMG and enables its localization during ARM reconstruction. Nondepolarizing M relaxation completely abolished the response. If M relaxant is necessary, cisatracurium is used. The most suitable method of anesthesia for ARM surgery appears to be inhalational anesthesia supplemented by opioids and epidural analgesia.     

Diagnostic accuracy of surgeon performed ultrasound (SPU) for appendicitis in children

Aim

Compare the diagnostic accuracy of surgeon performed ultrasound to radiology performed ultrasound in children presenting with suspected appendicitis to a tertiary care pediatric hospital in Australia.

Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery

BackgroundDexamethasone has anti-inflammatory properties that can affect postoperative analgesia when added to caudal bupivacaine.MethodsSeventy-two geriatric patients scheduled for elective total hip replacement under ultrasound guided caudal anesthesia were randomized blindly into two groups: Group BD received caudal isobaric bupivacaine 0.25% (20 ml) and dexamethasone 8 mg (2 ml) and Group BS received caudal isobaric bupivacaine 0.25% (20 ml) and normal saline (2 ml). Postoperative analgesia was assessed by recording time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively as a primary outcome. Secondary outcomes were the time taken to the onset of sensory analgesia at T10, time to the onset of complete motor block, VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12 and 24 h, and postoperative adverse events.ResultsGroup BD had a significantly longer time to first rescue analgesia [402 (63) vs 213 (53)] min and significantly lower doses of paracetamol [3389 (728) vs 2833 (697)] mg meperidine hydrochloride [78 (30) vs 142 (28)] mg than Group BS. VAS scores were significantly lower in Group BD than Group BS both at rest and on movement respectively at 4, 6, 8, 12 and 24 h.ConclusionAdding dexamethasone with isobaric bupivacaine caudal anesthesia prolongs the duration of postoperative analgesia and decreased postoperative analgesic requirement in geriatric patients undergoing total hip replacement surgery in comparison isobaric bupivacaine alone.     

Unusual coexistence of caudal duplication and caudal regression syndromes

Caudal duplication syndrome includes anomalies of the genitourinary system, gastrointestinal tract, and the distal neural tube. Caudal regression syndrome presents with lumbosacral hypogenesis, anomalies of the lower gastrointestinal tract, genitourinary system, and limb anomalies. Both happen as a result of insult to the caudal cell mass. We present a child having features consistent with both entities.     

Efficacy and feasibility of day surgery using transurethral seminal vesiculoscopy under caudal block anesthesia for intractable hemospermia

BackgroundTransurethral seminal vesiculoscopy (TSV) is a safe and effective method for intractable hemospermia. It uses a natural cavity, is fast, involves little trauma, and boasts a low incidence of complications. Because uncontrollable penile erection during general anesthesia will severely influence the surgical operation or even damage the endoscope, spinal anesthesia was applied more on TSV. But spinal anesthesia extends the length of stay in the hospital and brings patients unnecessary discomfort. As the TSV is a quick recovery operation, we should think about a more suitable mode for these patients.MethodsA total of 141 patients received TSV between January 2015 and July 2019: 81 patients received day surgery under caudal block (group A), and 60 received inpatient surgery under spinal anesthesia (group B). Operative time, postoperative hospital stay, hemospermia remission rate, magnetic resonance imaging (MRI) remission rate are compared. Visual analog scale (VAS) scores of groups were taken and compared at 2 time points: when there was pain during surgery (T1) and at the end of surgery (T2). Surgical methods of two groups are the same.ResultsThe mean operative time of two groups are 34 min (group A) and 32 min (group B), and there was no statistical difference. Postoperative hemospermia remission rates are both 100% at 3 months, which at 6 months are 60% and 48%, and there was no statistical difference. MRI remission at 3 months are 72% and 57%, which has no statistical difference. Postoperative complications were mild in two groups like hematuria and dysuria which can relieve within one day, and there were no severe complications. Intraoperative pain was present in 18.5% (15/81) of group A. Their highest VAS score was 3 points, indicating mild pain, which did not influence the surgical process or postoperative recovery. The postoperative VAS scores were similar between the 2 groups. Group A did not require postoperative hospitalization, whereas the average postoperative hospitalization in group B was 2 days.ConclusionsSeminal vesiculoscopy can be performed as a day surgery under caudal block, which has obvious advantages in accelerating postoperative recovery and shortening the hospital stay.     

Acquired posterior urethral diverticulum following surgery for anorectal malformations

Purpose

Despite significant advances in the surgical management of anorectal malformations (ARMs), many children still experience significant debilities from potentially avoidable complications. One complication, the posterior urethral diverticulum, may have untoward consequences if not recognized and treated.

Methods

A retrospective cohort review was undertaken of male patients who presented to us with persistent problems after being operated on elsewhere for ARM. Twenty-nine patients presented with a urethral diverticulum. Their charts were reviewed for the type of malformation, prior repair, presentation, treatment, and postoperative follow-up.

Results

Twenty-nine patients were identified that fit the criteria for this study. To date, 28 patients have been managed with reoperation. Urinary complaints were the most common presenting symptoms. All patients were repaired using a posterior sagittal approach. Pathology of the diverticulum in one patient revealed a well-differentiated mucinous adenocarcinoma.

Conclusion

The incidence of acquired posterior urethral diverticulum has decreased with the popularization of the posterior sagittal incision. There is a theoretical concern that the incidence may increase with the use of laparoscopy for the treatment of ARMs especially those where the fistula is below the peritoneal reflection. Once detected, the diverticulum should be excised.     

Local anesthetic infiltration versus caudal epidural block for anorectal surgery: a randomized controlled trial

STUDY OBJECTIVE: To compare patient satisfaction with local anesthetic infiltration versus caudal epidural block for anorectal procedures. DESIGN: Randomized controlled trial. SETTING: Operating room and postanesthesia care unit (PACU). PATIENTS: 22 adult, ASA physical status I, II, and III patients scheduled for anorectal surgery. INTERVENTIONS: Patients were randomized to receive either local anesthetic infiltration (LAI) (n = 10) by the surgeon or caudal epidural block (CEB) (n = 12) by the anesthesiologist. MEASUREMENTS: The primary outcome was patient satisfaction with the anesthetic technique and pain relief 12 hours after the procedure on a 4-point Likert scale. Secondary outcomes included time to first analgesic request, time to reach a PACU discharge score (REACT score) of 10, time to ambulation, time to discharge home, and adverse events. MAIN RESULTS: More subjects in the CEB group (83.3%) were highly satisfied than in the LAI group (20%; P = 0.003), assessed 12 hours postoperatively by telephone interview. Subjects in the CEB group requested analgesia 423 minutes later (95% confidence interval, 286-560 min) than subjects in the LAI group. Differences in time to reach a REACT score of 10, time to ambulation, and time to discharge home were not statistically significant. CONCLUSIONS: Caudal epidural block provides higher patient satisfaction and longer lasting analgesia than LAI without delaying discharge.     

氯普鲁卡因与利多卡因小儿骶管麻醉的比较

目的研究氯普鲁卡因用于小儿骶管麻醉的可行性与安全性。方法62例在骶管麻醉下行下肢或会阴部手术患儿(3~8岁),随机、双盲均分为氯普鲁卡因组(研究组)和利多卡因组(对照组),每组31例。清醒或吸入七氟醚诱导后行骶管穿刺(垂直穿刺法),分别一次性注入1.5%氯普鲁卡因或0.8%利多卡因1ml/kg。观察记录HR、BP、RR、SpO2和阻滞作用。结果研究组起效[(1.52±0.71)min]、疼痛消失[(4.07±0.82)min]、麻醉平面固定[(6.50±0.71)min]时间均明显短于对照组[(3.95±0.97)、(5.93±1.57)、(8.59±1.68)min](P<0.01)。麻醉持续时间,研究组(78.52±5.71)min,对照组(81.38±6.68)min。两组最高感觉阻滞神经节段相当。用药后HR、BP、RR和SpO2变化两组对比差异无统计学意义。两组患儿均无明显不良反应。结论1.5%氯普鲁卡因骶管阻滞用于3~8岁小儿较0.8%利多卡因起效、疼痛消失及麻醉平面固定快。呼吸与循环功能基本稳定,无明显不良反应。     

小儿骶管复合用药对术后镇痛的影响

目的观察小儿骶管复合用药对术后镇痛的影响。方法80例1～4岁患儿随机分为四组,每组20例。在静脉麻醉后行1%利多卡因1ml/kg骶管阻滞:Ⅰ组局麻药中不加其他药,Ⅱ组加芬太尼2μg/kg,Ⅲ组局麻药中加新斯的明2μg/kg,Ⅳ组局麻药中加曲马多2mg/kg。术后给予芬太尼护师控制泵注镇痛(NCA)治疗。分别于术后1、2、4、6、24h观察镇痛和镇静评分,记录镇痛时间(初次NCA)、NCA芬太尼用量、不良反应及出院时间。结果Ⅳ组的镇痛时间(510.7±64.9)min,长于Ⅰ组的(174.5±39.3)min、Ⅱ组的(291.7±50.8)min和Ⅲ组的(242.0±62.8)min(P0.01)。但Ⅳ组术后恶心呕吐的发生率高于其他三组(P0.05)。结论2mg/kg曲马多复合1%利多卡因1ml/kg行小儿骶管阻滞的术后镇痛效果较好,但其恶心呕吐发生率也有所增加。     

肛门直肠周围脓肿一次根治术的80例治疗经验

目的总结肛门直肠周围脓肿一次根治术的治疗经验。方法对80例肛门直肠周围脓肿病例回顾性分析,一期行一次根治术,控制感染及避免二期肛瘘手术痛苦。结果治愈率为97.5%,有2例因创面过大愈合欠佳二次行清创术治疗后治愈。结论具备适应证的病例一次根治术可以克服分期手术疗程长的缺点、减轻患者痛苦、降低手术费用,是一种值得推广的治疗方法。     

Use of anorectal manometry for evaluation of postoperative results of patients with anorectal malformation: a study from Kuwait

Purpose

The objective of this study is to use anorectal manometry for functional assessment of early postoperative results after corrective surgery for anorectal malformations (ARMs) in children and compare manometric observations with age-matched controls. Parents were counseled and management strategies were planned according to the manometric assessments.

Methods

From August 2005 to September 2009, 32 patients who underwent surgery for ARM were assessed postoperatively with anorectal manometry using a water-perfused anorectal motility catheter to record anal canal length or high-pressure zone, resting pressure of anal canal (RP), and rectoanal inhibitory reflex (RAIR). These patients were divided in 2 groups (infants, <1 year; children, >1 year) according to the age at the time of performance of anorectal manometry that was done at 6 months or later following stoma closure or anoplasty.

Results

Out of these 32 patients, high anomaly was present in 13, whereas 19 had low type of defect. Manometric anal canal length of the children with high and low ARM was 2.10 ± .44 and 2.25 ± .53 cm, respectively, which was significantly shorter than that of their age-matched controls(P < .05). In patients with high ARM, RP in infants (17 ± 7.7 mm of Hg) and children (21 ± 9.4 mm of Hg) was lower than that of controls (RP in infants = 42.43 ± 8.19 mm of Hg, RP in children = 43.43 ± 8.79 mm of Hg, P < .001). In patients with low ARM, RP in infants (34 ± 8.6 mm of Hg, P = .002) and children (26 ± 9.9 mm of Hg, P = .001) was lower than that in controls. Presence of RAIR was demonstrated in 5 (38.4%) of 13 patients with high ARM and in 11 (57.9%) of 19 cases with low ARM. Parental counseling was done after this early evaluation, and management strategies like bowel management program and biofeedback training were planned according to the results of the tests.

Conclusion

Our anorectal manometric results suggest that patients with ARM had short anal canal with lower RP and impaired RAIR, which could affect the ultimate functional outcome in these patients. Thus, postoperative anorectal manometric evaluation of the patients with ARM can give more realistic information about future continence and might help in planning future treatment strategies like bowel management program or biofeedback training.     

A randomized comparative study between selective walking spinal anesthesia and general anesthesia for anorectal surgeries in outpatient settings

BackgroundSpinal anesthesia is gradually increasing in ambulatory setting. The limiting factor to the more widespread use of spinal anesthesia in the outpatient setting refers to the effect of residual block. Selective spinal anesthesia (SSA) with low dose lidocaine was compared with modern general anesthesia (GA) technique in day care anorectal surgeries.ObjectiveOur objectives in this study was to compare SSA with propofol and fentanyl based modern GA as regard to 1 – operating conditions 2 – patients’ and surgeon’s satisfaction, 3 – intraoperative, postoperative adverse events and 4 – recovery profiles in ambulatory anorectal surgeries.MethodsProspective randomized clinical study was conducted on 60 patients undergoing elective day case anorectal surgery. The patients were randomly allocated into one of two groups (GA and SSA groups) of 30 patients each. In GA group anesthesia was induced with intravenous fentanyl (2 μg/kg) and propofol (2–3 mg/kg). Airway was secured with I-gel supraglottic airway. Anesthesia was maintained by sevoflurane 1.5–2%, nitrous oxide 60% in oxygen mixture. SSA group patients received spinal anesthesia with lidocaine 20 mg and fentanyl 25 μg to a total volume of 3 ml with sterile water for injection. Intraoperative, postoperative and home adverse events, time to ambulate, time to home discharge, patients’ and surgeon’s satisfactions were statistically compared between both groups.ResultsBoth anesthetic techniques showed acceptable operating conditions and high rate of patients’ satisfaction. Low pain intensity, shorter time to ambulate and home discharge in SSA compared to GA with a p value < 0.001. Intraoperative hemodynamic stability was reported in both groups. No major postoperative or home adverse events in both groups.ConclusionsSSA with low dose lidocaine may be suitable alternative and competitive for modern GA in ambulatory anorectal surgery.     

Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia

BACKGROUND: The frequency of emergence agitation in children is increased following sevoflurane anesthesia. However, controversies still exist concerning the exact etiology of this postanesthetic problem. Although this phenomenon is present with adequate pain relief or even following pain-free procedures, pain is still regarded as a major contributing factor. METHODS: In a prospective, randomized, double-blind study, we enrolled 48 premedicated and calm 2-6-year-old children undergoing inguinal hernia repair. We assigned children to one of two groups: children assigned to the caudal group (n = 24) received a caudal block to supplement sevoflurane, while children assigned to the fentanyl group (n = 24) received a bolus injection of 1 microg kg(-1) intravenous fentanyl before skin incision to supplement sevoflurane. In the post anesthesia care unit, all children were received by their parent, and the incidence of emergence agitation and pain scores, as well as hemodynamic changes, were compared in both groups. RESULTS: Forty-four children completed the study. In the fentanyl group, 59% of the children were agitated following emergence from anesthesia as compared to 4.5% in the caudal group (P < 0.001). Also, pain scores, mean values of heart rate and blood pressure as well as morphine requirement were significantly higher in the post anesthesia care unit in the fentanyl group compared to the caudal group. CONCLUSION: Our results show that in children undergoing inguinal hernia repair, pain control with a preoperative caudal block as compared to intraoperative intravenous fentanyl significantly reduces the incidence of emergence agitation and pain scores following sevoflurane anesthesia.     

经皮穴位电刺激预处理对蛛网膜下腔阻滞肛肠手术后尿潴留的影响

目的 评价经皮穴位电刺激（TEAS）预处理对蛛网膜下腔阻滞（腰麻）肛肠手术后尿潴留的影响。
方法 选择择期在腰麻下行肛肠手术的患者195例,男122例,女73例,年龄18～64岁,BMI 18～28 kg/m²,ASA Ⅰ或Ⅱ级。采用随机数字表法将患者随机分为三组：腰麻前TEAS预处理组（A组）、手术结束时TEAS组（B组）和对照组（C组）,每组65例。A组于腰麻前经皮电刺激中极穴（RN3）、气海穴（RN6）、关元穴（RN4）、关元俞穴（BL26）和八髎穴（BL31-34）,疏密波频率2/100 Hz,电流强度6～10 mA,刺激时间30 min;B组于手术结束后立刻选取与A组相同的穴位、频率、刺激强度及刺激时间;C组不予电刺激。记录首次排尿时间、首次排尿量、首次排尿等待时间以及术后当晚小腹胀满感评分以及术后尿潴留和术后因尿潴留导尿情况。
结果 与A组比较,B组首次排尿量明显减少（P＜0.05）;C组首次排尿时间、首次排尿等待时间明显延长,首次排尿量明显减少,术后当晚小腹胀满感评分明显升高（P＜0.05）。与B组比较,C组首次排尿时间明显延长（P＜0.05）。与A组比较,B组和C组术后尿潴留发生率明显升高（P＜0.05）,C组因尿潴留导尿率明显升高（P＜0.05）。
结论 腰麻前给予经皮穴位电刺激预处理可明显降低肛肠手术后尿潴留的发生率,能更好地保护膀胱功能,促进排尿功能的恢复。     

Robotic-assisted anorectal pull-through for anorectal malformations

Background/purpose

Many reports have addressed the feasibility and safety of using robotic surgery in children. To our knowledge, no published report has described the use of a surgical robot in the repair of anorectal malformations (ARMs).

Methods

Included children underwent robotic-assisted repair of ARMs with rectourethral fistula between April 2006 and March 2010 at King Khalid University Hospital, Riyadh, Saudi Arabia, using the da Vinci Surgical System. Their medical records were reviewed with respect to demographic data, associated anomalies, techniques and operative procedures, complications, outcomes, and follow-up.

Results

Five male infants (mean age, 6.6 months) underwent robotic-assisted repair of ARMs with rectourethral fistula using the Georgeson technique. The fistulae were divided and ligated in 4 patients and was left open in 1. All procedures were successfully completed without conversion to an open technique. One patient developed left-sided epididymo-orchitis postoperatively. All the patients had their colostomy closed. The follow-up ranged from 6 to 36 months. Fecal continence was difficult to assess in 2 patients. Two patients have voluntary bowel movements without soiling. One infant has fecal soiling and is on a laxative/enema for constipation.

Conclusions

Robotically assisted repair of ARMs with rectourethral fistula is feasible and safe. It offers a good alternative to the criterion standard, posterior sagittal anorectoplasty (PSARP), for repair of ARMs with rectourethral fistula. More patients and a longer follow-up period are needed for further evaluation of this novel approach.