Intravenous lidocaine does not reduce length of hospital stay following abdominal hysterectomy

Purpose

Intravenous lidocaine given both intraoperatively and postoperatively decreases pain scores, reduces opioid consumption, and promotes faster return of bowel function following abdominal surgery. The purpose of this trial was to determine if intravenous lidocaine limited to the intraoperative period reduces length of hospital stay and improves functional recovery following abdominal hysterectomy.

Methods

Following Research Ethics Board approval and informed consent, women of American Society of Anesthesiologists’ class I and II undergoing abdominal hysterectomy were assigned randomly to lidocaine and control groups. Lidocaine subjects received an intravenous bolus of 1.5 mg·kg^?1 followed by an infusion of 3 mg·kg^?1·hr^?1, while control subjects received matching placebo. Patients, anesthesiologists, and study personnel were blinded, and anesthesia and multimodal perioperative analgesia were standardized. The primary outcome of this trial was discharge from hospital on or before the second postoperative day (POD2). Additional criteria were assessed for secondary outcomes, i.e., discharge fitness on POD2, length of hospital stay, opioid use, numeric rating scores for pain, quality of recovery, and recovery of bowel function.

Results

Ninety of the 93 women who were recruited completed the study protocol. The characteristics of the patients in both groups were similar—lidocaine group (n = 44) and control group (n = 46)—and no difference was noted between groups in the numbers of women discharged from hospital on POD2 (10 lidocaine, 15 control; P = 0.295). Days to discharge fitness (P = 0.666) and length of hospital stay (P = 0.456) were also similar. Differences in opioid consumption, pain scores, and recovery were neither clinically nor statistically significant.

Conclusion

Intraoperative administration of intravenous lidocaine did not reduce hospital stay or improve objective measures of analgesia and recovery following abdominal hysterectomy. This trial was registered at ClinicalTrials.gov (NCT00382499).     

Valvular heart operation in patients with previous mediastinal radiation therapy

Background. The outcome of valvular heart operations in patients with previous mediastinal radiation therapy was studied.

Methods. This is a single center retrospective study of 60 patients (37 females, 23 males) with a mean age of 62 ± 15 years (28 to 88 years old) operated on from January 1976 to December 1998. Valvular heart operations performed included aortic valve replacements (n = 26), mitral valve procedures (n = 16), tricuspid valve procedures (n = 6), and multiple valve procedures (n = 12). A total of 264 clinical, hemodynamic, electrocardiographic and echocardiographic variables were analyzed.

Results. Total follow-up was 199 patient-years with a mean of 3.3 ± 3.1 years and a range of 0 to 12.4 years old. Early mortality was 7 patients (12%). Early mortality in patients with constrictive pericarditis was 40% (4 of 10) compared with 6% (3 of 50) in patients without constrictive pericarditis. By univariate analysis, early mortality was associated with constrictive pericarditis (p = 0.011), reduced preoperative ejection fraction (p = 0.015), and longer cardiopulmonary bypass times (p = 0.037). A total of 14 patients (23%) required permanent pacemaker placement before (n = 7), during (n = 1), or early (n = 6) after valvular heart operations. There were 19 late deaths (malignancies, 7; heart failures, 5; other cardiac, 4; and other noncardiac, 3). Overall survival and freedom from late cardiac death and cardiac reoperation at 5 years for hospital survivors were 66% ± 8%, 82% ± 7%, and 93% ± 4%, respectively. By univariate analysis, late cardiac death was associated with low ejection fraction (p = 0.002), New York Heart Association (NYHA) functional class IV (p = 0.004), preoperative congestive heart failure (p = 0.02), and preoperative atrial fibrillation (p = 0.038). Eighty-five percent of the discharged patients were in NYHA functional class I or II at follow-up.

Conclusions. Early results of valve replacement after mediastinal radiation therapy were good except in the presence of constrictive pericarditis. Long-term outcome was limited by malignancy and heart failure. Early surgical intervention is recommended before the development of risk factors for late death, namely, severe symptoms, left ventricular dysfunction, and atrial fibrillation.     

Spilled gallstones during laparoscopic cholecystectomy

Introduction

Incidental gallbladder cancer is found in 0.6–2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery.

Case History

A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour.

Conclusions

This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.