Future perspectives and research initiatives in fast-track surgery

Background and aims Major surgery is still followed by a risk of morbidity, a need for hospitalisation and convalescence. Fast-track surgery has been introduced as a coordinated effort to combine unimodal evidence-based principles of care into a multi-modal effort to enhance recovery. The aim of this article was to update recent data on fast-track abdominal surgery and outline future strategies for research.Results The data from fast-track colonic resection support the validity of the concept because pain, ileus, cardiopulmonary function and muscle function were all improved, compared with traditional treatment and with reduced post-operative fatigue and convalescence. Although less data is available, similar positive results may be achieved in other types of major surgery. Current research initiatives include improved multi-modal non-opioid analgesia, rational principles for perioperative fluid management, pharmacological reduction of surgical stress responses and the role of laparoscopic procedures within the fast-track concept.Conclusions Fast-track surgery has evolved as a valid concept to improve post-operative outcome. Further progress may be expected based upon intensified research within perioperative pathophysiology and a multi-disciplinary collaboration between surgeons, anaesthesiologists and surgical nurses.     

Is herniography useful?

Herniography has been used for 25 years in the diagnosis of occult herniation but has not gained widespread acceptance in the UK, despite studies confirming its high sensitivity and specificity for occult hernias and an excellent record of safety and patient acceptability. The traditional approach in the UK to suspected occult groin herniation has been surgical exploration. This study examined the use of herniography in a single district general hospital to assess its impact in limiting unnecessary groin explorations and allowing discharge of patients without hernias. The case notes of 90 successive patients referred for herniography by the department of general surgery in a single UK district general hospital over an 18-month period were reviewed. Eighty-seven completed examinations were analysed in which 23 hernias were diagnosed in 20 patients. Thirteen patients have undergone hernia repair with resolution of symptoms. There were no false positive examinations, although two inguinal hernias were incorrectly diagnosed radiologically as femoral hernias; there were two false negative examinations where additional hernias were found at laparoscopic repair. There were no reported complications. Twenty-four patients were discharged directly from the surgical clinic after a negative herniogram. Thirty patients were referred to other specialities. No patient had undergone groin exploration after a negative herniogram. Herniography is a useful tool in assessing obscure groin pain and potential occult herniation. It can reliably rule out the presence of a hernia and avoid the need for surgical exploration. Many patients with a negative herniogram can be reassured and discharged, whilst others may be referred on to other specialities safe in the knowledge that an occult hernia has been excluded.     

Pleural flap to prevent lobar torsion: a novel technique

Lobar torsion is reported as very rare but sometimes catastrophic complication if overlooked during the early postoperative period following a lobectomy, though it is totally preventable. In this novel technique, a piece of parietal pleural flap is harvested from the posterior wall of the chest using a hook diathermy while keeping its upper border as close to the apex as possible. Finally, distal end of the flap is secured to the upper edge of the lobe using a fine monofilament absorbable suture. This procedure not only protects the lobe from rotation but also maintains continuous expansion of the lung in the early postoperative period and may, therefore, be a good option to prevent such a serious complication in selected patients following a lobectomy.     

颈椎前路手术内置物并发症的分析

在颈椎前路减压、植骨、带锁钢板内固定技术日渐成熟的今天,越来越多的医院开展了该项手术。自1998年2月-2005年8月应用该方法治疗颈椎病215例,发生与内置物钢板及钛网相关的并发症14例,为此积累了一定的经验,现总结如下。1临床资料本组215例,男126例,女89例;年龄42～82岁,平均     

Intrathecal Ziconotide in the Treatment of Chronic Nonmalignant Pain: A Randomized,Double‐Blind,Placebo‐Controlled Clinical Trial

Objective. The safety and efficacy of intrathecal (IT) ziconotide was studied in a randomized, double‐blind, placebo‐controlled trial. Materials and Methods. Patients (169 ziconotide, 86 placebo) with severe chronic nonmalignant pain unresponsive to conventional therapy and a visual analog scale of pain intensity (VASPI score) ≥ 50 mm were treated over a 6‐day period in an inpatient hospital setting. Initial starting dose was 0.4 µg/hour and was titrated to analgesia or intolerance (maximum dose 7.0 µg/hour). The starting and maximum doses were reduced to 0.1 µg/hour and 2.4 µg/hour, respectively, due to adverse events (AEs). Results. The mean percent reduction in VASPI score from baseline was 31.2% and 6.0% for ziconotide‐ and placebo‐treated patients, respectively (p ≤ 0.001). During the initial titration phase, a significantly greater percentage of patients in the ziconotide group compared to the placebo group reported AEs, including abnormal gait, amblyopia, dizziness, nausea, nystagmus, pain, urinary retention, and vomiting. Conclusion. Ziconotide provided significant analgesia in patients for whom conventional therapy failed. However, there was a considerable incidence of ziconotide‐associated AEs due to the rapid titration and high doses administered.     

一对一责任助产加笑气吸入用于分娩镇痛的疗效观察

目的探讨一对一责任助产加笑气吸入对分娩镇痛的疗效。 方法将576例产妇随机分为观察组和对照组．每组288例，两组均采用一对一责任助产及其他产科处理措施，观察组同时给予笑气吸入．观察两组的产痛程度、产程时间、分娩方式、笑气对新生儿的影响、产后出血及尿潴留等。 结果观察组无痛分娩率达95．8％．而对照组则为0（P〈0．01），观察组的产程时间短于对照组（P〈0．01）。 结论笑气吸入分娩镇痛产程时间短，对母婴均无不良影响，加一对一责任助产．是一种理想的分娩方法，值得产科临床推广使用。     

经皮激光椎间盘减压术治疗椎间盘源性腰痛

目的探讨经皮激光椎间盘减压术（percutaneous laser disc decompression，PLDD）治疗椎间盘源性腰痛的疗效。方法2002年6月～2004年12月我院对36例椎间盘源性腰痛，采用英国DIOMED公司半导体激光仪，激光功率15W，每个激光脉冲持续1s，间隔1s，照射能量800～1200J。VAS评分评价治疗效果。结果手术时间15～60min，平均30min。32例出现“疼痛复制效应”。36例随访6～36个月，平均11个月，32例有效（术后VAS评分改善≥3分18例，≥分14例），4例无效，有效率88．9％（32／36）。结论PLDD治疗椎间盘源性腰痛安全、有效、微创。     

头皮冠状切口的并发症及其防治

目的：对采用头皮冠状切口所引发的并发症进行分析，探讨防治策略。方法：对我科2003-01～2006—07应用头皮冠状切口行颅颌面骨折修复重建、颌面部肿瘤切除与缺损修复、先天性颅颌面畸形矫正的221例中发生并发症的40例进行分析总结。结果：18例出现头皮麻木及感觉异常，9例有较宽切口瘢痕，6例出现脱发，4例发生颞窝凹陷，2例发生头皮下血肿，2例出现单侧面神经颞支损伤，1例发生鼻眶区肥厚。结论：头皮冠状切口具有切口隐蔽、面部疤痕不明显，显露充分的优点，但对其并发症也不容忽视。应根据具体情况选择合适的切口类型，术中精细的解剖、神经血管的良好保护以及正确的缝合方法可减少并发症的发生。     

Relationships Between Arousal-Related Moods and Episodic Tension-Type Headache: A Biopsychological Study

An exploratory study was conducted examining arousal-related moods and episodic tension-type headache. Twelve subjects meeting International Headache Society criteria for episodic tension-type headache and 12 headache-free controls recorded headache activity and mood eight times daily for 14 consecutive days. Moods were measured using the Activation-Deactivation Adjective Check List, a self-report list that subjectively represents general arousal along two dimensions of Tension and Energy. Headache subjects had higher Tension levels than controls even in the absence of pain, and greater variation in this dimension as well. Within the headache group, Tension during pain-free periods was significantly lower than when experiencing headache, and was correlated with headache activity. The results were taken to support Thayer's (1989) biopsychological model of mood and arousal, and are discussed in terms of the model's heuristic value for general arousal and headache research.