Local anesthesia with sedation for ambulatory anorectal surgery

Anorectal surgery is extremely painful and it is a challenge to the anesthetist and surgeon. Most patients are anxious about pain during and after the surgery. We tried in this study to solve this problem especially for patients who may have some problems with general anesthesia or contraindications to regional anesthesia. In this study our aim was to compare between the local anesthesia [which is not a common technique in our hospital], spinal anesthesia and general anesthesia for anorectal operations. We selected 87 patients for the study. The patients were allowed to choose between the three methods of anesthesia and then categorized according to their choice. 31 patients choose the local anesthesia and were categorized as [LA] group. 28 patients choose spinal anesthesia and were categorized as [SA] group. The third group was the general anesthesia [GA] group including 28 patients. Patient's satisfaction and intraoperative and postoperative VAS also reported. The operative time ranged from 23 to 55 [23 +/- 18] min in LA group and [25 +/- 12] in SA group, but in the GA group the operation time ranged from 20 to 40 min [20 +/- 10]. There was no difference between LA group, SA group and GA group regarding the personal data [age, weight, and ASA I /II/III]. The percent of female patients in the third group was more than that in the other two groups. The intraoperative pain scale in the in the LA and SA groups during the operation didn't exceed 3 form the start of operation till the end except only one patient in group LA who is shifted to general anesthesia as she was noncooperative and she asked for GA. Intraoperative pain scale more than 5 [3 and 2 patients] in the LA and SA groups during anal dilatation and early manipulations and intensity of pain decreased by time to pain scale less than 3. Five minutes after the end of operation, all patients received declofenaic sodium 75 mg IM. Twenty six patients in the GA start to complain of pain so pethidine 0.3mg /kg IV bolus dose followed by 0.7 mg / kg pethidine IM to control pain. In spite of this six patients of the GA group started to complain of pain again after 90 min of the last dose of pethidine, VAS for these patients was more than 5. 87% of patients in the LA group didn't need any analgesic in PACU for 120 min. Three patients [11%] in SA group developed urinary retention. No patient in LA or GA group developed urinary retention. No surgical complication reported in the three groups. Local anesthesia is more effective and more beneficial to the patients planned to have simple anorectal operations than general anesthesia. Local anesthesia is nearly as effective as the spinal anesthesia. It has the advantages of preemptive analgesia, early patient movements, and early return to the work, and fewer complications than GA

Evaluation of preoperative localization of parathyroid adenoma using [99m]tc-sestamibi scintigraphy as a single diagnostic modality for patients with primary hyperparathyroidism

This- study was designed to evaluate the diagnostic yield of Technetium-99m hexakis methoxyisobutylisonitrile [Tc-99m-MIBI] scintigraphy in patients with primary hyperparathyroidism [PHPT] for identification of the site of parathyroid adenoma compared versus operative and histopathological findings. The study included 23 cases with PHPT; 5 nales and 8 females with mean age of 56.5 +/- 10.3; range: 39-69 years. Preoperative scanning using [99m]Tc-sestamibi was done. All patients underwent surgical exploration after methylene blue transfusion. Imaging data were compared with intraoperative finding. All identified and excised glands were sent for histopathological examination. Preoperative sestamibi scan defined a case with mediastinal parathyroid gland and another active cervical gland in 2 patients with persistent and recurrent hypercalcaemia, respectively. Preoperative sestamibi scan defined 6 cases with single parathyroid adenoma in each case, while surgical exploration defined 7 parathyroid adenomata; 5 cases had solitary adenoma and one case had adenoma in 2 parathyroid glands both stained blue after methylene blue infusion. Thus, sestamibi scan defined solitary parathyroid adenomas with an accuracy rate of 83.3%. However, sestamibi scan defined 3 cases with adenoma in 2 parathyroid glands and 2 cases had adenoma in 3 glands. Surgical exploration defined adenoma that confirmed histopathologically in 9 glands of the 12 identified by sestamibi scan; 4 cases had 2 adenomas and one case had one solitary adenoma, the other 3 glands showed only hyperplasia without adenoma formation. Thus, sestamibi scan defined multiple parathyroid adenomos with an accuracy rate of 75%. It could be concluded that preoperative localization of parathyroid gland depending on preoperative sestamibi scan could identify ectopic active glands with accuracy 100% and active cervical glands with an overall accuracy rate of 79.2% and concomitant intraoperative methylene blue localization allowed detection of active glands missed by preoperative sestamibi scan

Pneumatic reduction of infantile intussusception [an economic non-operative solution for a major problem]

A prospective study was designed to evaluate results of pneumatic reduction under fluoroscopic guidance in patients suffering from acute infantile intussusception. Thirty cases of the study were selected as early cases with a history less than 48 hours, with absent general or abdominal signs of toxicity, pelitonism, or peritonitis and with reasonable blood electrolyte levels. Cases were offered trials of pneumatic reduction; of which there was 28 successes [90%] and 3 failures [10%]. They were managed and followed up for a period of at least 6 months. Failed cases were operated upon after failed trial. In 15 patients [50%], intussusception was successively reduced in the first trial, in 9 patients [30%], successful reduction required a second attempt to be complete and in three cases [10%] a third attempt was done to complete the reduction. In 3 cases [10%], reduction has failed after three trials and patients were operated upon. In one failure, Meckel's diverticulum was found for which limited ilea resection-anastomosis was done, in one failure there was ileal perforation, for which closure after manual reduction was done and the third one there was no pathology and simple reduction was done. There were 2 recurrences after one and two days of reduction [7%] for which the procedure was repeated with success. Two patients [7%] developed high-grade post- reduction fever [38.5 C] of which one infant developed an attack of febrile convulsions, which required anticonvulsive in addition to antipyretic treatment. Two patients [7%] had severe post-reduction diarrhea, which required proper hydration and intestinal antiseptics. One patient [3.5%] developed prolonged post-operative ileus which persists for 48 hours. One infant [3.5%] developed adhesive small bowel obstruction after one month of operative reduction which has had resolved by conservative measures. There was no mortality. We conclude that air reduction under fluoroscopic guidance is associated with highest success rate with few failures and few complications which can easily be managed. Proper selection of cases is crucial to achieve high success rate and to minimize complications. Air reduction is associated with much less hospital stay and much less cost for health care system. As well, it seems to be advantageous over all other non-operative methods of reduction i.e. it is safer, more economical and more effective than others as barium enema or saline enema. Finally, air enema is also readily learned and easily performed by pediatric surgery residents and overcomes the problem of absence of trained radiologist over the 24 hours of the day. Surgical management are done only for cases where pneumatic reduction is contraindicated or failed or if there are signs of local [peritonitis or peritonism] or general toxicity

Quantitative fluorescence intensity-structure relationships of certain quinolone-metal chelates

A quantitative relationship was found between the relative fluorescence intensities of certain metal chelates of some quinolone antibacterials and their physicochemical parameters namely: the pKa1 [corresponding to the ionisation of the 3-carboxylic group] and the calculated stability constants of the formed chelates as well as the second order connectivity indexes [2X v ], Hammett constant m], polar constants [F] and resonance constants [R] for the?[ substituent at position 1 of the quinolone nucleus. The studied quinolone antibacterials are amifloxacin, difloxacin, ciprofloxacin, nalidixic acid, norfloxacin, lomefloxacin, ofloxacin and pefloxacin and the metals involved are zirconium, molybdenum, vanadium and tungsten. Twenty highly significant regression equations were obtained m, F and R for the?and used to calculate the unreported values of substituent at position 1 of ofloxacin. Two correlation equations were used also to predict the fluorescence intensity of molybdenum chelates of the studied quinolones

Pneumatic reduction versus surgical reduction in cases of neonatal inutssusception

Intussusception is a common pediatric surgical emergency in Egypt. Diagnosis of intussusception is usually based on the clinical history and is confirmed by clinical examination. However, a high index of suspicion coupled with proper radiological studies may be necessary for diagnosis of atypical cases. Management of intussusception is initially non-surgical. Surgery is advised only when non-surgical therapy has failed or is contraindicated. The aim of this work was to evaluate the results of pneumatic reduction in patients suffering from acute infantile intussusception. The results were compared with the known international results. In this prospective study, twenty consecutive cases with the diagnosis of intussusception were managed and followed up for a period of at least 6 months, 18 Cases were offered trials of pneumatic reduction; of the 18 patients there was 14 successes, 3 failures and only one complications in the form of perforation. Six infants were operated upon, two patients were operated upon directly and 4 patients were operated upon after failed or complicated trial of pneumatic reduction. There was no mortality in this study

Repair of large paraesophageal hiatus hernia with polypropylene prosthesis

Posterior Cruroplasty repair of a large paraesophageal hiatus has a higher than desirable rate of recurrence attributable to the inexorable cyclic negative intrathoracic pressure of respiration and positive intrabdominal pressure produced by straining, physical exertion and coughing. To reduce the risk of recurrence, we have used posterior cruroplasty reinforced with an onlay polypropylene mesh prosthesis. Thirty consecutive patients with paraesophageal hiatus hernia had transabdominal posterior cruroplasty and onlay polypropylene mesh prosthesis applied to the crura and adjacent diaphragm to reinforce the hiatal defect with Nissen fundoplication to control associated reflux which was present in 80% of the patients. As regards to pre-and postoperative clinical manifestations, contrast radiography and upper gastrointestinal endoscopy, the results of the operation were excellent in 22 patients [73%], good in 6 patients [7%] Postoperative course was sound in most patients [23 from 30 patients]. After a period of follow up [from 18 to 48 months] there was neither cases of recurrence, nor complications related to the mesh. We conclude that mesh reinforcement of the esophageal hiatus hernia repair is effective, have a low clinical recurrence rate, and devoid of any complications related to the used polypropylene mesh. Concomitant antireflux procedure [we used Nissen fundoplication] is recommended in all operations for paraesophageal hiatus hernia especially if reflux can not be excluded before operation, or retroesophageal dissection is needed

Laparoscopic versus open appendicectomy: a prospective study

The benefits of laparoscopic appendicectomy are controversial, and the results of recent clinical studies have contradictory conclusions. A prospective study was performed to compare the results of laparoscopic [LA] and open appendicectomy [OA] in patients with signs and symptoms suggesting acute appendicitis who were seen by one surgical team. A total of 298 patients with clinical diagnosis of acute appendicitis underwent LA and 78 had OA. LA had a longer median operating time [63 minutes versus 40 minutes. The hospital stays were significantly short in LA. LA also reported less postoperative wound sepsis rate. The return to normal activity was an earlier in LA. The degree of appendiceal inflammation and doses of analgesics were similar in both groups. In 12 patients, the procedure was converted to OA. LA can significantly reduce hospital stay and decrease wound infection rate with quicker return to normal activities