A simplified endoscopic third ventriculostomy under local anesthesia.

The aim of this study is the analysis of our experience with awake endoscopic third ventriculostomy (ETVS) in hydrocephalic patients. From September 1994 to December 2001, 24 neuroendoscopic procedures were performed under local anesthesia. Local infiltration was administered using a bupivacaine and lidocaine mixture. Analgesics were titrated to the effect. A free-hand technique with a flexible endoscope was adopted in 24 patients with primitive and secondary (neoplastic) hydrocephalus. ETVS was performed successfully in all cases. No procedure needed to be discontinued due to seizures, bleeding or agitation. Dural incision/coagulation and Fogarty dilatation proved to be the most painful maneuvers requiring, sometimes, supplemental analgesic administration. No intraoperative complications were observed; however, two asymptomatic trajectory hematomas were incidentally discovered two and three days after the operation, respectively. Awake ETVS is a valuable alternative procedure that can be adopted in adult cooperative patients, provided that the procedure is done in an essential and fast way with the free-hand technique, by means of a flexible endoscope, and with the assistance of an anesthesiologist.

A modified laryngeal mask in the endoscopic management of an esophageal tumor.

The laryngeal mask airway (LMA) can be used for gastroscopy, but its use can result in loss of the seal and/or displacement of the cuff. We describe an LMA that was specifically modified for gastroscopy and report its use in a patient with an esophageal tumor. The modified LMA has (a) a second tube that allows instruments to be directed toward the esophagus and (b) a second cuff mounted on the dorsal surface that increases the efficacy of the seal with the larynx. A 78-year-old man weighing 65 kg presented with a large mediastinal adenocarcinoma that was infiltrating the lateral wall of the thoracic esophagus. An esophagoscopy under anesthesia was planned to debulk the tumor. The modified LMA was inserted easily following induction with propofol. Anesthesia was maintained with propofol and 50% O2 in air and spontaneous ventilation. A lubricated 10.5-mm external diameter gastroscope was inserted into the second tube and passed easily into the esophagus. The tumor was successfully debulked using a polypectomy snare and an argon plasma coagulator. There was no loss of seal or displacement of the cuff, and the patient was stable throughout the procedure. We conclude that gastroscopy is feasible with the modified LMA. The device has a potential application in patients who require ventilatory support during gastroscopy.

Morphine plus bupivacaine vs. morphine peridural analgesia in abdominal surgery: the effects on postoperative course in major hepatobiliary surgery.

Anaesthesia and surgical procedures lead to a reduction of intestinal motility, and opioids may produce a postoperative ileus, that might delay postoperative feeding. The aim of this prospective randomised study is to test whether or not different kinds of epidural analgesia (Group A: morphine 0.0017 mg/kg/h and bupivacaine 0.125%-0.058 mg/kg/h; Group B: morphine alone 0.035 mg/kg/12h in the postoperative period) allow earlier postoperative enteral feeding, enhance intestinal motility a passage of flatus and help avoid complications, such as nausea, vomiting, ileus, diarrhoea, pneumonia or other infective diseases. We included in the study 60 patients (28 males and 32 females) with a mean age of 61.2 years (range 50-70) and with an ASA score of 2 or 3. All patients had hepato-biliary-pancreatic neoplasm and were candidates for major surgery. We compared two different pharmacological approaches, i.e., morphine plus bupivacaine (30 patients, Group A) versus morphine alone (30 patients, Group B). Each medication was administered by means of a thoracic epidural catheter for the control of postoperative pain. In the postoperative course we recorded every 6 hours peristaltic activity. We also noted morbidity (pneumonia, wound sepsis) and mortality. Effective peristalsis was present in all patients in Group A within the first six postoperative hours; in Group B, after 30 hours. Six patients in Group A had bowel motions in the first postoperative day, 11 in the second day, 10 in the third day and 3 in fourth day, while in Group B none in the first day, two in the second, 7 in the third, 15 in the fourth, and 6 in the fifth: the difference between the two groups was significant (p<0.05 in 1st, 2nd, 4th and 5th days). Pneumonia occurred in 2 patients of Group A, and in 10 of Group B (p < 0.05). We conclude that epidural analgesia with morphine plus bupivacaine allowed a move rapid return to normal gut activity and early enteral nutrition compared with epidural analgesia with morphine alone.

Day surgery: the value of monitored anesthesia care and intraoperative monitoring.

Recently an increasing percentage of patients is receiving care and surgical procedures in Day Surgery (DS), undergoing local or loco-regional anesthesia techniques, to which many patients appear to be rather reluctant and show fear and anxiety. The anesthesiologist can resolve this problem administering i.v. hypnotic and analgesic drugs and adjusting their level to patient's needs and type of surgery. They increase the patient's compliance to DS care and contribute to its diffusion. Nowadays, commonly used drugs permit quick changes of anesthesia depth with a fast and safe recovery but these require an appropriate monitoring in order to prevent and rapidly detect the onset of complications. In this study we analyze the peculiarity of Monitored Anesthesia Care and the appropriate intraoperative monitoring especially regarding the use of pulse oximetry.

Pulse oximetry with the laryngeal mask airway.

This study evaluated the accuracy of pulse oximetry measured by a modified laryngeal mask airway (LMA). Ten anaesthetized patients (ASA I-II, aged 18-45) undergoing elective knee arthroscopies (mean-duration 40 min) were studied. A transmission pulse oximeter probe/sound OHMEDA was attached on the back of LMA (sizes 4 and 5) in an area in contact with the floor of the laryngeal part of the pharynx. Pharyngeal pulse oximetry as well as LMA cuff pressure were monitored and recorded every 5 min from the time of insertion (T0) to removal (T8) and were compared to simultaneous finger pulse oximeter readings. At T2 the cuff was over-inflated to obtain a 100 cm H2O intracuff pressure. At T3 the cuff pressure was decreased at 60 cm H2O. Pharyngeal pulse oximetry correlated with finger pulse oximetry throughout the study and was not effected by over-inflation of the LMA. This modification of the LMA provides an accurate method of measuring pulse oximetry which may be of use in a variety of circumstances.

[Management of postoperative pain in stomatology with ibuprofen L-arginine and naproxen]. / Trattamento del dolore postoperatorio in odontostomatologia con ibuprofene L-arginina e naprossene.

BACKGROUND: The aim of this prospective, randomized study is to compare the efficacy and safety of ibuprofen L-arginine and naproxen in the treatment of postoperative dental pain. METHODS: Seventy patients undergoing removal of impacted third molars were randomly allocated to receive 4 hours after surgery a single oral dose of either ibuprofen L-arginine 400 mg or naproxen 550 mg. Ten patients dropped out from the study because they took the study drug before the allowed time. Using a self-rating record, patients rated their pain and its relief for 1 hour after the drug administration. Remedication, if needed, and mean time of remedication were also recorded. RESULTS: A statistically significant reduction in pain scores with respect to the baseline values was recorded 5 minutes and 15 minutes after the drug administration in the ibuprofen L-arginine and in the naproxen-treated group, respectively. The summed pain intensity difference (SPID) over 60 minutes resulted significantly higher in the ibuprofen L-arginine than in the naproxen-treated group. A complete abolition of pain 60 minutes after medication was obtained in 12/28 patients (42.9%) in the ibuprofen L-arginine and in 5/32 patients (15.6%) in the naproxen-treated group, respectively (p = 0.04). Number of patients requiring remedication, mean time of remedication and drug related adverse effects did not significantly differ in the two treatment group. CONCLUSIONS: Global evaluation of the drugs by the patients showed ibuprofen more effective drug than naproxen.

[Hepatobiliopancreatic surgery in patients over 70 years old: which anesthesia?]. / Chirurgia epatobiliopancreatica nei pazienti oltre i 70 anni: quale anestesia?

In the last years the criteria of operability have been extended to elderly patients with hepato-pancreatic-biliary diseases. We selected 46 patients (in the seventies or older, class 3 or 4 of ASA score, affected by hepato-pancreatic-biliary neoplasms) in order to evaluate the behavior of these patients undergoing to different anaesthesiological techniques. Randomly, we treated 24 patients (group A) in general anaesthesia, and 22 patients (group B) in peridural anaesthesia. We considered mortality rate, morbidity rate, as sepsis, wound infection, pleuritis, and pneumonias. The data were analyzed by chi2-test and Fisher's exact test (p < 0.05). Mortality rate was similar in the two groups (A = 4.1, B = 4.5) (p = ns), and no complications were determined by the different anesthesiologic procedures. Pleuritis was present in 44% of group A vs 45% of group B (p = ns). Atelectasis areas were present in 58% of group A vs 27% of group B (p = ns), pneumonia was present in 33% of group A vs 9% of group B: this value was significant (p = 0.049). There were no differences between the two groups regarding wound infection rate (only one case in group B). We think that pulmonary diseases can be determined by intubation and mechanical ventilation. We show a significant reduction of pneumonia in the patients that underwent peridural anaesthesia. For this reason, peridural technique can be safely extended to elderly patients with hepato-pancreatic-biliary diseases.

[Treatment of postoperative pain by balanced spinal analgesia]. / Il trattamento del dolore post-operatorio mediante analgesia spinale bilanciata.

Postoperative pain relief has the aim to provide patient subjective comfort, to inhibit neuroendocrine and metabolic responses to surgical injury and to enhance restoration of function by allowing the patient to breathe, cough, move more easily and to begin enteral nutrition. Opioid analgesics, independently from the route of administration, are unable to provide all this. In addition to spinal opioids other drugs, such as local anesthetics, alpha 2-agonists and cholinergic drugs, may produce an antinociceptive effect when administered by spinal route. All these drugs may be administered in combination between them, realising the so called "balanced spinal analgesia". The aim of this study is to analyse the available methods for the evaluation of pharmacological interactions, the types of interaction among different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of postoperative pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of postoperative pain, because these drug combinations are able to provide a satisfactory pain control at low doses with a reduction of the adverse effects. Furthermore, the combined use of opioids-local anesthetics proved to be effective also in abolishing postoperative incident pain and in inhibiting neuroendocrine and metabolic responses to surgical injury. Especially in high risk patients this is related to a better outcome. Finally, even if the synergism between cholinergic drugs with opioids or a2-agonists have been proved, at the moment their use in man by spinal route in the treatment of postoperative pain is not advisable.

[Role of surgical splanchnicectomy in the treatment of pancreatic carcinoma]. / Il ruolo della splancnicectomia chirurgica nel trattamento del carcinoma pancreatico.

Palliative surgical procedures offer considerable benefit for the patients with unresectable pancreatic cancer: surgical splanchnicectomy performed in conjunction with biliary-enteric by-pass offers good results as regard pain relief without increased morbidity and mortality. We treated 25 patients with unresectable pancreatic cancer by mean of biliary-enteric by-pass plus bilateral splanchnicectomy performed through different surgical approaches. In this series of patients postoperative mortality was nil, mean survival time was 7.2 months (range 3-14 months). Preoperatively, we assessed all patients as affected by visceral pain: Scott-Huskisson 10 mark-scale value in quantitative assessment of pain was equal or above the 7th mark in 87.5% of patients. One month later in the postoperative follow-up, 96% of the patients had a significant reduction in pain intensity from a preoperative median of 7 mark to a postoperative median of 1.5 mark (p = 0.0001). The mean period free of pain recurrence was 4.8 months. However, after 6 months only 46% of survivors were pain-free with such rate decreasing further to a 10% of survivors after 8 months. Nevertheless, the patients had around 70% of their survival span free of pain. We strongly believe that failure in relief of pain is due to a mistake in preoperative evaluation of the type of pain (somatic and not visceral, or both) and to the onset of somatic pain in the course of the disease rather than to surgical technical errors. Recurrence of pain has been considered inevitable in the biological progression of unresected cancer, and would be treated by combination of therapies, such as non steroidal anti-inflammatory drugs, transaortic coeliac plexus block, narcotics and cervical cordotomy.