Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial.

INTRODUCTION: Opioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric surgery. In this randomized controlled study, we hypothesized that an opioid-free anesthetic using lidocaine, ketamine, and dexmedetomidine would result in a clinically significant reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique. METHODS: Subjects presenting for laparoscopic or robotic bariatric surgery were randomized in a 1:1 ratio to receive either standard opioid-inclusive anesthesia (group A: control) or OFA (group B: OFA). The primary outcome was opioid consumption in the first 24 hours postoperatively in oral morphine equivalents (OMEs). Secondary outcomes included postoperative pain scores, patient-reported incidence of opioid-related adverse effects, hospital length of stay, patient satisfaction, and ongoing opioid use at 1 and 3 months after hospital discharge. RESULTS: 181 subjects, 86 from the control group and 95 from the OFA group, completed the study per protocol. Analysis of the primary outcome showed no significant difference in total opioid consumption at 24 hours between the two treatment groups (control: 52 OMEs vs OFA: 55 OMEs, p=0.49). No secondary outcomes showed statistically significant differences between groups. CONCLUSIONS: This study demonstrates that an OFA protocol using dexmedetomidine, ketamine, and lidocaine for laparoscopic or robotic bariatric surgery was not associated with a reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique using fentanyl.

Laparoscopic resection of a gastric glomus tumor.

Surgeons are commonly asked to evaluate patients with subepithelial masses of the stomach. Glomus tumors are subepithelial mesenchymal tumors that are rarely included in the differential diagnosis when evaluating these patients. We present the case of 55-year old man with a gastric glomus tumor that was diagnosed preoperatively and removed by laparoscopic wedge resection. We review the preoperative evaluation and classic finding associated with this uncommon entity.

Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett's esophagus.

Endoscopic surveillance is recommended for patients with Barrett's esophagus to detect high-grade dysplasia (HGD) or cancer. We studied the outcome of esophagectomy in a cohort of patients who developed HGD or cancer between 1995 and 2003 while under surveillance for Barrett's. Outcomes were measured by analysis of clinical records, symptom questionnaire, and SF-36 (version 2). In 34 patients, mean surveillance time was 48 months (range, 4-132); the mean number of endoscopies was 10 (range, 3-30). Preoperative diagnosis was HGD in 9 patients (26.5%), carcinoma in situ in 16 (47%), and adenocarcinoma in 9 (26.5%). There was no esophagectomy-related mortality; 10 patients (29%) had complications. At mean follow-up of 46 months (range, 13-108), SF-36 (version 2) results showed quality of life scores equal to or better than those of healthy individuals. Incidence and severity scores (VAS 1-10) for postoperative symptoms were reflux, 59% (2.8); dysphagia, 28% (3.7); bloating, 45% (2.6); nausea, 28% (2.1); and diarrhea, 55% (2.5). Twenty-nine patients (85%) have no clinical, radiographic, or endoscopic evidence of recurrent esophageal cancer or metastasis. One patient has metastatic disease. Endoscopic surveillance in Barrett's patients yields malignant lesions at an early, generally curable, stage. Esophagectomy is curative in the great majority and can be accomplished with minimal mortality and excellent quality of life.