A Prospective Observational Study of High-Dose Intrathecal Diamorphine in Laparoscopic Bariatric Surgery: a Single-Centre Experience.

BACKGROUND: Post-operative pain management following laparoscopic bariatric surgery can be challenging. There are concerns regarding the use of opioids. The rate of cardiorespiratory problems following neuraxial opioids is unclear. There is little published data on their use in bariatric surgery. This study aimed to assess technique feasibility, pain outcomes, patient acceptability, and the side effects and complications of a 'high-dose' (1.0 mg) intrathecal diamorphine technique for patients undergoing primary laparoscopic bariatric surgery. MATERIALS AND METHODS: Fifty patients were included. Eleven patients (22%) had a diagnosis of OSA. All patients had a spinal anaesthetic with 2.0 mL of 0.25% isobaric bupivacaine containing 1.0 mg diamorphine. General anaesthesia followed together with multi-modal analgesia and anti-emesis. Post-operative pain scores, complications, and side effects in the first 24 h post-operative period were documented. Patients were followed up 6 to 8 weeks after discharge. RESULTS: All patients had a working spinal anaesthetic with thirty-nine insertions (78%) on the first attempt. Pain scores were similar to previously published data where they were found to be superior to a non-spinal analgesic regime. The median 24 h post-operative oral morphine equivalent consumption was 5 mg. Eight patients (16%) required urinary catheterisation. Four patients (8%) complained of pruritus. Eighteen patients (36%) had post-operative nausea or vomiting. Thirty-three patients (66%) responded to the follow-up request. Thirty of the thirty-three patients (91%) stated they would have the spinal anaesthetic again. CONCLUSION: We have demonstrated that neuraxial blockade is a simple, practical, and feasible technique to adopt. Our case series demonstrated a high level of patient acceptability.

The cost of trauma operating theatre inefficiency.

The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends.

Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy.

BACKGROUND: Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy. METHODS: A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale. RESULTS: Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047). CONCLUSION: Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.

[Incidence of disability in Iceland before and after introduction of a new method of disability evaluation.].

OBJECTIVE: To assess changes in disability evaluation, since the introduction on September 1st 1999 of a new assessment method based on the British functional capacity evaluation, "All work test". Previously, the disability assessment was based on the applicant's medical, social and financial circumstances. MATERIAL AND METHODS: The study includes all those having their disability assessed for the first time at the State Social Security Institute of Iceland in 1997, 1998 and 2000. Information was obtained from the disability register on degree of disability, gender, age and primary diagnoses. RESULTS: After the introduction of the new assessment method, there has been a significant increase in the number of women who have disability more then 75% (p<0.0001). This increase occurs amongst women older than 30 years, having musculoskeletal disorders (mainly soft tissue disorders). There has also been a slight (statistically insignificant) increase in more than 75% disability amongst men (p=0.25). The number of people who have had their disability evaluated as 50-65% has decreased (p<0.0001). No significant change in the total number of new disability pensioners (having their disability assessed as being more than 75% or 50-65%) was observed. CONCLUSIONS: The new method of disability assessment has resulted in a significant rise in the number of women who have had their disability assessed as being more than 75%, but there has not been a rise in the total number of new disability pensioners, as the increased number of women with the higher degree of disability has been balanced by a significant fall in the number of new disability pensioners with the lower degree of disability.

[Retroperitoneal approach to the abdominal aorta for occlusive disease.].

The abdominal aorta can be approached through the peritoneum or retroperitoneally. The aim of this study was to compare these two routes of exposure. Over a 10 year period, between 1979 and 1989, 48 patients were operated on for an aortobifemoral bypass, because of occlusive diseases of aorta or iliac arteries. The retroperitoneal approach was used in 20 cases and 28 were operated by the standard transperitoneal approach. In a non randomized retrospective study the outcome was compared regarding; operation time, blood transfusion during operation, initiation of alimentation, hospitalisation and mortality. All of the patients were operated on by two experienced vascular surgeons. In the retroperitoneal group there were 11 men and 10 women with a mean age of 63,4 years. In the transperitoneal group there were 16 men and 10 women with a mean age of 60,3 years. With the retroperitoneal approach the operating time was 185 min. v. 248 min. for the transperitoneal group (p<0.05). The fasting period after operation was four days for the retroperitoneal group v. five days for the transperitoneal group (p<0.05). The hospitalization was 11 days when the retroperitoneal approach was used v. 15 days for the transperitoneal group (ns). The results of this study indicate that it is advantageous to approach the abdominal aorta through a retroperitoneal route.

[Surgery for abdominal aortic aneurysm. What is an acceptable complications rate?]. / Kirurgi for abdominale aortaaneurismer. Hva er akseptabel komplikasjonsfrekvens?

At the annual meeting of the Vascular Section of the Scandinavian Surgical Society in 1993 it was decided to discuss standards for quality in vascular surgery. This article is discussing operations for abdominal aortic aneurysms with special reference to early mortality and complications like graft infection and aortoenteric fistula. The discussion is based on national vascular registers and investigations on vascular surgical activity in the Scandinavian countries. In addition, a survey of the literature is given. Although these data should be regarded as a guide-line only, we feel that one should try to keep the 30 day mortality following elective resection for asymptomatic abdominal aortic aneurysm below 5-7 per cent. A mortality less than 50-60 per cent following operation for ruptured aneurysm may be regarded as reasonable. Patient-selection regarding age, concomitant disease etc. could significantly influence these results, and should be taken into consideration when comparison between different series is made. Graft infection is a serious complication and if the frequency is higher than 2 per cent, or there is an accumulation of graft infections in a vascular centre, the hospital routines should be reviewed carefully. The occurrence of infection is higher following operations for ruptured aneurysms than following elective operations. Early operations for haemorrhage and early occlusion should be below 5-6 per cent. Some authors have shown a correlation between the volume of operation, postoperative mortality and the frequency of complications. We therefore think that it might be reasonable to suggest that at least patients who have concomitant diseases like serious coronary heart disease or renal insufficiency should be operated on in vascular centres.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer of the pancreas in Iceland. An epidemiologic and clinical study, 1974-85.

A retrospective study was performed of all patients diagnosed as having pancreatic cancer in Iceland during the period 1974-85 (12 years). The incidence of the disease during the period according to this study was 10.7 per 100,000 males and 9.8 per 100,000 females, with age-adjusted world standard incidences of 9.0 per 100,000 males and 6.7 per 100,000 females. A total of 301 patients were identified; adequate information could be obtained for 281 patients, and 225 (74.8%) had the diagnosis histologically confirmed. Two hundred and five patients with adenocarcinoma were accepted for detailed analysis. Of the patients with adenocarcinoma 139 (67.8%) were diagnosed at laparotomy, and 33 of them had the tumour resected, with an operative mortality of 12.1%. The cancer was located in the head of the pancreas in 102 patients (49.8%), and in 159 (77.6%) metastases were found at the time of diagnosis. The median survival time for the patients with adenocarcinoma was 95.4 days (SD +/- 11.1 days), although there were two patients in this group who were alive 5 years after diagnosis. The median survival for the total group of 281 patients was 98.3 days (SD +/- 11.0 days), although 6 of these patients lived for more than 5 years. The percentage of histologically confirmed tumours in Iceland is high compared with many previously reported studies.

The influence of acute normovolemic anemia on cerebral blood flow and oxygen consumption of anesthetized rats.

The influence of acute normovolemic anemia on cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRo2) was studied in normocapnic rats under nitrous oxide anaesthesia. The arterial hemoglobin content was reduced to values of about 12, 9, 6 and 3 g.(100 ml)(-1) by arterial bleeding and substitution with equal volumes of homolgous plasma. The CBF increased in proportion to the reduction in hemoglobin content to reach values of 500-600 per cent of normal at extreme degrees of anemia, but CMR02 remained unchanged. Cerebral venous PO2 and oxygen saturation did not decrease below normal values, indicating that tissue hypoxia did not develop. However, since the increase in CBF at hemoglobin concentrations of below 9 g(100 ml)(-1) was far in excess of that expected from the decrease in viscosity the results indicate thatdilatation of cerebral resistance vessels occurred. This dilatation, which was obviously related to the fall in arterial oxygen content, cannot be explained by any of the current theories proposed to explain cerebral hyperemia in hypoxia.

The relationship between arterial po2 and cerebral blood flow in hypoxic hypoxia.

The relationship between arterial oxygen tension (PaO2) and cerebral blood flow (CBF) in hypoxic hypoxia was studied in artificially ventilated and normocapnic rats. Changes in CBF were evaluated from arteriovenous differences in oxygen content after 2, 5, 15 and 30 min exposure to PaO2 85, 75, 55, 45, 35, and 25 mm Hg. In separate experiments the PaO2 was decreased to 25 mm Hg for 1, 2, 5, 15 and 30 min in animals in which PaCO2 was allowed to fall by 5-10 mm Hg. There was a small, gradual increase in CBF when PaO2 was lowered in steps from 130 to 55 mm Hg, and a more pronounced increase at PO2 values below 50 mm Hg. At PaO2 25 mm Hg CBF increased to values of 500% of normal. Significant increased in CBF were recorded at PaO2 values of 85 and 75 mm Hg in spite of the fact that previous studies have failed to record an elevated tissue lactate content at these po2 levels, and in spite of an unchanged cerebral venous PO2. When the PaO2 was reduced to 25 mm Hg CBF increased markedly already at 1 and 2 min, and this increase in CBF occurred even if PaCO2 was allowed to fall by 5-10 mm Hg. Previous results have shown that in such short periods enough lactic acid is not formed to induce a net tissue acidosis. The results thus give no support to the hypothesis that cerebral hyperemia in hypoxia is coupled to accumulation of lactic acid in the tissue.

Cerebral blood flow and oxygen consumption in the rat in hypoxic hypoxia.

In order to measure cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRo(2)) at pronounced degrees of hypoxic hypoxia the Pao(2) of artificially ventilated and normocapnic rats was reduced to between 47 and 22 mm Hg for 15-25 min with subsequent measurements of CBF, using a -133Xenon modification of the Kety and Schmidt technique, and of the arteriovenous difference in oxygen content, the venous blood being obtained from the superior sagittal sinus. When the Pao(2) was reduced to minimal values of 22 mm Hg CBF increased 4- to 6-fold, the increase in CBF being unrelated to changes in blood pressure or Paco(2). The CMRo(2) remained unchanged at all levels of hypoxia. It is concluded that the maintenance of a normal, or near-normal, cerebral energy state even at extreme degrees of hypoxic hypoxia depends solely on a homeostatic increase in CBF.

Effects of different gas flow patterns on central circulation during respirator treatment.

The effects of different inspiratory gas flow patterns on the central circulation during respirator treatment were investigated, first with a retrospective study consisting of 15 patients, where the effects on the mean intrathoracic pressure were represented by the variations in the amplitude and time development of the oesophageal pressure curve. In another study on eight intensive care patients undergoing respirator treatment, right-sided heart catheterisation was performed with pressure recordings in the central venous position, the right ventricle, the pulmonary artery and in the pulmonary capillary venous position. Estimations of the arterial-mixed venous oxygen content difference were also made. The development and transmission of the airway pressure curve to the central circulation were illustrated and discussed. The results showed very small effects on the mean intrathoracic pressure from different inspiratory gas flow patterns, and, therefore, it could be expected that the effects on the central circulation would be insignificant. This was also the conclusion in the catheterisation study. No important changes in the pressures of the a-vo2 difference occured. Most of the characteristics of a particular gas flow pattern are lost during the passage through the airways and are not transmitted to the oesophagus or the central vessels.