Topical Analgesia with Lidocaine Plus Diclofenac Decreases Pain in Benign Anorectal Surgery: Randomized, Double-blind, and Controlled Clinical Trial.

OBJECTIVE: The aim of this study is to evaluate the efficacy and safety of a topical formulation containing lidocaine plus diclofenac (CLIFE1) compared to lidocaine (CLIFE2), to decrease pain in benign anorectal surgery (BARS) to date not evaluated. More than 50% of patients undergoing BARS, especially hemorrhoidectomy, suffer from moderate and severe postoperative pain. This remains an unresolved problem that could be addressed with the new CLIFE1 topical treatment. METHODS: A multicenter, randomized double-blind, active-controlled parallel-group superiority trial, was conducted in two Spanish hospitals. Patients undergoing BARS (hemorrhoids, anal fistula and anal fissure) were randomized at the end of surgery at a 1:1 ratio to receive first dose either CLIFE1 (n = 60) or CLIFE2 (n = 60) anorectal topical treatment, and after every 12 h for the first three postoperative days and once a day from the fourth to sixth. The primary outcome was average of pain decrease after topical treatment, measured with visual analogue scale (VAS) by the patients themselves, the evening in the surgery day and four times daily for the first three postoperative days. RESULTS: The results of 120 patients included out of 150 selected undergoing BARS show a decrease in pain after CLIFE1 topical treatment (7.47 ± 13.09) greater than with CLIFE2 (4.38 ± 6.75), difference -3.21 95% CI (-5.75; -0.68), p = 0.008, decreasing significantly postoperative pain ( ≥ 9 mm, VAS) in 35% of patients undergoing benign anorectal surgery, compared to 18.33 % treated with lidocaine. CONCLUSIONS: The CLIFE1 topical treatment shows better analgesic efficacy than CLIFE2 in BARS.

Postoperative analgesia with continuous wound infusion of local anaesthesia vs saline: a double-blind randomized, controlled trial in colorectal surgery.

AIM: The aim of this prospective double-blind randomized clinical trial was to determine whether preperitoneal continuous wound infusion (CWI) of the local anaesthetic ropivacaine after either laparotomy or video-assisted laparoscopy for colorectal surgery would reduce patient consumption of morphine. METHOD: Patients scheduled for colorectal surgery randomly received a 48-h preperitoneal CWI of either 0.38% ropivacaine or 0.9% saline at rates of 5 ml/h after laparotomy or 2 ml/h after laparoscopy. The primary end-point was total morphine consumption in surgery and afterwards through a patient-controlled analgesia device. Results in the laparotomy and laparoscopy subgroups were also compared. RESULTS: Sixty-seven patients were included, 33 in the ropivacaine CWI group and 34 in the saline group. Median [interquartile range (IQR)] morphine consumption was lower in the ropivacaine group [23.5 mg (11.25-42.75)] than in the saline group [52 mg (24.5-64)] (P = 0.010). Morphine consumption was also lower in the laparotomy subgroup receiving ropivacaine [21.5 (15.6-34.7)] than in the saline group [52.5 (22.5-65) ml] (P = 0.041). Consumption was statistically similar in laparoscopy patients on ropivacaine or saline. No side effects were observed. Sixteen patients had a surgical wound infection (23.9%); 11 (16.4%) presented wound infection and five (7.5%) organ space infection. Forty-six catheter cultures were obtained; 10 (21.7%) were positive, assessed to be due to contamination. CONCLUSION: Preperitoneal CWI of ropivacaine is a good, safe addition to a multimodal analgesia regimen for colorectal surgery. CWI can reduce morphine consumption without increasing adverse effects.

[Influence of the severity of obesity on morbidity and mortality after gastric bypass surgery]. / Influencia del grado de obesidad en la morbimortalidad operatoria de la cirugia bariátrica.

OBJECTIVE: To determine the influence of severity of obesity on morbidity and mortality following Roux-en-Y gastric bypass and vertical ringed gastroplasty, with severity classified as morbid obesity (MO) defined by a body mass index (BMI) between 35 and 55 Kg/m2 and super-morbid obesity (SMO) defined by a BMI exceeding 55 Kg/m2. METHOD: A series of patients who underwent the aforementioned type of gastric bypass surgery were followed for 5 years. The patients were classified as to whether they had associated sleep apnea syndrome, alveolar hypoventilation, or "overlap syndrome". RESULTS: A total of 105 patients were enrolled: 70 (66.7%) classified as having MO and 35 (33.3%) classified as having SMO. Distribution by sex was significantly different in the 2 groups, but respiratory diseases were similar. PaO2 was higher in the MO group, PaCO2 was lower, and the alveolar-arterial gradient was smaller. Duration of surgery was shorter in the MO group (120.43 +/- 32.97 vs. 136.76 +/- 28.28 minutes). The percentage of complications was similar in the 2 groups (32.86% and 45.7% in the MO and SMO groups, respectively), although the incidence of respiratory complications was higher in SMO patients (8.57% vs. 20% in the MO and SMO groups, respectively). No differences were observed in the rates of surgical, hemodynamic, or infectious complications. Length of hospital stay was similar (6.44 vs. 6.69 for MO and SMO patients, respectively). CONCLUSIONS: More severe obesity can be associated with preoperative arterial blood gas alterations in patients with concomitant respiratory disease and a higher incidence of respiratory complications in the early phase of recovery from gastric bypass surgery.

[Hemodynamics of the cirrhotic patient during liver transplantation. Influence of the preservation of portal and vena cava flow]. / Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava.

OBJECTIVE: To describe the hemodynamic pattern of patients undergoing liver transplantation with preservation of portocaval flow. PATIENTS AND METHODS: A prospective study of 20 cirrhotic patients who had not previously undergone surgery for portal hypertension or had porto-systemic bypass, both of which have hemodynamic effects in the cirrhotic patient. The patients were transplanted with preservation of inferior vena cava flow and temporary portocaval shunt. RESULTS: The decrease in cardiac output during the anhepatic phase was only 10% and mean blood pressure (77.6 +/- 11 versus 76 +/- 10 mm Hg) and supply pressures (central venous pressure 9.1 +/- 5.5 versus 8.4 +/- 5.3 mm Hg; pulmonary capillary pressure 11.4 +/- 6.1 versus 11.3 +/- 7.4 mm Hg) remained stable. Likewise, no significant increase in systemic vascular resistance (614 +/- 223 versus 676 +/- 306 dyne-sec/cm5) or heart rate (90 +/- 14 versus 97 +/- 17 beats/min). The number of units of packed red cells was 2.7 +/- 2.5 and 35% of the patients required no transfusions. Diuresis was stable throughout the procedure (total diuresis 3.6 +/- 2.4 mL/Kg/h; anhepatic phase 1.3 +/- 1.5 mL/Kg/h). CONCLUSIONS: Creation of a portocaval shunt during the anhepatic phase of liver transplantation allows hemodynamic vital signs to be held stable, decreases the need for transfusion and maintains diuresis.

Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava / Hemodynamics of the cirrhotic patient during liver transplantation: the effect of preserving portocaval flow

OBJETIVO: Describir el patrón hemodinámico de aquellos pacientes sometidos a trasplante hepático con preservación de flujo caval y portal. PACIENTES Y MÉTODOS: Estudio prospectivo de un grupo de 20 pacientes cirróticos, sin cirugía de la hipertensión portal o derivación portosistémica previa que influya en la hemodinámica del paciente cirrótico, trasplantados según la técnica de preservación de vena cava inferior asociándose anastomosis porto-cava temporal. RESULTADOS: La disminución del gasto cardíaco durante la fase anhepática fue tan sólo del 10 por ciento, manteniéndose estables tanto la presión arterial media (77,6 ñ 11 frente a 76 ñ 10 mm Hg) como las presiones de llenado (presión venosa central: 9,1 ñ 5,5 frente a 8,4 ñ 5,3 mm Hg; presión capilar pulmonar: 11,4 ñ 6,1 frente a 11,3 ñ 7,4 mm Hg). Asimismo no hubo un aumento significativo de las resistencias vasculares sistémicas (614 ñ 223 frente a 676 ñ 306 dinas-s/cm5) ni de la frecuencia cardíaca (90 ñ 14 frente a 97 ñ 17 latidos/min). El requerimiento de concentrados de hematíes fue de 2,7 ñ 2,5 pudiéndose trasplantar el 35 por ciento de los pacientes sin transfusión. La diuresis se mantuvo estable a lo largo del trasplante (diuresis total: 3,6 ñ 2,4 ml/Kg/h; fase anhepática: 1,3 ñ 1,5 ml/Kg/h). CONCLUSIONES: la realización de una anastomosis porto-cava durante la fase anhepática del trasplante hepático permite mantener la estabilidad hemodinámica, así como disminuir los requerimientos transfusionales y mantener la diuresis (AU)

[Quality in anesthetic management during hepatic transplant. Hepatic Transplant Anesthesia Group]. / Estudio de la calidad en el manejo anestésico durante el transplante hepático. Grupo de Anestesia de Trasplante Hepático (GATHa).

INTRODUCTION: To measure the quality of anesthetic management during liver transplants (LT) and to assess the effect on improving patient care after establishing a quality policy based on self evaluation of quality indicators. MATERIAL AND METHODS: Two periods were studied: January 1993 through December 1994 (93 LT) and March 1995 through November 1995 (45 LT). Compliance with the anesthetic protocol was assessed by way of 14 indicators as follows: exposure and analysis of the results for the 1993-1994 period followed by later evaluation of quality indicators for the period 1995. RESULTS: The index for revascularization of the graft was lower than any of the following six indicators: temperature, systolic arterial pressure, hemoglobin, fibrinogen, pH value and sodium values over 155 mmol/l. In the phase during which the liver was removed, the indicator for calcium level lower than 1 mmol/l was the only indicator with low compliance. Multiple regression analysis showed that mechanical ventilation was associated to transfusion requirements, to non compliance with hemostatic and coagulation indicators, and to presence of a decrease in systolic arterial pressure below 70 mmHg. CONCLUSION: We conclude that adverse effects can be partially improved by implementing a quality policy based exclusively on analysis of results and ongoing professional training. The impact of non compliance with the indicators, policy structure and process of delivering health care should be explored.