Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases.

OBJECTIVE: To assess safety and efficacy of the regional anesthetic technique paravertebral block for operative treatment of breast cancer, and to compare postoperative pain, nausea, vomiting, and length of hospital stay in patients undergoing breast surgery using paravertebral block and general anesthesia. BACKGROUND: General anesthesia is currently the standard technique used for surgical treatment of breast cancer. Increasing hospital costs have focused attention on reducing the length of hospital stay for these patients. However, the side effects and complications of general anesthesia preclude ambulatory surgery for most patients undergoing breast surgery. In April 1994, the authors initiated the use of paravertebral block anesthesia for patients undergoing primary breast cancer surgery. A review of our early experience revealed that this regional anesthetic technique enables effective anesthesia for operative procedures of the breast and axilla, reduces postoperative nausea and vomiting, and provides prolonged postoperative sensory block that minimizes narcotic requirements. METHODS: A retrospective analysis of 145 consecutive patients undergoing 156 breast cancer operations using paravertebral block and 100 patients undergoing general anesthesia during a 2-year period was performed. Anesthetic effectiveness and complications, inpatient experience with postoperative pain, nausea, vomiting, and length of stay were measured. RESULTS: Surgery was successfully completed in 85% of the cases attempted by using paravertebral block alone, and in 91% of the cases, surgery was completed by using paravertebral block supplemented with local anesthetic. There was a 2.6% incidence of complications associated with block placement. Twenty percent of patients in the paravertebral group required medication for nausea and vomiting during their hospital stay compared with 39% in the general anesthesia group. Narcotic analgesia was required in 98% of general anesthesia patients, as opposed to 25% of patients undergoing paravertebral block. Ninety-six percent of patients having paravertebral block anesthesia were discharged within the day of surgery, compared with 76% of patients who had a general anesthetic. CONCLUSIONS: Paravertebral block can be used to perform major operations for breast cancer with minimal complications and a low rate of conversion to general anesthesia. Paravertebral block markedly improves the quality of recovery after breast cancer surgery and provides the patient with the option of ambulatory discharge.

Ambulatory surgical management of breast carcinoma using paravertebral block.

OBJECTIVE: The authors describe an initial experience using paravertebral block for ambulatory or short-stay operations for breast cancer. BACKGROUND: Rising hospital costs have focused attention on limiting the length of stay for patients undergoing surgical treatment of breast cancer. Thus far, ambulatory surgery has been limited by side effects and complications of general anesthesia. Paravertebral block offers the potential benefit of effective analgesia, with limited postoperative nausea and vomiting. METHODS: The medical records of the first 15 patients with breast cancer who underwent 16 major operations for the treatment of breast cancer using paravertebral block were reviewed. Patients were either discharged directly from the recovery room or after overnight hospital admission. The effectiveness of anesthesia, surgical outcome, patient satisfaction, and hospital costs are reviewed. RESULTS: Paravertebral block achieved effective anesthesia for cancer operations of the breast and axilla; conversion to general anesthesia or supplementation with local anesthesia was not required. There was one postoperative hemorrhage, there were two seromas, and there was one superficial wound infection. Sensory block persisted for an average of 23 hours. Postoperative pain was effectively controlled, in fact, nine patients required no postoperative narcotic for pain control. Nausea and vomiting transiently afflicted three patients and prompted overnight observation in one patient originally scheduled for immediate discharge. Fourteen patients (93%) rated their experience as "very satisfactory." CONCLUSION: Breast operations for the surgical management of breast cancer using paravertebral block can be performed safely, with great patient satisfaction, and with potential for significant cost savings.

Surgical jejunostomy in aspiration risk patients.

One hundred patients underwent laparotomy for independent jejunal feeding tube placement. Neurologic disease was present in 50%, and obtundation (28) and oropharyngeal dysmotility (25) were the most common indications for enteral feeding. The post-pyloric route was chosen because of aspiration risk in almost all (94%) patients. Postoperative (30-day) mortality rate was 21%, because of cardiopulmonary failure in most (18). One death resulted directly from aspiration of tube feeds. Two surgical complications required reoperation: one wound dehiscence and one small bowel obstruction. Four wound infections occurred. Two patients underwent reoperation after tube removal, and four tubes required fluoroscopically guided reinsertion for peritubular drainage (2), removal (1), and occlusion (1). Aspiration pneumonia was present in 18 patients preoperatively and in eight postoperatively. None of the patients with feeding-related preoperative aspiration pneumonia (13) had a recurrence while fed by jejunostomy. Three patients developed postoperative aspiration pneumonia before initiation of jejunostomy feedings. Jejunostomy may be performed with low morbidity rate and substantial reduction of feeding-related aspiration pneumonia, and is the feeding route of choice in aspiration risk patients.

Blunt abdominal trauma resulting in intestinal obstruction: when to operate?

The overall approach to blunt abdominal trauma resulting in hematoma and intestinal obstruction has been variable and controversial. Recent reports recommend conservative nonoperative management. We reviewed six cases of duodenal and jejunal hematomas resulting from blunt trauma of which five resolved with nasogastric decompression and parenteral nutrition. The average hospital stay was 16 days (10-23 days), and total parenteral nutrition days were 9 days (4-16 days). Upper gastrointestinal series (UGI) demonstrated partial bowel obstruction in all five cases. In contrast, the sixth case was a restrained passenger who had evidence of complete bowel obstruction on UGI series, which failed to resolve after 18 days of conservative management. Laparotomy revealed jejunal and colonic strictures with fibrosis, which were successfully resected. We recommend that based on radiologic documentation of persistent high-grade obstruction, as well as the clinical course, patients whose obstructions do not resolve by 10 to 14 days ought to be further investigated and operative intervention considered. This approach may facilitate an earlier diagnosis of complications, reduce length of hospitalization and days on parenteral nutrition, as well as to expedite the proper management.