Association of increased postoperative opioid administration with non-small-cell lung cancer recurrence: a retrospective analysis.

BACKGROUND: Evidence suggests that opioid-sparing anaesthetic techniques might be associated with increased cancer-free postoperative survival. This could be related to suppression of natural killer cells by opioid analgesics in the perioperative period. This retrospective analysis tested the hypothesis that greater opioid use in the postoperative period is associated with a higher incidence of recurrences after surgery for lung cancer. METHODS: The medical records of 99 consecutive patients who underwent video-assisted thoracoscopic surgery with lobectomy for Stage I or IIa biopsy-proven non-small-cell lung cancer (NSCLC) were reviewed. Perioperative information including patient characteristics, laboratory data, and surgical, anaesthetic, nursing, and pharmacy reports were collected. Doses of opioids administered intra-operatively and for the first 96 h after operation were converted into equianalgesic doses of oral morphine using a standard conversion table. Data were then compared with the National Cancer Registry's incidence of disease-free survival for 5 yr. RESULTS: A total of 99 patients with similar characteristics were included in the final analysis, 73 of whom were NSCLC recurrence-free at 5 yr and 26 had NSCLC recurrence within 5 yr. Total opioid dose during the 96 h postoperative period was 124 (101) mg of morphine equivalents in the cancer-free group and 232 mg (355) mg in the recurrence group (P=0.02). CONCLUSIONS: This retrospective analysis suggests an association between increased doses of opioids during the initial 96 h postoperative period with a higher recurrence rate of NSCLC within 5 yr.

Prophylactic antibiotics for elective laparoscopic cholecystectomy: are they necessary?

HYPOTHESIS: Prophylactic antibiotic treatment in elective laparoscopic cholecystectomy does not lower the already low infection rate associated with this procedure. DESIGN AND SETTING: Prospective double-blind randomized trial at a community-based training hospital. PATIENTS: Four hundred fifty patients undergoing elective laparoscopic cholecystectomy were randomized into 1 of 3 treatment arms: (1) preoperative cefotetan disodium, 1g intravenously; (2) preoperative cefazolin, 1g intravenously; and (3) intravenous placebo. There were no demographic differences between groups in age, smoking history, American Society of Anesthesiologists score, infection risk class, time of antibiotic administration prior to surgery, and type of skin preparation. INTERVENTIONS: Laparoscopic cholecystectomy was attempted in all cases; however, 10 patients required conversion to an open cholecystectomy and they were included in the statistical analysis. Preoperatively, all patients were randomized in a blinded manner and received cefotetan, cefazolin, or placebo intravenously. RESULTS: There were 10 postoperative infections. In the cefotetan group, there were 3 cases of superficial surgical site infections. In the cefazolin group, there were 2 superficial surgical site infections-1 pneumonia and 1 rhinosinusitis. In the placebo group, there were 2 superficial surgical site infections and 1 urinary tract infection. The overall infection rate in this series was 2.4%. Follow-up was performed at routine postoperative visits and by telephone contact. Data were evaluated using the chi2 test and analysis of variance with Duncan post hoc test (P<.05). CONCLUSION: Based on our data, use of prophylactic antibiotics does not decrease the rate of wound infections in elective laparoscopic cholecystectomy.

Pain control after thoracotomy: bupivacaine versus lidocaine in continuous extrapleural intercostal nerve blockade.

BACKGROUND: The use of a continuous bupivacaine extrapleural intercostal nerve block after posterolateral thoracotomy has been shown in randomized controlled studies to be effective in reducing postoperative pain and restoring pulmonary function. It is our hypothesis that when using a continuous infusion for nerve block, a long-acting agent (bupivacaine) is unnecessary and a shorter-acting agent (lidocaine) would offer equivalent results with less systemic toxicity. This study was designed to determine whether lidocaine was as effective as bupivacaine in a continuous extrapleural intercostal nerve block after posterolateral thoracotomy because lidocaine is a less toxic analgesic agent. The study was prospectively randomized and double-blinded. METHODS: Forty-six patients undergoing elective posterolateral thoracotomy were randomized to blindly receive bupivacaine (n = 23) or lidocaine (n = 23) by continuous infusion pump through an intraoperatively placed indwelling extrapleural catheter. Postoperative pain was assessed for 48 hours by patient-controlled morphine consumption and by linear visual analog scale. There was no statistically significant difference in age, sex, or type of operation between the two groups. RESULTS: There was no statistically significant difference between the bupivacaine and lidocaine groups in patient-controlled morphine use or in visual analog scale scores. CONCLUSIONS: Lidocaine offers equivalent pain control to bupivacaine when administered for continuous extrapleural intercostal nerve block after posterolateral thoracotomy, with less risk of systemic toxicity.

Axillary lymph node dissection: is it required in T1a breast cancer?

BACKGROUND: Several authors have questioned the need for axillary lymph node dissection in T1a breast cancer (primary tumors 5 mm or less in diameter), although current practice typically includes routine axillary lymph node dissection. STUDY DESIGN: We retrospectively reviewed the records of 2,242 breast cancers in our tumor registries from 1987 to 1994. The incidence of axillary lymph node metastases was determined according to primary breast cancer size. The objective was to determine the need for axillary lymph node dissection in T1a breast cancers, and our data included 74 T1a cancers. Axillary lymph node dissection was performed in 66 of these patients. RESULTS: Axillary lymph node metastases were found in 3 of 66 cases (4.5 percent). We also reviewed several other institutional series of T1a breast cancers and found no statistical difference in the reported axillary lymph node metastases and our data (p < .10). The combined single-institution data included 256 T1a breast cancers and had a 3.9 percent incidence of axillary lymph node metastases. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute published data statistically different from ours. From 1977 to 1982, 339 T1a lesions had a 21 percent incidence of axillary lymph node metastases (p < .005), and from 1983 to 1987, 1,491 T1a lesions had an 11 percent metastatic rate (p < .001). We believe that the SEER data is flawed, because SEER results do not require histologic confirmation of axillary lymph node status. CONCLUSIONS: We believe the single-institution rate of 3.9 percent axillary lymph node metastases in T1a breast tumors results from state-of-the-art breast cancer screening and detection of earlier and smaller lesions. Our data support abandoning routine axillary lymph node dissection in T1a breast cancer.

Diagnostic pneumoperitoneum accurately predicts the presence of patent processus vaginalis.

Ninety-four infants with unilateral indirect inguinal hernia underwent repair and diagnostic pneumoperitoneum (DPP). Contralateral groin exploration was performed in all patients including those with a negative DPP result. Thirty-seven (39%) of the 94 patients had a positive DPP result, and 36 of 37 (97%) had a patent processus vaginalis (PPV) on the side contralateral to the clinical hernia. Fifty-seven (61%) of the 94 patients had a negative DPP result, and 54 (95%) of these had no PPV. Female patients had a 1:1 correlation between DPP and PPV. DPP can predict the presence of PPV in the contralateral groin of patients with unilateral hernia with precision and minimizes the need for diagnostic groin exploration.

Mycobacterium fortuitum infection following treatment of a ganglion cyst: case report and literature review.

Mycobacterium fortuitum infections in the hand and upper extremity are uncommon. Most previously reported cases have been secondary to trauma. A case of extensor tenosynovitis due to M fortuitum following treatment for a wrist ganglion is discussed here. The presentation, diagnosis, and treatment of M fortuitum infections are reviewed.

Granular cell tumor in the hand.

A case of multifocal granular cell myoblastoma involving the hand is reported. Granular cell tumors are uncommon benign neoplasms infrequently seen in the hand. Multifocal occurrence is even more unusual. Clinical and pathologic diagnosis may be difficult.

Pseudomonas cervical osteomyelitis in a polytrauma patient.

Cervical osteomyelitis, an uncommon disease, is rarely associated with Pseudomonas organisms in non-drug-users. This report describes a case of cervical vertebral osteomyelitis associated with Pseudomonas aeruginosa pneumonia following panfacial trauma and closed head injury. Delays in diagnosing vertebral osteomyelitis are common because of the nonspecific nature of the history and the initial absence of clinical evidence, both of which may help to foster a generally low index of suspicion.

Complex upper extremity vascular trauma in an urban population.

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.