Safety of pediatric continuous interscalene block catheters placed under general anesthesia: a single center's experience.

BACKGROUND: The use of interscalene catheters is an effective treatment strategy for children and adolescents undergoing shoulder surgery. Although placement of interscalene catheters in the awake child is challenging, some have cautioned against performing regional anesthesia in the patient under general anesthesia. We present a case series of 154 interscalene catheters placed in pediatric patients under general anesthesia and managed in the outpatient setting. METHODS: A total of 154 interscalene catheters were placed at a single institution between April 2006 and December 2011 using a modified lateral approach. All catheters were placed with the patient under general anesthesia. The patients discharged home with the catheters were followed-up with daily phone calls until removal of the catheter. RESULTS: Of the 154 patients with an interscalene CPNB, 132 (85.7%) were discharged home with the interscalene CPNB in place. The success rate for the catheters was 92.1% (CI: 86.9-95.7%). The most common reason for catheter failure (6%) was early dislodgement (within 24 h). In addition to these 12 patients, 3 other patients had adverse events related to the interscalene CPNB. CONCLUSION: Interscalene catheter placement under general anesthesia and management on an outpatient basis is feasible in the pediatric population and is associated with a low rate of catheter-related complications.

Multiple simultaneous perineural infusions for postoperative analgesia in adolescents in an outpatient setting.

We report a case series of five adolescents who were managed with dual simultaneous perineural infusions after orthopaedic surgery on an outpatient basis. Adolescents undergoing orthopaedic procedures involving more than one extremity or nerve distribution can be managed after operation with multiple catheters. Use of low concentrations of local anaesthetic infusions along with good patient and family education and close follow-up by a dedicated paediatric pain management team can make this feasible in an outpatient setting.

Side-effects of postoperative epidural analgesia in children: a randomized study comparing morphine and clonidine.

BACKGROUND: Morphine is widely used in association with local anaesthetics for postoperative epidural analgesia. There are no data on the prolonged use of clonidine for postoperative analgesia in children. The primary outcome of this randomized, double-blind trial was to compare the incidence of side-effects after epidural infusion of clonidine or morphine, in association with ropivacaine in children. METHODS: After institutional approval, 26 children, aged 3-12 years, who were scheduled for abdominal surgery, had an epidural catheter placed after induction of general anaesthesia. Patients were then randomized to two different groups. After an initial bolus of 2.5 mg x kg-1 0.25% ropivacaine with either 40 micro g x kg-1 morphine (group M, n = 14) or 1 micro g x kg-1 clonidine (group C, n = 12), an epidural infusion was started at a rate of 0.4 ml x kg-1 x h-1. The patients in the M group received an infusion of 0.08% ropivacaine with 10 micro g.ml-1 morphine, those in the group C an infusion of 0.08% ropivacaine with 0.6 micro g.ml-1 clonidine. RESULTS: The two groups were similar with respect to age, sex and weight. One patient in the C group was excluded for misplacement of the epidural catheter. The incidence of vomiting and pruritus was significantly higher in the M group compared with the C group (64% and 85% versus 0%, respectively). The incidence of pain was significantly higher in the C group compared with the M group (73% versus 29%) as well as the need for rescue analgesia medications. CONCLUSIONS: Epidural clonidine is followed by a significantly lower incidence of side-effects. However, its analgesic effects, at least at the doses used in this study, are less potent than those of epidural morphine.

Drogas ilicitas e esquizofrenia em adolescentes / Use of illicit drugs and schizophrenia in adolescents

Este trabalho trata da investigacao dos registros medicos de todos os adolescentes hospitalizados no Departamento de Psiquiatria infantil e de adolescentes com o diagnostico de esquizofrenia ou psicose esquizoafetiva (DSM-IV) associado ao uso e abuso de drogas ilicitas...

Surgical treatment of 724 carcinomas of the gallbladder. Results of the French Surgical Association Survey.

OBJECTIVE: The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival. SUMMARY BACKGROUND DATA: Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available. METHODS: Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival. RESULTS: Seventy-eight per cent of the patients were women, and 22% were men (p < 0.001). Gallstones were present in 86% of the cases. Four per cent of the patients had Tis stage lesions, 11% had T1 to T2 stage lesions, and 85% had T3 to T4 stage lesions (p < 0.001). Pain was the most frequent symptom (77%). Twenty-three per cent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (> 70 years) had a higher operative risk (p < 0.04). The overall median survival was 3 months, and long-term survival correlated with the cancer stage (Tis, > 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted. CONCLUSIONS: No progress has been made in the last 10 years in the treatment of gallbladder malignancies.

Management of major biliary complications after laparoscopic cholecystectomy.

OBJECTIVE: A total of 50 major bile duct injuries after laparoscopic cholecystectomy were managed by the Duke University Hepatobiliary Service from 1990-1992. The management of these complex cases is reviewed. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is the preferred method for removing the gallbladder. Bile duct injury is the most feared complication of the new procedure. METHODS: Review of videotapes, pathology, and management of the original operations were reviewed retrospectively, and the injuries categorized. Major biliary injury was defined as a recognized disruption of any part of the major extrahepatic biliary system. Biliary leakage was defined as a clinically significant biliary fistula in the absence of major biliary injury, i.e., with an intact extrahepatic biliary system. RESULTS: Thirty-eight injuries were major biliary ductal injuries and 12 patients had simple biliary leakage. Twenty-four patients had the classic type injury or some variant of the classic injury. A standard treatment approach was developed which consisted of ERCP for diagnosis, preoperative PTC with the placement of stents, CT drainage immediately after the PTC for drainage of biliary ascites, and usually Roux-en-Y hepaticojejunostomy with placement of O-rings for future biliary access if necessary. Major ductal injuries were high in the biliary system involving multiple ducts in 31 of the 38 patients. Re-operation was required in 5 of the 38 patients with particularly complex problems. CONCLUSIONS: Successful management of bile duct injury after laparoscopic cholecystectomy requires careful understanding of the mechanisms, considerable preoperative assessment by experts, and a multidisciplinary approach.

Complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a safe and effective treatment of cholelithiasis in experienced hands. Mortality is rare. The Southern Surgeons Club data and several other recent large series indicate that major complications occur in less than 3% of patients. The most significant common complication is injury to the bile duct, for which the greatest risk factor is inexperience. Major biliary injury usually requires reoperations. Roux-en-Y hepaticojejunostomies, often multiple, are usually necessary for repair. The popularity of this technique continues, and further efforts should be focused on elimination of the learning curve for major biliary injury. If injuries do occur, they should be recognized early, and patients should be referred to centers experienced in their treatment.

[The influence of the clinical course and diagnosis on the length of surgical stays]. / L'influenza dell'iter clinico e diagnostico sulla durata delle degenze chirurgiche.

The length of stay (LOS) is one of the major determinants of rising costs in surgical patient care. We studied the timing of the diagnostic procedures performed in 323 surgical patients admitted to 8 surgical departments of a large hospital. Of these: 50 underwent gastrectomy, 28 colectomy, 90 biliary tract (BT) operation, 94 appendectomy and 61 saphenectomy. The average total and preoperative LOS were respectively 27 and 11 days in the gastrectomy group, 26 and 10 in the colectomy group, 10 and 4 in the appendectomy group, 20 and 11 in the BT group, 12 and 6 in the saphenectomy group. The LOS was not affected by the presence of a benign or malignant lesion in gastrectomy and colectomy. In the appendectomy and BT groups, patients admitted from the emergency room had a significantly lower total LOS when compared to elective admissions (8 vs 12 and 9 vs 21 days respectively, p < 0.01). The multiple regression model showed that global and preoperative LOS were influenced by the number of instrumental exams (contrastographic, endoscopic, echographic).

[Early postoperative complications of resection anastomosis in colonic and colorectal surgery. An analysis of 624 cases]. / Complications postopératoires précoces des résections anastomoses en chirurgie colique ou colo-rectale. Analyse de 627 observations.

Six hundred twenty seven patients have been studied retrospectively to evaluate early complications after sewn or staples colonic anastomosis. Seventy four per cent of the patients underwent surgery because of malignant lesions and seventy seven per cent had an elective operation. Fourty seven per cent of the patients had a sewn anastomosis, 53% a stapled anastomosis. In elective surgery, most of the right hemicolectomies and partial proctocolectomies have been performed using stapler devices (p < 0.05). In emergency surgery, most of the anastomosis after partial and total colectomy have been hand sewn (p < 0.05). Operative mortality was 5.6%. It was significantly higher in older patients (> 80 years old) (p < 0.01) and after emergency operations (p < 0.0001). The rate of anastomotic leak was 3.7% and it was significantly higher after right hemicolectomy and partial proctocolectomies when anastomosis has been hand sewn compared to stapled anastomosis (p < 0.05). With regard to postoperative mortality, intra-abdominal abscess, intestinal obstruction, evisceration, pulmonary embolism and anastomotic stenosis 1.4% (global: after a 6 months follow-up) no significant differences have been observed between sewn and stapled anastomosis.

Biliary response to glucagon in humans.

Glucagon has been demonstrated to have profound effect on biliary secretion in several species. Glucagon's biliary effects were studied in humans following biliary tract surgery. Nine patients underwent common bile duct exploration and insertion of a balloon-occludable t tube. An aliquot of the collected sample was kept and the enterohepatic circulation was maintained by reinfusion of the collected bile via the distal t-tube port. Glucagon increased bile flow and decreased cholesterol and phospholipid output during stable bile acid output. Furthermore high-performance liquid chromatographic analysis of bile acid profiles revealed no significant changes in bile salt species or conjugation after glucagon infusion. Glucagon is probably important in the physiologic regulation of biliary secretion in humans.

Emergency portosystemic shunt in patients with variceal bleeding.

Thirty-five patients for whom emergency sclerotherapy or conservative treatment, or both, failed to arrest variceal bleeding, or who had early rebleeding and required emergency portosystemic shunts (EPSS) were studied. EPSS permanently controlled the variceal bleeding in all but one patient. In this patient, the shunt was patent as demonstrated by angiography. Esophageal varices disappeared in 18 patients and were reduced in 14. Three patients died before the endoscopic examination could be performed. The causes of death were hepatic failure in two and bleeding ulcerations of the gastric fundus in the other patient. One patient was classified in Child's category B and two in Child's category C. Thirty-two patients submitted to EPSS and were discharged alive. Twelve of these patients subsequently died, at an average of 11.2 months after undergoing the shunt procedure. Four of 12 patients died of hepatic failure; two patients died of hepatomas; two, other neoplasia; three, hemorrhaging duodenal ulcers, and one patient, renal failure. Analysis of actuarial survival rates showed that the five year survival rate was 43 per cent. The long term survival rates were fewer for patients with Child's category C than for those with combined Child's categories A and B (five year survival rates were 21 versus 55 per cent; p less than 0.05). During the follow-up period, none of the patients had variceal bleeding. Chronic encephalopathy developed in six, which was mild in three, moderate in one instance and severe in two. It developed soon after EPSS, with onset in the first month after discharge in three. Thus, when conservative treatment fails to arrest variceal bleeding, EPSS should be performed to guarantee definitive control of hemorrhage and prolong the survival period.

Evaluation of selective liver denervation methods.

This study compares four methods of hepatic denervation and defines the rate and physiological significance of reinnervation. Five groups of rats were prepared: 10 underwent orthotopic liver transplantation. In nine rats a 90% aqueous phenol solution was applied circumferentially to the portal vein. Thirteen rats underwent microsurgical denervation; 28 received different doses of 6-hydroxydopamine (6-HODA) administered as a single intraportal injection [50 (n = 10), 75 (n = 6), and 100 mg/kg (n = 6)]. Twelve rats were studied as controls. Rats were killed 1, 4, and 8 wk after surgery to determine liver tissue content of norepinephrine (NE). Changes in mean arterial pressure (MAP) in response to hepatic nerve stimulation, which was supramaximum in intensity and frequency, were measured before rats were killed. NE content in controls ranged from 121 to 204 ng/g and MAP increased by 30-38 mmHg after electrical stimulation. At 1, 4, and 8 wk after treatment the liver NE content was less than 1, 2.3, and 20.2 ng/g in the transplant group; less than 1, 2.7, 4.1 ng/g in the phenol group; and 17.2, less than 1, and 3 ng/g in the surgically denervated group. In the 6-HODA group, values were 18.9, 47, and 61.5 ng/g (50 mg/kg); 5.7, 20.2, and 15 ng/g (75 mg/kg); and 7.7, 2.5, and 17.5 ng/g (100 mg/kg). When the level of NE was undetectable, MAP increase after stimulation was 0-18% that of controls. When NE content was 15-23% of normal, MAP increased 49-62% regardless of the denervation technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary response to glucagon and insulin following hepatic transplantation in humans.

Glucagon and insulin are postulated to be physiologic regulators of hepatic biliary secretion. Effects of these hormones were studied following orthotopic transplantation. Five adult hepatic graft recipients had triple lumen t-tubes placed at the time of surgery and were studied 3 months after surgery. Experiments were performed after cholangiographic confirmation of t-tube placement and function. After overnight fast, t-tubes were inflated and bile was collected. A small quantity was saved for analysis and the remainder was reinfused to maintain enterohepatic circulation. After 1 hr of observation, the patients received a 2-hr infusion of insulin (0.125 U kg-1 hr-1), glucagon (2 micrograms kg-1 hr-1), or 0.9% saline. During saline infusions, all parameters remained stable. As has been previously demonstrated in the canine model and intact patients, bile salt outputs were constant under all experimental conditions. Glucagon stimulated bile secretion by 30% (6.7 +/- 1.5 to 8.7 +/- 1.2 ml/15 min) and inhibited biliary cholesterol output by 47% (16.4 +/- 3.2 to 8.7 +/- 1.5 mg/15 min). Bile flow and lipid secretion were not affected by insulin. Glucagon had profound effects on bile flow and lipid secretion, suggesting effects independent of innervation, while insulin at this dose had no statistically significant effects.

Subtotal colectomy for familial polyposis. A clinical series and review of the literature.

Familial polyposis is an inherited syndrome in which untreated persons have virtually a 100% incidence of developing colon cancer. Much controversy exists over whether subtotal colectomy with ileoproctostomy is the appropriate procedure in these patients owing to the risk of subsequent cancer in the retained portion of the rectum. At Duke University Medical Center, Durham, NC, a group of 25 patients chose to undergo the subtotal colectomy and ileoproctostomy instead of the definitive total proctocolectomy. Of the 25 patients in this series, invasive adenocarcinoma has developed in the rectal segment in only 1 patient. This patient, the oldest in our series, had carcinoma in situ in her initial operative specimen and has done well following an abdominal perineal resection and 13 years of follow-up. Six other patients have subsequently undergone definitive resections of the rectum because of intractable benign polyps. These results compare favorably with those reported in the literature. We conclude that subtotal colectomy with ileoproctostomy is still a useful and successful mode of treatment for select patients with familial polyposis if they are followed up frequently and aggressively and if the surgeon maintains a low threshold for recommending completion proctectomy.

Clinical significance of ultrasonographically detected coincidental gallstones.

The clinical profiles of 139 patients with gallstones found coincidentally during ultrasonography were reviewed and the patients followed prospectively for five years. Indications for ultrasonography included follow-up of abdominal malignancy (33%), evaluation of abdominal aortic aneurysm or other arteriosclerotic vascular disease (22%), renal insufficiency (12%), and lower abdominal pain (7%). At the time of gallstone detection, 14 patients (10%) had symptoms attributable to cholelithiasis. Over the next five years, only 15 patients (11%) developed episodes resembling biliary pain. Nine patients underwent cholecystectomy during this period. Three of the cholecystectomies were incidental to other abdominal procedures. Two cholecystectomies were performed as emergencies for gallstone complications with no perioperative mortality. Interestingly, 54 patients (40%) with coincidental gallstones died during the follow-up period. All the deaths were unrelated to gallstones. These data indicate that ultrasonographically detected coincidental gallstones rarely have clinical significance, leading strong support to the expectant management of most patients with purely coincidental gallstones.

Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. First stage of a randomized, controlled trial.

In 1984 we started a prospective controlled trial comparing endoscopic sclerotherapy (ES) with the distal splenorenal shunt (DSRS) in the elective treatment of variceal hemorrhage in cirrhotic patients. The study population included 40 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1988. These patients were drawn from a pool of 173 patients who underwent either elective surgery or endoscopic sclerotherapy during this time. Patients were assigned to one of the two groups according to a random-number table: 20 to DSRS and 20 to ES. During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS. Four ES patients suffered at least one episode of gastrointestinal bleeding: two from varices and two from esophageal ulcerations. Five ES patients developed transitory dysphagia. Long-term follow-up was complete in all patients. Two-year survival rates for shunt (95%) and ES (90%) groups were similar. One DSRS patient rebled from duodenal ulcer, while three ES patients had recurrent bleeding from esophagogastric sources (two from varices and one from hypertensive gastropathy). One DSRS and two ES patients have evolved a mild chronic encephalopathy; four DSRS and two ES patients suffered at least one episode of acute encephalopathy. Two ES patients had esophageal stenoses, which were successfully dilated. Preliminary data from this trial seem to indicate that DSRS, in a subgroup of patients with good liver function and a correct portal-azygos disconnection, more effectively prevents variceal rebleeding than ES. However no significant difference in the survival of the two treatment groups was noted.

Early hemodynamic changes following selective distal splenorenal shunt for portal hypertension: comparison of surgical techniques.

Ninety patients with cirrhosis undergoing elective distal splenorenal shunt (DSRS) for variceal bleeding between January, 1977 and September, 1988 comprised the study group. In 63 cases, the original technique of Warren was used and, in 15, the modified Britton procedure was employed. Twelve patients had a DSRS plus splenopancreatic disconnection. Thirty-four had alcoholic cirrhosis and 56 had nonalcoholic cirrhosis. Intraoperative portal pressure remained high after the shunt (29.4 cm H2O) even if its initial value was probably decreased by the loss of the splenic flow. Splenic pressure was reduced to 21 cm H2O. The hepatic artery diameter enlarged even after selective shunt (from 6.5 to 7.1 mm). The persistence of a high portal pressure allowed for the preservation of hepatopedal portal flow in 87% of cases. Disconnection between the high-pressure mesenteric area and the low-pressure splenic area seemed to be ideal in only 17% of cases. Fifty-five percent of cases had the early development of minimal or moderate portomesenteric gastrosplenic (PM-GS) collateral pathways. In 33%, the PM-GS collaterals were generally abundant and often allowed visualization of the splenic and caval veins during the venous phase of the superior mesenteric arteriograms. In this group, portal flow was generally highly reduced and even abolished. The incidence of portal thrombosis was 11%. Early angiographic checks after DSRS did not show a different hemodynamic behavior between alcoholics and nonalcoholics. Splenopancreatic disconnection seems to prevent the development of collaterals and the loss of portal perfusion after shunt surgery.