Continuous wound infiltration versus epidural analgesia for midline abdominal incisions - a randomized-controlled pilot trial (Painless-Pilot trial; DRKS Number: DRKS00008023).

OBJECTIVES: To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial. DESIGN, SETTING, PARTICIPANTS: CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative. INTERVENTIONS: CWI with local anaesthetics (experimental group) vs. thoracic EDA (control). RESULTS: Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI. CONCLUSION: This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment. TRIAL REGISTRATION: DRKS00008023.

Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. Widespread variations in key standards of care between hospitals exist and are associated with differences in mortality rates.Recently there have been three large-scale initiatives to improve quality of care for emergency laparotomy patients: the National Emergency Laparotomy Audit, the enhanced perioperative care for high-risk patients trial and the Emergency Laparotomy Collaborative. Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.