Preemptive Caudal Ropivacaine: An Effective Analgesic during Degenerative Lumbar Spine Surgery

STUDY DESIGN: This was a prospective, randomized, controlled trial comprising 60 patients undergoing lumbosacral spine (noninstrumentation/nonfusion) surgery. PURPOSE: The purpose of this study was to evaluate the efficacy of 0.2% ropivacaine (20 mL) administered alone as a single, preoperative, caudal epidural block injection versus that of intravenous analgesics in providing effective postoperative analgesia to patients undergoing lumbosacral spine surgery. OVERVIEW OF LITERATURE: Various studies have shown the effectiveness of a caudal epidural injection (bupivacaine or ropivacaine) in providing postoperative analgesia in combination with steroids or other analgesics. This study uniquely analyzed the efficacy of a single injection of caudal epidural ropivacaine in providing postoperative pain relief. METHODS: Sixty patients who were scheduled to undergo surgery for degenerative lumbar spine disease (noninstrumentation/nonfusion) were consecutively divided into two groups, group R (Study) and group I (Control). 30 group R patients received a caudal epidural block with 20 mL of 0.2% ropivacaine after the administration of general anesthesia. 30 group I patients received no preoperative analgesia. Intravenous analgesics were administered during the postoperative period after a complaint of pain. Various parameters indicating analgesic effect were recorded. RESULTS: There was a significant delay in the average time to the first demand for rescue analgesia in the study group, suggesting significantly better postoperative pain relief than that in the control group. In comparison with the control group, the study group also showed earlier ambulation with minimal adverse effects. The requirement for intraoperative fentanyl was higher in the control group than that in the study group. CONCLUSIONS: Preemptive analgesia with a single epidural injection of ropivacaine is a safe, simple, and effective approach, providing better postoperative pain relief, facilitating early mobilization, and decreasing the intraoperative requirement for opioid administration.

Safety and Efficacy of Endoscopic Therapy for Nonmalignant Duodenal Duplication Cysts: Case Report and Comprehensive Review of 28 Cases Reported in the Literature.

Analyze efficacy, safety of endoscopic therapy for duodenal duplication cysts (DDC) by comprehensively reviewing case reports.Tandem, independent, systematic, computerized, literature searches were performed via PubMed using medical subject headings or Keywords "cyst" and "duodenal" and "duplication"; or "cyst", and "endoscopy" or "endoscopic", and "therapy" or "decompression"; with reconciliation of generated references by two experts. Case report followed CARE guidelines.Literature review revealed 28 cases (mean = 1.3 ±â€Š1.2 cases/report). Endoscopic therapy is increasingly reported recently (1984-1999: 3 cases, 2000-2015: 25 cases, P = 0.003, OR = 8.33, 95%-CI: 1.77-44.5). Fourteen (54%) of 26 patients were men (unknown-sex = 2). Mean age = 32.2 ±â€Š18.3 years old. Procedure indications: acute pancreatitis-16, abdominal pain-8, jaundice-2, gastrointestinal (GI) obstruction-1, asymptomatic cyst-1. Mean maximal DDC dimension = 3.20 ±â€Š1.53 cm (range, 1-6.5 cm). Endoscopic techniques included cyst puncture via needle knife papillotomy (NKP)/papillotome-18, snare resection of cyst-7, cystotome-2, and cyst needle aspiration/ligation-1. Endoscopic therapy was successful in all cases. Among 24 initially symptomatic patients, all remained asymptomatic post-therapy without relapses (mean follow-up = 36.5 ±â€Š48.6 months, 3 others reported asymptomatic at follow-up of unknown duration; 1 initially asymptomatic patient remained asymptomatic 3 years post-therapy). Two complications occurred: mild intraprocedural duodenal bleeding related to NKP and treated locally endoscopically.A patient is reported who presented with vomiting, 15-kg-weight-loss, and profound dehydration for 1 month from extrinsic compression of duodenum by 14 × 6 cm DDC, underwent successful endosonographic cyst decompression with large fenestration of cyst and endoscopic aspiration of 1 L of fluid from cyst with rapid relief of symptoms. At endoscopy the DDC was intubated and visualized and random endoscopic mucosal biopsies were obtained to help exclude malignant or dysplastic DDC.Study limitations include retrospective literature review, potential reporting bias, limited patient number, variable follow-up.In conclusion, endoscopic therapy for DDC was efficacious in all 29 reported patients including current case, including patients presenting acutely with acute pancreatitis, or GI obstruction. Complications were rare and minor, suggesting that endoscopic therapy may be a useful alternative to surgery for nonmalignant DDC when performed by expert endoscopists.

Pulmonary Hypertension an Independent Risk Factor for Death in Intensive Care Unit: Correlation of Hemodynamic Factors with Mortality.

OBJECTIVE: Critically ill patients with pulmonary hypertension (PH) pose additional challenges due to the existence of right ventricular (RV) dysfunction. The purpose of this study was to assess the impact of hemodynamic factors on the outcome. METHODS: We reviewed the records of patients with a diagnosis of PH admitted to the intensive care unit. In addition to evaluating traditional hemodynamic parameters, we defined severe PH as right atrial pressure >20 mmHg, mean pulmonary artery pressure >55 mmHg, or cardiac index (CI) <2 L/min/m(2). We also defined the RV functional index (RFI) as pulmonary artery systolic pressure (PASP) adjusted for CI as PASP/CI; increasing values reflect RV dysfunction. RESULTS: Fifty-three patients (mean age 60 years, 72% women, 79% Blacks), were included in the study. Severe PH was present in 68% of patients who had higher Sequential Organ Failure Assessment (SOFA) score (6.8 ± 3.3 vs 3.8 ± 1.6; P = 0.001) and overall in-hospital mortality (36% vs 6%; P = 0.02) compared to nonsevere patients, although Acute Physiology and Chronic Health Evaluation (APACHE) II scores (19.9 ± 7.5 vs 18.5 ± 6.04; P = 0.52) were similar and sepsis was more frequent among nonsevere PH patients (31 vs 64%; P = 0.02). Severe PH (P = 0.04), lower mean arterial pressure (P = 0.04), and CI (P = 0.01); need for invasive ventilation (P = 0.02) and vasopressors (P = 0.03); and higher SOFA (P = 0.001), APACHE II (P = 0.03), pulmonary vascular resistance index (PVRI) (P = 0.01), and RFI (P = 0.004) were associated with increased mortality. In a multivariate model, SOFA [OR = 1.45, 95% confidence interval (C.I.) = 1.09-1.93; P = 0.01], PVRI (OR = 1.12, 95% C.I. = 1.02-1.24; P = 0.02), and increasing RFI (OR = 1.06, 95% C.I. = 1.01-1.11; P = 0.01) were independently associated with mortality. CONCLUSION: PH is an independent risk factor for mortality in critically ill patients. Composite factors rather than individual hemodynamic parameters are better predictors of outcome. Monitoring of RV function using composite hemodynamic factors resulting in specific interventions is likely to improve survival and needs to be studied further.

Dislodgement of variceal bands after esophageal balloon tamponade for variceal bleeding.

A 43-year-old male with alcoholic cirrhosis underwent EGD for hematemesis which revealed bleeding, grade II, lower esophageal varices that were endoscopically ligated with 6 bands. All the bands remained attached to varices at the completion of EGD. Despite apparent initial hemostasis, balloon tamponade was performed one hour later for suspected continued bleeding. Due to suspected continuing bleeding, EGD was repeated 4 h after initial EGD, and 3 h after balloon tamponade. This EGD revealed the esophageal varices; none of the bands remaining on esophageal mucosa; multiple mucosal stigmata likely from trauma at initial site of variceal bands before dislodgement; and 3 dislodged bands in gastric body, duodenal bulb, or descending duodenum. The patient expired 17 h thereafter from hypovolemic shock. This single report may suggest an apparently novel, balloon tamponade complication: dislodgement of previously placed, endoscopic bands. The proposed pathophysiology is release of bands by stretching entrapped, esophageal mucosa during esophageal balloon tamponade. This complication, if confirmed, might render balloon tamponade a less desirable option very soon after band ligation.

Incidence of esophageal adenocarcinoma in Barrett's esophagus with low-grade dysplasia: a systematic review and meta-analysis.

BACKGROUND: The natural history of low-grade dysplasia (LGD) in patients with Barrett's esophagus (BE) is unclear. OBJECTIVE: We performed a systematic review and meta-analysis of studies that reported the incidence of esophageal adenocarcinoma (EAC) and/or high-grade dysplasia (HGD) among patients with BE with LGD. DESIGN: Systematic review and meta-analysis of cohort studies. PATIENTS: Patients with BE-LGD, with mean cohort follow-up ≥ 2 years. MAIN OUTCOME MEASUREMENTS: Pooled incidence rates with 95% confidence intervals (CI) of EAC and/or BE-HGD. RESULTS: We identified 24 studies reporting on 2694 patients with BE-LGD, with 119 cases of EAC. Pooled annual incidence rates of EAC alone and EAC and/or HGD in patients with BE-LGD were 0.54% (95% CI, 0.32-0.76; 24 studies) and 1.73% (95% CI, 0.99-2.47; 17 studies). The results were stable across study setting and location and in high-quality studies. Substantial heterogeneity was observed, which could be explained by stratifying based on LGD/BE ratio as a surrogate for quality of pathology; the pooled annual incidence rates of EAC were 0.76% (95% CI, 0.44-1.09; 14 studies) for LGD/BE ratio <0.15 and 0.32% (95% CI, 0.07-0.58; 10 studies) for LGD/BE ratio >0.15. The annual rate of mortality not related to esophageal disease in patients with BE-LGD was 4.7% (95% CI, 3.2-6.2; 4 studies). LIMITATIONS: Substantial heterogeneity was observed in the overall analysis. CONCLUSION: The incidence of EAC among patients with BE-LGD is 0.54% annually. The LGD/BE ratio appears to explain the variation observed in the reported incidence of EAC in different cohorts. Conditions not related to esophageal disease are a major cause of mortality in patients with BE-LGD, although additional studies are warranted.

Characterization of the syndrome of acute liver failure caused by metastases from breast carcinoma.

AIM: To characterize syndrome of acute liver failure (ALF) from metastatic breast cancer to promote premortem diagnosis. Up to now, only 25 % of the reported 32 cases of this syndrome were diagnosed premortem. METHODS: Cases identified by computerized literature review and review of files maintained by senior investigator. RESULTS: Among 32 cases, average age at presentation was 47.9 ± 9.9 years. Common signs include jaundice, hepatomegaly, shifting dullness, and bilateral leg edema. Mean serum level of AST was 296.4 ± 204.0 U/L, ALT, 183.2 ± 198.9 U/L; alkaline phosphatase, 641.5 ± 610.1; and total bilirubin, 8.6 ± 8.3 mg/dL. Twenty-seven patients (84 %) have known prior breast cancer (mean diagnosis = 4.1 + 4.8 years earlier). Abdominal ultrasound findings (N = 10) include hepatomegaly in three cases, heterogeneous/multifocal hepatic lesions in three, ascites in three, and other in two. Abdominal CT findings (N = 16) include heterogeneous/multifocal hepatic lesions in six cases, ascites in five, hepatomegaly in three, cirrhosis in three, fatty liver in two, other in two. Hepatic metastases may not be suspected when abdominal CT shows no hepatic lesions. The diagnosis is made postmortem in 24 cases and antemortem in eight, with a statistically significant trend of increasing premortem diagnosis since 2000 (0 % before 2000 vs. 50 % after 2000; p = .001, 95 %--ORCI ≥ 2.86, Fisher's exact test). A new case of ALF from breast cancer is reported with notable features: abdominal CT revealed no discrete hepatic lesions despite widespread hepatic metastases demonstrated by liver biopsy; hepatic metastases occurred 21 years after original breast primary; and original diagnosis of lobular breast cancer in primary lesion was corrected to mixed ductal and lobular carcinoma, based on immunohistochemistry, performed 21 years afterward. CONCLUSIONS: This review characterizes the clinical presentation and natural history of this syndrome to promote liver biopsy for premortem diagnosis and appropriate therapy.

Conscious sedation: a dying practice?

Sedation practices vary according to countries with different health system regulations, the procedures done, and local circumstances. Interestingly, differences in the setting in which the practice of gastroenterology and endoscopy takes place (university-based vs academic practice) as well as other systematic practice differences influence the attitude of endoscopists concerning sedation practices. Conscious sedation using midazolam and opioids is the current standard method of sedation in diagnostic and therapeutic endoscopy. Interestingly, propofol is a commonly preferred sedation method by endoscopists due to higher satisfaction rates along with its short half-life and thus lower risk of hepatic encephalopathy. On the other hand, midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. The administration of sedation under the supervision of a properly trained endoscopist could become the standard practice and the urgent development of an updated international consensus regarding the use of sedative agents like propofol is needed.