The use of local anaesthesia in haemorrhoidal banding: a randomized controlled trial.

AIM: Rubber band ligation is a common office procedure for the treatment of symptomatic haemorrhoids. It can be associated with pain and vasovagal symptoms. The effect of local anaesthetic use during banding was studied. METHOD: A single-blinded randomized controlled trial was carried out in the colorectal outpatient clinic. Patients presenting with symptomatic haemorrhoids suitable for banding were prospectively recruited and randomized to undergo the procedure with local anaesthetic or without (control). Submucosal bupivacaine was injected immediately after banding just proximal to the site. Vasovagal symptoms were assessed at the time of banding and pain scores (visual analogue scale) were recorded at the conclusion of the procedure, after 15 min, and on leaving the clinic. RESULTS: Seventy-two patients (40 local anaesthetic injection, group 1; 32 no injection, group 2) were recruited. The mean ages were 50 and 54 years respectively, the median duration of symptoms was 12 months in each group and the median number of haemorrhoids banded was three in each group. The mean pain score on leaving the clinic was 2.6 (95% CI 2.1, 3.1) in group 1 and 4.1 (95% CI 3.3, 5.0) (P = 0.04) in group 2. There were no complications related to local anaesthetic use. No significant difference in vasovagal symptoms was found (P = 0.832). CONCLUSION: Local anaesthetic injection at the time of banding is simple and safe. It may reduce patient discomfort following banding of haemorrhoids.

Port-site pyoderma gangrenosum - a rare complication of surgical trauma.

We report a case of pyoderma gangrenosum occurring at the site of a laparoscopic port insertion following laparoscopic inguinal hernia repair.

A prospective case-matched comparison of clinical and financial outcomes of open versus laparoscopic colorectal resection.

BACKGROUND: We aimed to assess the clinical outcomes and costs associated with laparoscopic resection within an elective colorectal practice. METHOD: Over a 12-month period data were prospectively collected on patients undergoing elective colorectal resection under the care of a single consultant surgeon. Thirty patients undergoing laparoscopic colorectal resection were case-matched by type of resection, disease process, and, where appropriate, cancer stage to patients having open surgery. A cost analysis was carried out incorporating cost of surgical bed stay, theater time, and specific equipment costs. RESULTS: In the 30 patients having laparoscopic resection, a conversion rate of 13% was observed. Surgery was performed for colorectal cancer in 83% of patients, and 53% of resections were rectal. No significant differences were found in age (65 versus 69 years, p = 0.415), BMI (27.4 versus 26.1, p = 0.527), POSSUM physiology score (16 versus 16.5, p = 0.102), American Society of Anesthesiologists (ASA) grade (2 versus 2, p = 0.171), or length of theater time (160 min versus 160 min, p = 0.233) between the laparoscopic and open patients. Hospital stay was reduced in the laparoscopic group (5 versus 9 days, p < 0.001). Average cost of surgical equipment used for a laparoscopic resection was greater than for open surgery (912.39 versus 276.41 pounds, p = 0.001). Cost of hospital stay was significantly less (1259.75 versus 2267.55 pounds, p < 0.001). Cost of operating room time was similar for the two groups (2066.63 versus 1945.07 pounds, p = 0.152). Overall no significant cost difference could be found between open and laparoscopic resection (4560.9 versus 4348.45 pounds, p = 0.976). More postoperative complications were seen in the open resection group (14 versus 4, p < 0.001). CONCLUSIONS: Intraoperative equipment costs are greater for laparoscopic resection than for open surgery. However, benefits can be seen in terms of quicker recovery and shorter hospital stay. Laparoscopic surgery is a financially viable alternative to open resection in selected patients.

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection.

BACKGROUND: Protocolized fluid administration using oesophageal Doppler monitoring may improve the postoperative outcome in patients undergoing surgery. METHODS: A total of 108 patients undergoing elective colorectal resection were recruited into a double-blind prospective randomized controlled trial. An oesophageal Doppler probe was placed in all patients. The control group received perioperative fluid at the discretion of the anaesthetist, whereas the intervention group received additional colloid boluses based on Doppler assessment. Primary outcome was length of postoperative hospital stay. Secondary outcomes were morbidity, return of gastrointestinal function and cytokine markers of the systemic inflammatory response. Standard preoperative and postoperative management was used in all patients. RESULTS: Demographic and surgical details were similar in the two groups. Aortic flow time, stroke volume, cardiac output and cardiac index during the intraoperative period were higher in the intervention group (P<0.050). The intervention group had a reduced postoperative hospital stay (7 versus 9 days in the control group; P=0.005), fewer intermediate or major postoperative complications (2 versus 15 percent; P=0.043) and tolerated diet earlier (2 versus 4 days; P=0.029). There was a reduced rise in perioperative level of the cytokine interleukin 6 in the intervention group (P=0.039). CONCLUSION: A protocol-based fluid optimization programme using intraoperative oesophageal Doppler monitoring leads to a shorter hospital stay and decreased morbidity in patients undergoing elective colorectal resection.

Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial.

OBJECTIVE: Surgery induces a catabolic response with stress hormone release and insulin resistance. The aim of this study was to assess the effect of pre-operative carbohydrate administration on grip strength, gastrointestinal function and hospital stay following elective colorectal surgery. METHODS: Thirty-six patients undergoing elective colonic resection were randomized into one of three groups. Group 1 were fasted; Group 2 were given pre-operative oral water, Group 3 received equivalent volumes of a Maltodextrin drink. Time to first flatus, first bowel movement and hospital stay were recorded. Muscle strength was measured pre-operatively, and on alternate days thereafter until discharge using a grip strength dynamometer. RESULTS: Patients in the carbohydrate group had a median postoperative hospital stay of 7.5 days compared with 13 days in the water group (P > 0.01) and 10 days in the fasted group (P = 0.06). The median time postsurgery to first flatus was 3 days for both the fasted and water groups compared with 1.5 days in the carbohydrate group (P = 0.13). First bowel movement occurred on day 3 in the carbohydrate group, day 4 in the fasting group and day 5 in the water group. The fasted group showed a significant reduction in postoperative grip strength (P < 0.05) with a median drop of 10% at discharge. Neither the water nor the carbohydrate groups showed significant reductions in muscle strength. CONCLUSION: We found that pre-operative administration of oral carbohydrate leads to a significantly reduced postoperative hospital stay, and a trend towards earlier return of gut function when compared with fasting or supplementary water.