Outcomes and complications of thyroid surgery: retrospective study

OBJECTIVE

To study the outcome and complications of thyroid surgery.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Three hundred and twelve patients (266 women and 46 men) underwent thyroid surgery between January 1994 and December 1999.

MAIN OUTCOME MEASURES

Complications of thyroidectomy for various thyroid diseases according to surgical technique used.

RESULTS

Capsular dissection gradually became a more popular surgical technique: 33% and 58% in the first and second halves of the study period respectively (P<0.001). The overall rate of permanent vocal cord palsy was 2%. Near-total thyroidectomy became the preferred surgical treatment for toxic goitre over the study period. The incidence of recurrent hyperthyroidism was reduced from 21% to 7% (P>0.1, not significant). The incidence of hypoparathyroidism was approximately 30% after thyroidectomy for cancer.

CONCLUSION

Capsular dissection is increasingly utilised in thyroid surgery. Low complication rates can be achieved after thyroidectomy for benign diseases. Hypoparathyroidism, however, is a relatively common complication after surgery for thyroid cancer.

Digital replantations including fingertip and ring avulsion

To reduce ischemic time and yet achieve a high-quality repair, the replantation team should be well organized. The team should be conversant with microvascular techniques and employ efficient methods of tendon repair and bone fixation. Developments in instrumentation and technique in recent years have improved success rates and consequently enlarged the indications for replantation surgery. Nevertheless, the economics of care and long-term functional outcome should not be overlooked, and these issues remain unresolved in the replantation versus terminalization question. The authors address topics relevant to replantation, including techniques and complications of digital replantation, ring avulsion injuries, and distal replantation.

Sternomastoid-muscle transposition improves the cosmetic outcome of superficial parotidectomy

A facial depressed deformity subsequent to superficial parotidectomy is unsightly. Although a facelift incision can improve the cosmetic outcome by concealing the scar, the hollow contour around the angle of the mandible remains conspicuous. We have attempted to mitigate this problem by transposition of the sternomastoid muscle. Transposition of the sternomastoid muscle to cover the parotid bed after superficial parotidectomy for benign tumour was performed in eight consecutive patients. The histopathology and postoperative results, including complications and patient satisfaction, were analysed. The depressed deformity was considerably alleviated in all eight patients. All patients except one, who had a wound infection, were satisfied with the cosmetic outcome postoperatively. The extra operative time required for sternomastoid-muscle transposition was only 10 min. There was no morbidity related to this additional procedure. By combining this simple method with a facelift incision, an appealing cosmetic outcome can be achieved after superficial parotidectomy.

A recombinant antigen-based IgG4 ELISA for the specific and sensitive detection of Brugia malayi infection

An IgG4 ELISA based on a novel recombinant antigen was evaluated for detection of Brugia malayi infection, using 2487 sera from various institutions: 2031 samples from Universiti Sains Malaysia, 276 blinded sera from 2 other institutions in Malaysia, 140 blinded sera from India and 40 blinded sera from Thailand. These sera were from various groups of individuals, i.e., microfilaraemics, chronic patients, endemic normals, non-endemic normals and individuals with other parasitic and bacterial infections. Based on a cut-off optical density reading of 0.300, the IgG4 ELISA demonstrated specificity rates of 95.6-100%, sensitivity rates of 96-100%, positive predictive values of 75-100% and negative predictive values of 98.9-100%. These evaluation studies demonstrated the high specificity and sensitivity of this test for the detection of active B. malayi infection. Thus, the IgG4 ELISA would be very useful as a tool in diagnosis and in elimination programmes for brugian filariasis.

A modification of the technique for intravenous regional blockade for hand surgery

A prospective study was conducted to assess a modification to Bier's intravenous regional anaesthesia which introduced a third temporary distal forearm tourniquet. This confines the injected lignocaine to the hand, resulting in a higher local lignocaine concentration. Subsequent exsanguination of the limb then channels the remaining intravascular lignocaine under the distal cuff of a double tourniquet. Of the 18 patients, none experienced pain during operation and all tolerated the tourniquet without significant discomfort. Mild postoperative giddiness was noted in one patient. No other anaesthetic complications were encountered. In a subjective assessment of the bloodlessness of the operating field, two were ranked satisfactory, ten good and six excellent. None of the patients required re-exsanguination when using this technique.

Correlative assessment of hemodynamic parameters obtained with T2*-weighted perfusion MR imaging and SPECT in symptomatic carotid artery occlusion

BACKGROUND AND PURPOSE

Perfusion MR imaging and single-photon emission CT (SPECT) are commonly used to evaluate hemodynamic status in patients with symptomatic occlusive cerebrovascular disease. These techniques rely on different underlying physiological mechanisms, and the data may not correspond. We studied the relationship between hemodynamic parameters obtained with these two methods.

METHODS

We performed perfusion MR imaging and SPECT in 10 patients with symptomatic unilateral internal carotid artery occlusion. Relative cerebral blood volume (rCBV) and uncorrected mean transit time (uMTT) were obtained with dynamic contrast-enhanced T2*-weighted MR imaging. Relative cerebral blood flow (rCBF) and vascular reserve capacity were measured with 99mTc-HMPAO SPECT; vascular reserve capacity was calculated by the difference in CBF before and after acetazolamide challenge. Ratios of these hemodynamic parameters between the affected and contralateral vascular territories were calculated and compared.

RESULTS

Normal-to-increased CBV, prolonged uMTT, decreased CBF, and normal-to-diminished vascular reserve capacity were observed in the affected vascular territories. Reduction of vascular reserve capacity corresponded well with uMTT but not with CBF and CBV. CBF, CBV, and uMTT did not correspond to one another.

CONCLUSION

uMTT is more sensitive than the other parameters in estimating vascular reserve capacity. The relationship between parameters obtained with perfusion MR imaging and SPECT should be considered in assessing the hemodynamic status of patients with symptomatic occlusive cerebrovascular disease.

The lateral forearm flap as a modification of the lateral arm flap: vascular anatomy and clinical implications

The forearm extension of the lateral arm flap was introduced on the basis of the vascular territory of the posterior radial collateral artery extending beyond the elbow into the forearm. However, there is controversy as to whether the posterior radial collateral artery extends as a single trunk below the elbow or if it terminates more proximally with only a rich vascular plexus extending beyond the elbow. The purpose of this study was to revisit the artery's anatomy in the region of the elbow and to study its distribution in the forearm. Using latex and barium-gelatin injections of the posterior radial collateral artery in ten cadaveric upper limbs, it was observed that terminal branching of the artery occurred 4.5 cm proximal to the lateral epicondyle of the humerus. Distal to the epicondyle, the terminal branches of the posterior radial collateral artery were seen to fan out as finely arborized branches supplying the lateral forearm skin. No single, constant vascular trunk to the forearm skin could be identified. Furthermore, in its distribution toward the periphery, the terminal branches of the posterior radial collateral artery took an increasingly superficial course. Proximal to the epicondyle, the vessels lay deep within the subcutaneous fat, whereas distal to the epicondyle, they were very close to skin. These findings suggest that lateral forearm skin cannot be islanded without risk of vascular disruption and that the distally sited flap should include skin proximal to the epicondyle for safety.

Soft Tissue Complications Following Kirschner Wire Fixation for Fusion of Basal Joint Arthritis

Basal joint arthritis is a common hand condition presenting with pain and swelling, often requiring surgical treatment in the late stages. Surgical options include arthrodesis, excision arthroplasty, implant arthroplasty and ligament reconstruction, and tendon interposition arthroplasty. A patient with bilateral basal joint arthritis underwent K-wire arthrodesis of the left basal joint. Subsequently, she developed complications due to impingement of the K-wire on the median nerve, superficial radial nerve, and flexor tendons of the index finger. The diagnosis was made three years post-operatively and she then underwent reconstructive surgery. Eventually she recovered with good movement and sensation of the affected digits. Although K-wire arthrodesis of basal joint is a simple and effective procedure used primarily in treatment of arthritis, this case highlights the importance of appreciating surgical anatomy and post-operative clinical features and investigations.

A comparative analysis of the six-strand double-loop flexor tendon repair and three other techniques: a human cadaveric study

The ideal zone II flexor tendon repair would be easy to perform, cause minimal scarring, and be strong enough to allow early active motion. A 6-strand loop suture technique devised by the senior author (T.M.T.) was studied in vitro. Forty flexor tendons were harvested from fresh-frozen human hands and divided into 4 groups of 10 tendons each. Each group of tendons was repaired with a specific technique: group 1, the modified Kirchmayr (modified Kessler) technique; group 2, the single-loop 2-strand technique described by Tsuge; group 3, Tsai's double-loop 4-strand modification of Tsuge's technique; and group 4, Tsai's double-loop 6-strand modification of Tsuge's technique. Gap resistance of each repair technique was recorded on a computer using a Differential Variable Reluctance Transducer (MicroStrain, Burlington, VT) and on videotape to record first gap formation, 1-mm and 2-mm gap formation, and maximum load. Statistically significant differences between groups were as follows: at first gap formation between the 2-strand and 6-strand loop suture techniques, and at maximum load between the modified Kessler and 4-strand, modified Kessler and 6-strand, 2-strand and 4-strand, and 2-strand and 6-strand loop suture techniques. The 6-strand double-loop suture technique had a higher tensile strength than the other techniques, as measured in this model at each stage in our experiment. The 6-strand double-loop suture technique simplifies flexor tendon repair. It improves the repair's strength and its resistance to gapping without increasing tendon handling or bulk. This increased repair strength allows us to pursue a more aggressive rehabilitation program.

Various patterns of perfusion-weighted MR imaging and MR angiographic findings in hyperacute ischemic stroke

BACKGROUND AND PURPOSE

Various clinical subtypes of patients presenting with sudden-onset ischemic stroke have been recognized, but classification of those types is not simple. We identified various patterns of perfusion-weighted MR imaging and MR angiographic findings in hyperacute ischemic stroke with relation to clinical outcomes.

METHODS

Twelve patients with symptoms of acute ischemic stroke due to middle cerebral artery occlusion underwent perfusion-weighted MR imaging and MR angiography within 6 hours after the onset of symptoms. Perfusion-weighted imaging was performed with a conventional dynamic contrast-enhanced T2*-weighted sequence, and cerebral blood volume (CBV) maps were then created. CBV maps and MR angiographic findings were compared with 99mTc-HMPAO brain SPECT scans, short-term outcomes, and follow-up imaging findings.

RESULTS

The combined CBV and MR angiographic findings were classified into three patterns: arterial occlusion and decreased CBV (n = 8), arterial occlusion and increased CBV (n = 2), and no arterial occlusion and normal CBV (n = 2). These three patterns were strongly related to SPECT findings, short-term outcomes, and follow-up imaging findings. Perfusion on SPECT decreased markedly in the affected regions in all patients with the first pattern, decreased slightly in the second pattern, and was normal in the third pattern. Symptoms were not significantly changed at 24 hours after onset in any of the patients with the first pattern, but resolved completely in all patients with the latter two patterns. Follow-up imaging showed large infarctions in all patients with the first pattern. Initially, no infarction was seen in the second pattern, but watershed infarction developed later in one of these patients.

CONCLUSION

Hyperacute ischemic stroke may be differentiated into three imaging patterns with different clinical outcomes. The combined use of perfusion-weighted MR imaging and MR angiography may play a substantial role in guiding the choice of treatment of this disease.

Cubital tunnel release with endoscopic assistance: results of a new technique

We evaluated the results of cubital tunnel release with endoscopic assistance. The study included 76 patients (85 elbows); 47 women and 29 men. Nine patients had bilateral procedures. Patients were excluded if they had less than 1 year of follow-up, associated pathology at the elbow to account for the nerve compression, or recurrent cubital tunnel syndrome. Before surgery, cases were categorized by stage of cubital tunnel syndrome according to Dellon's classification: 33 (39%) elbows were classified as mild, 35 (41%) moderate, and 17 (20%) severe. Surgical results were assessed according to a modified Bishop rating system. The mean follow-up period was 32 months (range, 12-52 months). Results were excellent in 42% of the elbows, good in 45%, fair in 11%, and poor in 2%. Recurrence occurred in 3 elbows. There were no serious complications. The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.

Establishment of animal models using experimental rats for allogeneic tissue transplantation and quantitative flow cytometric detection of immunochimera

Establishment of animal models used for allogeneic tissue transplantation, MHC phenotyping as well as quantitative detection of immunochimera were carried out in this study. Both Buffalo (BUF) and Lewis (LEW) rats were chosen as the target animals. The rats were treated with single dose cyclophosphamide (Cy) of 25 to 100 mg/kg to mimic the standard conditioning therapy. Total white blood cells (WBC) were monitored daily for up to 8 days: WBC reached the nadir by day 4 and started to recover by day 5 with an obvious rebounce at day 7 of Cy treatment. Flow cytometric techniques were used to determine the haplotypes of the major histocompatibility complex (MHC) as well as quantitative detection of immunochimerism in unfractionated rat WBC. Monoclonal antibodies against the rat class-I MHC antigens RT1Aab and RT1Au were used to label the class-I MHC antigens on total rat WBC. The results showed that the BUF rats were positive for both RT1Aab and RT1Au antigens, whilst the LEW rats were negative for both. Immunochimera was mimicked in vitro by serial dilution, ranging from 1/1 to 1/10(5) of (BUF/LEW) WBC. A sensitivity of 1/10(4) (BUF/LEW WBC) was achieved. The results showed that there were at least 2 major MHC mismatched loci between BUF and LEW rats and flow cytometry provided a sensitive method for the detection of immunochimera in unfractionated rat WBC. We concluded from this study that both strains of rats could be used as models for allogeneic tissue transplantation across at least two major MHC-mismatches. The sensitivity of flow cytometric method was satisfactory for the detection of immunochimera.

A Brugia malayi antigen specifically recognized by infected individuals

Western blot analyses were performed on 444 serum specimens: 40 sera from microfilaraemic individuals, 10 sera from elephantiasis patients, 24 treated individuals, 50 sera from residents of endemic areas without anti-filarial IgG4 antibodies (endemic normals), 20 sera from amicrofilaraemic individuals with high anti-filarial IgG4 antibodies, 200 sera from healthy city-dwellers (non-endemic samples), and 100 sera from soil-transmitted helminth-infected individuals. Phast electrophoresis system was used to electrophorese Brugia malayi soluble adult worm antigen on 10-15% SDS-PAGE gradient gels followed by electrophoretic transfer onto PVDF membranes. Membrane strips were then successively incubated with blocking solution, human sera, and monoclonal anti-human IgG4 antibody-HRP, with adequate washings done in between each incubation step. Luminol chemiluminescence detection was then used to develop the blots. An antigenic band with the MW of approximately 37 kDa was found to be consistently present in the Western blots of all microfilaraemic sera, all amicrofilaraemic sera with high titres of anti-filarial IgG4 antibodies, some treated patients, and some elephantiasis patients. The antigen did not occur in immunoblots of individuals with other helminthic infections, normal endemic individuals, and city dwellers. Therefore the B. malayi antigen of with the MW of approximately 37 kDa demonstrated specific reactions with sera of B. malayi-infected individuals and thus may be useful for diagnostic application.

Screening of chlorpropamide in horse plasma by high-performance liquid chromatography with ultraviolet absorbance detection, and confirmation by gas chromatography-mass spectrometry

A chromatographic method was developed to detect and confirm the presence of chlorpropamide (I) in horse plasma samples, for antidoping control. The plasma sample (1 ml) was extracted with dichloromethane and screened by high-performance liquid chromatography, and confirmation of the drug's presence was accomplished by using gas chromatography-mass spectrometry (GC-MS). The limit of detection was found to be 3.5 ng/ml at a signal-to-noise ratio of three. Derivatization of I with N,O-bis-(trimethylsilyl)trifluoroacetamide with 1% trimethylchlorosilane allowed for highly stable, accurate and sensitive GC-MS analysis. Plasma samples collected after the administration of diabinese were positive for I (one-five days) in all samples analysed.

Temporal pattern of blood volume change in cerebral infarction: evaluation with dynamic contrast-enhanced T2*-weighted MR imaging

OBJECTIVE

The purposes of this study were to evaluate the temporal pattern of blood volume change in cerebral infarction and to provide a guideline in the interpretation of blood volume data, which are known to vary according to the stage of infarction.

SUBJECTS AND METHODS

Thirty-three patients with large middle cerebral infarctions were examined one to three times (one time in 20 patients, two times in eight patients, and three times in five patients) after the onset of stroke by dynamic contrast-enhanced T2*-weighted MR imaging and MR angiography. A total of 54 infarctions (29 in an acute stage [up to 7 days], 15 in a subacute stage [8-21 days], and 10 in a chronic stage [22-35 days]) were included. After blood volume maps were created, blood volume ratios (blood volume of the infarcted region divided by blood volume of corresponding contralateral region) were compared at different stages. Likewise, findings on MR angiography were compared at different stages.

RESULTS

Mean blood volume ratios in each stage of infarction were 0.46 in the acute stage, 1.48 in the subacute stage, and 0.73 in the chronic stage (p < .001). Recanalization of occluded arteries occurred in 21% of infarctions in the acute stage and 80% in the subacute stage. Infarctions with recanalization had higher blood volume ratios than did those without recanalization (p < .001). A biphasic pattern of blood volume ratios was found in 13 patients who underwent at least two MR examinations: increased blood volume in the subacute stage and decreased blood volume in the chronic stage, regardless of recanalization (p < .01).

CONCLUSION

Blood volume that initially decreases in cerebral infarction increases in the subacute stage, reflecting reperfusion hyperemia. Blood volume decreases again in the chronic stage. The time interval between onset of stroke and MR examination must be considered for correct interpretation of blood volume data in cerebral infarction at various stages.

Anti-Helicobacter pylori treatment in bleeding ulcers: randomized controlled trial comparing 2-day versus 7-day bismuth quadruple therapy

BACKGROUND

One-week bismuth triple therapy has been established to be highly effective in curing H. pylori infection, but patient compliance has been the major factor of success in therapy. For patients hospitalized for ulcer bleeding, an effective regimen that can completed before discharge will ensure full compliance.

AIM

To compare 2-day versus 1-wk bismuth triple therapy plus omeprazole in curing H. pylori infection and bleeding peptic ulcers.

METHODS

100 patients with non-actively bleeding duodenal (DU) or gastric ulcers (GU) and confirmed H. pylori infection were randomized to receive either bismuth subcitrate 120 mg, tetracycline 500 mg, and metronidazole 400 mg four times daily for 1 wk (OBTM-7) or bismuth subcitrate 240 mg, tetracycline 500 mg, and metronidazole 400 mg four times daily for 2 days (OBTM-2). Both groups of patients also received omeprazole 20 mg twice daily for the first week. In the OBTM-2 group, the anti-Helicobacter therapy was finished during hospitalization. Endoscopy was repeated 5 wk after randomization to monitor ulcer healing and determine H. pylori status. Side effects related to the anti-Helicobacter therapy was graded as follows: A, mild discomfort, which did not affect daily activity; B, moderate discomfort affecting daily activity; and C, severe discomfort and patients discontinued therapy.

RESULTS

Forty-six patients in the OBTM-2 group and 50 in the OBTM-7 group returned for follow-up endoscopy. With an intention-to-treat analysis, ulcer healing was achieved in 44 of 46 patients (95.7%) in the OBTM-2 group versus 49 of 50 (98%) in the OBTM-7 group, p = 0.61. H. pylori eradication was successful in 35 of 46 patients (76.1%) in the OBTM-2 and in all 50 patients (100%) in the OBTM-7 group, p = 0.00024. There was no difference in the severity of side effects experienced by the patients in the OBTM-2 group than in the OBTM-7 group (19 vs 32%, p = 0.16). None of the patients had rebled during the period of follow-up.

CONCLUSION

Despite similar efficacy in ulcer healing, the 2-day quadruple therapy is less effective than the 1-wk regimen in curing H. pylori infection.

Thyroid storm presenting as status epilepticus and stroke

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Free vascularized transfer of the metatarsophalangeal and proximal interphalangeal joints of the second toe for reconstruction of the metacarpophalangeal joints of the thumb and index finger using a single vascular pedicle

Previously described double-joint transfers from a single toe have required a separate vascular pedicle for each joint transferred. In this case report, however, we describe the use of a single vascular pedicle to perform a free vascularized double-joint transfer of the metatarsophalangeal and proximal interphalangeal joints of a single toe to the metacarpophalangeal joints of the thumb and index finger. Although a pollicization could have restored adequate function to the patient's hand, she desired five digits. Given the increased distance between the metacarpophalangeal joints of the thumb and index finger, an increased interjoint pedicle length was needed. We obtained this by mobilizing the digital vessels away from the joints of the second toe. This involved transecting the tibial digital vascular branches of the proximal interphalangeal joint and the fibular vascular branches of the metatarsophalangeal joint. Based on a single pedicle, the vascularity of the proximal interphalangeal joint was maintained by preserving the distal commissural vessels at the distal phalanx. Advantages of this technique include using a single donor artery and reconstruction of two metacarpal joints with a single toe.

p53 accumulation and mutation are prognostic indicators of poor survival in human gastric carcinoma

The aim of our study was to examine the prognostic significance of p53 protein accumulation and gene mutation in a series of 116 gastric carcinomas from a low incidence population. Formalin-fixed, paraffin-embedded tumour sections were used to investigate p53 protein accumulation by immunostaining with monoclonal antibody (MAb) DO-7 and p53 gene mutation by single-strand conformation polymorphism analysis of exons 5-8. Nuclear p53 accumulation was detected in 23% of tumours and mutation in 28%. Concordance between the 2 alterations was observed in 73% of cases. p53 protein accumulation was more frequent in tumours with lymph node metastasis, while p53 mutations were more frequent in tumours from older patients. The histopathological parameters of depth of invasion, grade and histological type showed no significant associations with either p53 alteration. In univariate analysis, both alterations were associated with significantly shortened patient survival. The 5-year survival rate for patients with a p53 mutation was 9% compared to 42% for those without a mutation. In multivariate analysis adjusted for the other histopathological parameters, p53 gene mutation but not immunohistochemically-detected p53 protein accumulation was an independent prognostic indicator of poor survival in gastric carcinoma.

Clinics in diagnostic imaging (8). Adrenal metastasis from bronchial carcinoma

A 73-year-old Chinese woman was incidentally discovered having a right supra-renal mass on ultrasound. Computerised tomography (CT) demonstrated this large, mostly cystic mass, with thick enhancing rims, located within the right adrenal gland. Plain radiograph and CT showed a bronchial tumour causing destruction of the adjacent ribs. Ultrasound-guided aspiration biopsy of the right adrenal mass confirmed the diagnosis of metastasis. Imaging plays an important role in detection of asymptomatic adrenal masses and in the staging of lung cancer.

Cerebral venous thrombosis associated with maxillary and ethmoid sinusitis--a case report

We herein report a young patient with cerebral venous thrombosis (CVT) with clinical and neuroradiological findings of the left maxillary and anterior ethmoid sinusitis. Serial brain MRIs showed cerebral venous infarct and thrombosis in the superior sagittal sinus (SSS). MR angiography demonstrated nonvisualization of SSS and bilateral transverse sinus. According to our knowledge, CVT associated with maxillary and ethmoid sinusitis has been reported very rarely. High index of suspicion and neuroimaging studies, especially brain MRI, and conventional or MR angiography are very important for the early diagnosis of CVT.

Gastric carcinoma with synchronous liver metastases: palliative gastrectomy or not?

During a 6 year period, 38 patients with gastric cancer presented with synchronous liver metastases and 25 underwent gastric resection. Forty per cent of the operated patients presented with complications, whereas most of the non-operated patients presented with pain or an abdominal mass. Eight patients (32%) developed postoperative morbidity, five of whom died (20%). The median duration of hospital stay for those surviving surgery was 33 days. In the non-operated group 61% died while in hospital and the median duration of hospital stay was 28 days. The respective median survival time and duration of home stay were 13 and 9 weeks for the operated patients and 6 and 3 weeks for the non-operated patients. The difference of the duration of home stay between the two groups of patients was statistically insignificant. There was also no significant relief of pain after surgery. Univariate analyses of the influence on survival time of operation among 13 other factors showed that only bilirubin was significant. We conclude that gastrectomy neither prolongs life nor improves the quality of survival in patients with gastric cancer and discontiguous liver metastases. However, gastrectomy may be beneficial in selected patients presenting with potentially lethal complications such as bleeding and obstruction.

Postoperative continuous interscalene brachial plexus blockade for hand surgery

Interscalene brachial plexus blockade is a well-established means of providing analgesia and anesthesia for upper extremity surgery. Extension into the postoperative period with continuous infusions of 0.25% bupivacaine provides several added advantages. Our survey over two years covered 126 patients undergoing surgery by the Department of Hand Surgery of our hospital. Postoperative verbal analogue pain scores obtained for three days showed scores of 4 or less (range 0 to 10) being reported by more than 70% of all patients with 6.3% and 11.9% requiring additional narcotics and non-steroidal anti-inflammatory drugs, respectively. Compliance with early occupational therapy was good with only 7 patients having difficulty with active mobilisation as a result of excessive motor blockade. The insertion complication rate was 11.1%; all these cases were attributed to the bolus dose given and resolved over the next few hours. Eighteen (14.3%) of the patients developed complications while on continuous infusion, the most frequent being catheter dislodgement and pain at the insertion site. In all we found this method of providing postoperative analgesia to be effective, inexpensive and easy to implement in our large hospital setting.