Continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of modified radical mastectomy

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5--10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1--2 mg of midazolam or 50--100 microg/mL of fentanyl followed by 50--150 mg of propofol and was maintained with sevoflurane and 50% N(2)O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

A laparoscopic approach to posterior gastric wall leiomyomectomy

Leiomyomas represent 2% of gastric tumors. Commonly, gastric leiomyomas are clinically silent. Most often they become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa. Surgical extirpation of the tumor is the standard treatment. Gastric leiomyomectomy was done routinely through open laparotomy until availability of laparoscopic equipment and techniques. Recently, there have been a few published reports regarding laparoscopic or laparoscopic-assisted removal of smooth muscle gastric tumors. There is little data, however, describing or discussing a laparoscopic approach to gastric leiomyomas located on the posterior gastric wall. We describe two different laparoscopic approaches to posterior wall gastric leiomyomas that we used in two patients. The postoperative recovery of both patients was remarkably quick and uneventful.

Ligation: an alternative for control of exsanguination in major vascular injuries

BACKGROUND

Temporization in the management of patients in extremis has gained acceptance in trauma surgery. Resection, without anastomosis, in major visceral injuries followed by delayed reconstruction has been successful.

METHODS

To evaluate this approach in patients with substantial vascular trauma, we reviewed our experience of five patients with major vascular injuries that were ligated as a temporizing procedure during a 58-month period. If the patient was hypothermic, acidotic, and potentially or actually coagulopathic with significant blood loss, achieving expeditious hemostasis was the primary consideration. After hemodynamic resuscitation, warming, and correction of the coagulation profile, if necessary the patients were returned to the operating room for definitive reconstruction.

RESULTS

All patients survived; only two required subsequent vascular reconstruction.

CONCLUSIONS

The prompt control of hemorrhage must be the first objective of treatment in critically injured patients. Ligation of major vessel injury is a therapeutic alternative as part of the "damage control" philosophy.

Delayed gastrointestinal reconstruction following massive abdominal trauma

Routine use of the concepts of expeditious hemostasis including the use of packing and temporizing surgical resection without anastomosis followed by delayed reexploration and reconstruction in victims of major pancreaticoduodenal trauma encouraged us to manage other devastating abdominal injuries in a similar fashion. A variety of multiple organ injuries accompanied by massive blood loss, hypothermia, and acidosis also have been managed with the philosophy that hemostasis and control of continued gastrointestinal soiling were the only necessary initial surgical procedures. Following recovery room or surgical intensive care unit stabilization with full hemodynamic resuscitation and restoration of coagulation variables to normal, delayed definitive reconstruction was done. A summary of our experience and principles of management are presented.

Pancreaticoduodenectomy for trauma: delayed reconstruction: a case report

Experience and success with packing, resuscitation, and re-exploration for severe traumatic liver injury stimulated application of this concept to more complicated problems. In the case presented, these principles were utilized in managing a combined major hepatic and pancreaticoduodenal disruption. We emphasize stabilization, temporization, and delayed reconstruction.