PubMed · 10149047
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R N Wissler, D G Bjoraker. Continuous spinal anesthesia microcatheters.. https://pubmed.ncbi.nlm.nih.gov/10149047/
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BACKGROUND AND AIMS: Postoperative pain is the most distressing sequela of conventional hemorrhoidectomy. A modern alternative of circumferential mucosectomy has been proposed to reduce the pain in this procedure. PATIENTS AND METHODS: This controlled trial included 80 patients with second to fourth degree hemorrhoidal disease operated on over a 2-year period. The patients were randomly allocated to undergo either the stapled Longo procedure (group 1) or Milligan-Morgan hemorrhoidectomy (group 2) under epidural anesthesia. The operating time, postoperative pain scores at 3, 6, 12, and 24 h, analgesic consumption, hospital stay, and complication rate were recorded. At follow-up the outcome and patient satisfaction were evaluated. RESULTS: The mean operating time in group 1 was shorter than in group 2, postoperative pain scores at all time points and the mean epidural morphine requirement was lower, and mean hospital stay was shorter. The complication rate did not differ (three cases of postoperative bleeding in group 1 and two cases in group. At follow-up no recurrence or complains were recorded except three cases of mild incontinence (one in group 1 and two in group 2). The patients in group 1 (95%) were more satisfied than in group 2 (89%). CONCLUSION: The Longo procedure is thus a simple, safe, and effective method that entails less postoperative pain, more satisfaction, and shorter hospital stay than the standard Milligan-Morgan hemorrhoidectomy.
OBJECTIVE: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. BACKGROUND: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated. METHODS: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. RESULTS: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. CONCLUSIONS: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.
Various studies report conflicting data with regard to the level of risk of cesarean delivery for nulliparous women who receive epidural analgesia before 5 cm of cervical dilatation. As a result, some institutions are requiring that laboring women reach 4-5 cm of dilatation before receiving epidural analgesia. The American College of Obstetricians and Gynecologists wishes to reaffirm the opinion published jointly with the American Society of Anesthesiologists that while under a physician's care, in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. Decisions regarding analgesia should be coordinated among the obstetrician, the anesthesiologist, the patient, and support personnel.