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Advantages of abandoning abdominal cavity irrigation and drainage in operations performed on children with perforated appendicitis

PURPOSE This study evaluates the effect of peritoneal irrigation and drainage on postoperative morbidity when used together for perforated appendicitis. MATERIAL AND METHODS This study was conducted on children undergoing open appendectomy for perforated appendicitis. Sixty-one children with perforated appendicitis operated on with irrigation and drainage between July 1998 and September 2001 (group DI) and 173 children with perforated appendicitis who underwent surgery without irrigation and drainage (group NDI) between October 2001 and November 2011 were retrospectively evaluated (a total of 234 patients). All patients were treated and followed up by the same pediatric surgeon using the same protocol. Both groups were compared in respect to postoperative complications, including wound infection, wound dehiscence, intraabdominal abscess, prolonged ileus, the presence of small bowel obstruction requiring surgery, operative time, and length of postoperative hospital stay. RESULTS Of the total 234 patients, 151 were male and 83 were female with a mean age of 8.9 ± 3.7 years (range, 1.5-15 years). The wound infection rates were 4.9% in group DI and 1.7% in group NDI (P = .184). Wound dehiscence was seen in 1.6% vs 0%, prolonged ileus in 8% vs 2.3%, intraabdominal abscess in 4.9% vs 1.7%, and small bowel obstruction requiring surgery in 1.6% vs 0.6% of the patients (P = .261, P = .054, P = .184, and P = .454, respectively). No statistically significant difference in postoperative infectious complications was found between both groups. The length of postoperative hospital stay was 9.9 ± 4.1 days in group DI vs 6.3 ± 2.4 days in group NDI (P < .001). The operation times were 39 ± 8 and 31 ± 11 minutes, respectively (P < .001). CONCLUSION This study demonstrates that peritoneal irrigation and drainage in children with perforated appendicitis is not required, and in fact, these procedures cause an increase in operative time.

Chronic postsurgical pain and neuropathic symptoms after abdominal hysterectomy: A silent epidemic.

Abstract Chronic postsurgical pain (CPSP) is an important clinic problem. It is assessed that prevalence of chronic pain extends to 30% but it is contended that there are various risk factors. We aimed to evaluate the prevalence of chronic pain after hysterectomy, risk factors of chronicity, neuropathic features of pain, and sensorial alterations at surgery area. Between years 2012 and 2015, 16 to 65 ages old patients that electively undergone total abdominal hysterectomy bilateral salpingo-oophorectomy and passed minimum 3 months after surgery were included to study. Visual analog scale (VAS) and Douleur Neuropathique 4-questionnaire (DN-4) surveys were used to evaluate pain symptoms, algometry device was used for evaluating abdominal pressure threshold and Von Frey Filament was used for sensorial alterations. Ninety-three of 165 eligible patients were included to study. As the groups were compared by demographic data, no difference was obtained (P > 0.05). There was no difference between groups regarding patient and surgery attributes (P > 0.05). Most frequently performed incision type was Pfannenstiel. Neuropathic symptoms were observed in 90 patients (96.8%). Sensorial alterations as hypoesthesia and hyperesthesia were detected around abdominal scar in 18 patients (19.4%) with pinprick test. Neuropathic symptoms should not be ignored in studies evaluating CPSP and a standard methodology should be designed for studies in this topic.

Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study

BACKGROUND AND OBJECTIVES Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5). RESULTS There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

Efeitos da insuflação de dióxido de carbono sobre a oxigenação cerebral regional durante cirurgia laparoscópica em crianças: um estudo prospectivo

BACKGROUND AND OBJECTIVES Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5). RESULTS There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

Unique Liver Disease of Pregnancy Requiring Anaesthesia Support: A Case with Severe Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is one of the common unique liver diseases that occurs during pregnancy. Mild cases can be spontaneously resolved in time but severe cases usually require supportive medical treatment to relieve symptoms. Moreover, differential diagnosis may be required in severe cases that manifest with persistent nausea-vomiting, dehydration and weight loss refractory to treatment. Thus, to rule out any gastrointestinal pathology, this case was referred to the outpatient anaesthesia clinic after the first unsuccessful awake endoscopy attempt without sedation. Therefore, anaesthetic support for endoscopy of a pregnant woman with severe HG was presented in this case report.

Does Sugammadex Administration Affect Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy: A Prospective, Double-Blind, Randomized Study

Background: The aim of this study is to assess the effect of sugammadex on postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. Methods: Eighty patients who were scheduled for elective laparoscopic cholecystectomy surgery were enrolled in this prospective study. Patients were randomly assigned to neostigmine (group N) or sugammadex (group S) for neuromuscular antagonism at the end of anesthesia. The incidence of PONV and antiemetic consumption were recorded. Results: Nausea and vomiting were observed in 60% of the patients given sugammadex and 77.5% given neostigmine during the initial 24 hours postoperatively. The incidence of nausea and the need for rescue antiemetic were lower in group S than group N during all time intervals but there were no significant differences between the groups. Conclusions: Sugammadex seems to be effective in decreasing the incidence of PONV, severity of nausea, number of patients who suffered from nausea and vomiting, and need for rescue antiemetic, although there were no significant differences.

Comparison of the intravenous and epidural administration of tumor necrosis factor-alpha antagonists in an experimental rat pain model

Introduction: Inflammatory cytokines secreted from the nucleus pulposus are thought to lead to lumbar nerve root compression-like symptoms. Tumor necrosis factor-alpha (TNF-α), an inflammatory cytokine, likely plays an important role in lumbar disc hernia-related leg pain. In this experimental study, we compared the effectiveness of TNF-α antagonists administered through the intravenous or epidural route in lumbar spine pathologies. Materials and Methods: After ethics committee approval had been obtained, 24 Sprague Dawley male rats aged 70–90 days and weighing 250–300 g each were allocated to four groups. In Group I, only the surgical procedure was performed; in Group II, 1 ml of saline solution was administered into the epidural field; in Group III, 10 mg/kg of infliximab was administered into the coccygeal vein; and in Group IV (epidural group), 25 mg of etanercept was administered into the epidural region. Results: When the left leg pull values were analyzed on day 14, whereas there was not a significant difference among the three groups, a decreasing difference was observed in Group IV (P < 0.05). When the 21st and 28th day left leg pull values were compared between groups, the values from Groups II, III, and IV were significantly lower than those of Group I (P < 0.05). Conclusion: The absence of a difference between the baseline values and left leg pull values on days 14, 21, and 28 in Group IV indicates that recovery began on day 21 with the epidural administration of etanercept. There was no difference between intravenous saline administration and intravenous infliximab administration with regard to the start of the recovery. In the present study of rats with discopathy, TNF-α antagonists administered epidurally led to earlier recovery from radiculopathy-related allodynia compared to intravenous administration.

Lateral Sagittal Infraclavicular Block Under Sedation in a Four-Year-Old Child

To the Editor, The advantages of a lateral sagittal infraclavicular block (LSIB) include easily identifiable landmarks, the ability to determine the needle entry site and a minimal risk of pneumothorax, as described by Klaastad et al. (1) using magnetic resonance imaging (MRI) in adults. However, there are few studies and cases concerning the use of LSIB under sedation or general anaesthesia (2–4). In a letter including four paediatric cases, 15–20 mL of bupivacaine 0.25% with epinephrine (1:200,000) was used, and in a study with 80 children, 0.5 mL kg−1 of bupivacaine 0.25% with adrenaline (5 μg mL−1) was used for LSIB under general anaesthesia (2, 3). In another study, 0.5 mL kg−1 of ropivacaine 0.5% was used for the lateral vertical infraclavicular block, under sedation, in children (4). Here, we report the case of a 4-year-old male child (height 110 cm, weight 20 kg, ASA I) who received LSIB under sedation for left trigger thumb surgery. EMLA® cream (Astra Zeneca, Wedel, Germany) was applied to the right hand for venous cannulation, in which a 22 G venous cannula was inserted, and 0.05 mg kg−1 of midazolam and 0.5 mg kg−1 of ketamine were administered intravenously for sedation. In the operating room, standard monitoring (electrocardiogram, non-invasive blood pressure, pulse oximetry) was applied. The level of sedation was assessed using the Ramsey Sedation Scale, and while the sedation score (SS) was 2, the block was performed with the patient in the supine position and head turned to his right side. With the anaesthesiologist standing behind the child’s left shoulder, the arm was adducted, and the left hand was placed on the abdomen. Although the point of the needle insertion is stated as the intersection between the clavicle and the coracoid process (CP) in the literature (1–3), we inserted the needle 1 cm inferiorly to the intersection between the clavicle and the CP (Figure 1). Figure 1 Left infraclavicular region illustrating the lateral sagittal infraclavicular block using the inferior approach. The needle is placed at the 1 cm inferiorly to the intersection between the clavicle and the CP After antiseptic preparation of the area, 1 mL of lidocaine 1% was infiltrated. A 22 G, 50-mm, insulated needle (Stimuplex A; B. Braun Medical Ltd., Melsungen, Germany) was connected to the active lead of the nerve stimulator (Stimuplex HNS 11; B. Braun Medical Ltd., Melsungen, Germany), and 1.5-mA current impulses of 0.1 ms in duration at a frequency of 1 Hz were delivered. The needle was inserted caudally in a sagittal plane and 60° from the skin on a horizontal plane. At a depth of 10 mm, flexion of the thumb, second and third fingers was accepted as a median nerve response, elicited with a current of 0.3 mA but not with 0.2 mA. Slowly, 5 mL of a bupivacaine 0.25% and lidocaine 1% mixture was injected. During needle insertion and redirection, continuous aspiration was performed to detect any possible intravascular placement. Twenty minutes after the block was completed, the patient was tested by the surgeon before incision, and pain-free surgery was begun. During the surgery, the patient was cooperative (SS=1) and required no additional sedation. The surgical procedure lasted 30 minutes. The duration of motor block and sensory block were approximately 2.5 and 6 hours, respectively. Throughout the anaesthesia, there was no change in haemodynamic parameters. Additionally, there were no intra- or postoperative complications. We conclude that LSIB using the inferior approach with lowdose local anaesthetics (0.25 mL kg−1) under sedation may be an option for regional and general anaesthesia in minor hand, forearm and elbow surgery in children. However, the limitation of block performance under sedation in children is the risk of sudden, unexpected movements, which may be higher in children than in adults.

Laparoscopic Excision of Omental Infarction Mass: A Case Report

Omental infarction is a very rare cause of an acute abdomen in children. Symptoms, in particular, display a great similarity to those of appendicitis. A 10-year-old boy with omental infarction was successfully treated by laparoscopic excision. The authors have demonstrated that laparoscopic excision is a technically feasible and safe method associated with a shorter hospital stay, no requirement for analgesics and a good cosmetic outcome.