Denis Quill

Analgesia following appendicectomy — the value of peritoneal bupi-vacaine

PurposePeritoneal inflammation is an important feature in many patients presenting with appendicitis. The contribution of peritoneal nerve fibres to pain experienced after appendicectomy has received little attention.MethodIn this prospective double blind randomized study a consecutive series of 60 patients undergoing appendicectomy for suspected appendicitis were enrolled. A dose of 1.5 mg·kg−1 bupivacaine 0.5 % was used. Group one patients received the entire dose of bupivacaine subcutaneously. Group two patients received half the dose subcutaneously (sc) and half the dose to the peritoneum. Pain scores were assessed pre-operatively and at 30 min, 12 and 24 hr post-operatively using a visual analogue scale. Time to first analgesia and total analgesia requirements in the first 24 hr were recorded.ResultsThe patients receiving the sc combined with peritoneal bupivacaine had a lower pain score 30 min postoperatively (32 ± 2 vs 54 ± 4;P < 0.0001), a longer time to first analgesia (248 ± 20 vs 164 ± 17 min; P = 0.002)as well as lower opioid (68 ± 5 vs 100 ± 7 mg; P = 0.0002) and non steroidal analgesic requirements (65 ± 6 vs 96 ± 6 mg; P = 0.007) in the first 24 hr post-operatively.ConclusionA combination of sc and peritoneal infiltration with bupivacaine is superior to skin infiltration alone in the relief of pain post appendicectomy.RésuméObjectifLinflammation péritonéale est un signe important chez de nombreux patients souffrant d’une appendicite. La participation des fibres nerveuses du péritoine à la douleur éprouvée après l’appendicectomie n’a jamais vraiment retenu l’attention.MéthodeUne série de 60 patients consécutifs suspects d’appendicite et devant subir une appendicectomie ont été inclus dans une étude prospective, en double insu et randomisée. Une dose de 1,5 mg·kg−1 de bupivacaïne 0,5 % a été utilisée. Les patients du premier groupe ont reçu la dose complète en infiltration sous-cutanée. Ceux du deuxième groupe ont reçu la moitié de la dose en infiltration sous-cutanée (sc) et le reste en infiltration péritonéale. Les niveaux de douleur ont été évalués avant l’intervention, puis 30 min., 12 et 24 h après l’intervention, d’après une échelle visuelle analogue. Le moment où a eu lieu la première analgésie et les besoins totaux d’analgésie pendant les 24 premières heures ont été enregistrés.RésultatsLes patients qui ont reçu une combinaison d’infiltration sc et péritonéale de bupivacaïne ont présenté un niveau de douleur plus bas 30 min après l’intervention (32 ± 2 vs 54 ± 4;P < 0,0001), ont eu besoin d’une première analgésie plus tard que ceux de l’autre groupe (248 ± 20 vs 164 ± 17 min; P = 0,002), d’une plus faible quantité d’opioïde (68 ± 5 vs 100 ± 7 mg; P = 0,0002) et d’analgésique non stéroïdien (65 ± 6 vs 96 ± 6 mg; P = 0,007) pendant les 24 premières heures postopératoires.ConclusionUne combinaison d’infiltration sc et péritonéale de bupivacaïne est supérieure à l’infiltration cutanée employée seule pour soulager la douleur ressentie après l’appendicectomie.

Changing practices in the surgical management of hyperparathyroidism – A 10-year review

AIM Parathyroid surgery has undergone a paradigm shift over the last decade, with a move from traditional bilateral neck exploration to minimally invasive parathyroidectomy (MIP), and increasing reliance on pre- and intra-operative localization of overactive glands. We aimed to assess changing surgical practices and their impact on the management of parathyroid disease in a tertiary referral centre in the West of Ireland. METHODS A retrospective cohort analysis of those patients undergoing a surgical intervention for parathyroid disease in the period between 1999 and 2009 in our centre was carried out. Data was analysed using PASW (v18) software. RESULTS 248 procedures were performed, increasing from an annual rate of 6 in 1999 to 45 in 2009. 129 procedures were completed by minimally invasive means, following the introduction of MIP in 2003. Single-gland disease accounted for 87% of cases (n = 216) with carcinomas in 2 patients (0.8%). Pre-operative localization had disappointing diagnostic value, with high false negative rates for both ultrasound (37.3%) and Sestamibi Scanning (35.81%). Intra-operative adjuncts were more helpful, with intra-operative Parathyroid hormone monitoring facilitating curative resection of adenomas in 94.03% at 10 min. Median length of post-operative stay has significantly decreased from 6 days in 1999 to 1 night only in 2009 (p < 0.01, ANOVA). Those patients undergoing MIP had shorter stay than the open group (1.71 days -v-4.73, p = 0.003,t-test). CONCLUSION The practice in our centre has shifted to a less invasive approach. Increased utilisation of intra-operative adjuncts has facilitated this change, and resulted in favourable changes in length of stay, extent of dissection, and number of patients treated.

Differentiated Thyroid Cancer: How Do Current Practice Guidelines Affect Management?

Background: International best-practice guidelines recommend completion thyroidectomy and radioiodine remnant ablation (RRA) for patients with differentiated thyroid cancer (DTC) > 4 cm or with specific risk factors. Patients with DTC < 1 cm without risk factors are recommended for lobectomy alone. Indications for aggressive surgery and RRA are less clearly defined for tumours measuring 1–4 cm. A personalised approach to decision-making is recommended. Objectives: This study assesses therapeutic approaches to DTC as compared to the current British Thyroid Association (BTA) clinical practice guidelines. We ascertained the effect of equivocal guidance in the 1–4 cm tumour cohort on contemporary practice patterns. Methods: Data were obtained from a prospectively maintained thyroid cancer database of patients treated for DTC in a tertiary referral centre at the University Hospital Galway. Consecutive patients attending a dedicated thyroid cancer clinic between August 2014 and August 2017 were included. Clinicopathological characteristics and management strategies were assessed. Results: Ninety-four percent (n = 168/178) of patients were surgically managed in adherence with guidelines. A minority (n = 10) received surgery not aligned with guidelines. Ninety-seven percent (n = 172/178) of RRA treatment decisions were in accordance with guidelines. The BTA guidelines recommended a personalised decision-making approach for 18.0% (n = 32) and 44.9% (n = 80) of surgery and RRA treatment decisions, respectively. The more aggressive, treatment-driven approach was typically favoured by the multidisciplinary team, with 97% (n = 31/32) undergoing completion thyroidectomy and 100% (n = 80) proceeding to RRA. Conclusions: Management of DTC at our institution closely adheres to contemporary clinical practice guidelines. The finding of more aggressive management in those requiring a personalised decision-making approach highlights the requirement for improved risk stratification in this cohort to rationalise management strategies.

Oesophago-vascular fistulae secondary to benign peptic ulcer disease: A rare cause of fatal haemorrhage

Oesophago-vascular fistulas are a very rare cause of massive upper gastrointestinal haemorrhage. The syndrome of sentinel haemorrhage, retrosternal pain and massive subsequent haemorrhage described by Chiari ~ is not always present and even though these fistulas are often associated with the presence of an aortic aneurysm or malignancy, this is not always the case. We present two cases of fatal haematemesis from an oesophago-vascular fistula secondary to benign peptic ulcer diseas4.