Makoto Matsushima

Wound infiltration with lidocaine prolongs postoperative analgesia after haemorrhoidectomy with spinal anaesthesia

PurposeThere are few clinical data examining whether sensitization of peripheral nerves contributes to postoperative pain when the entry of noxious impulses to the central nervous system is blocked. We hypothesized that wound infiltration with lidocaine would provide better postoperative analgesia than with normal saline following haemorrhoidectomy with spinal blockade.MethodsIn a randomized, placebo-controlled, blinded study, 168 adults undergoing haemorrhoidectomy were allocated to two groups. In Group L (n = 88) local infiltration was provided with lidocaine 1% and in Group S (n = 80) with normal saline. Following spinal anaesthesia with lidocaine 3%, the surgeon infiltrated 15 ml of either infiltration solution to the surgical area. Postoperative analgesia was obtained by continuous epidural administration of 90 mg eptazocine in normal saline for 48 hr. Supplemental analgesics were given on request. Postoperative pain control was assessed at rest and during coughing with a 10 cm VAS on the 1st, 2nd, and 3rd postoperative days (POD).ResultsThe VAS scores at rest in Group L were lower than those in Group S throughout the postoperative period. During coughing, VAS scores in Group S were increased on the 3rd postoperative day, while those in Group L remained constant (4.42 ± 0.27 vs 3.14 ± 0.28, P < 0.05). Fewer patients in Group L than in Group S required supplemental analgesics.ConclusionPreoperative lidocaine infiltration to the surgical area provided prolonged postoperative analgesia in patients receiving haemorrhoidectomy with spinal anaesthesia.RésuméObjectifNous ne possédons que peu de données portant sur l’influence de la sensibilisation des nerfs périphériques sur la douleur postopératoire quand la voie d’entrée des stimuli nocifs au système nerveux central est bloquée. Nous avons assumé que l’infiltration d’une plaie avec de la lidocaïne peut procurer une meilleure analgésie postopératoire que le sol. physiologique après une hémorroïdectomie sous rachianesthésie.MéthodesAu cours d’une anesthésie contrôlée avec placebo et en aveugle, 168 adultes programmés pour une hémmorroïdectomie étaient répartis en deux groupes. Dans le groupe L (n = 88), une infiltration à la lidocaïne 1% était effectuée et dans le groupe S (n = 88), on utilisait du sol. physiologique. Après une anesthésie épidurale à la lidocaïne 3%, le chirurgien infiltrait le site chirurgical avec 15 ml d’une des deux solutions. L’analgésie postopératoire était réalisée par l’administration épidurale de 90 mg d’épiazocine dans du sol. physiologique pendant 24 h. Des analgésiques additionnels étaient administrés à la demande. Le contrôle de la douleur postopératoire était évalué au repos et pendant la toux sur une EVA de 10 cm les le, 2e et 3e jours postopératoires.RésultatsAu repos les scores d’EVA du groupe L étaient inférieurs à ceux du groupe S pendant la période postopératoire. Pendant la toux, les scores d’EVA du groupe S augmentaient à la 3e journée postopératoire, alors que ceux du groupe L étaient constants (4,42 ± 0,27 vs 3,14 ± 0,28, P < 0,05). Moins de patients du groupe L que du groupe S avaient besoin d’analgésiques additionnels.ConclusionL’infiltration préopératoire de lidocaïne au site chirurgical procure une analgésie postopératoire prolongée aux hémorroïdectomisés sous rachianesthésie.

Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis

Background and aimsTreatment of anorectal sepsis requires prompt surgical drainage, but it is important to identify any associated anal fistula for preventing recurrence. We evaluated whether microbiological analysis and/or endoanal ultrasonography could be used to predict anal fistula in patients with acute anorectal sepsis.MethodsFive hundred fourteen consecutive patients with acute anorectal sepsis were studied. Clinical data, digital examination findings, endosonographic findings, and results of microbiological analysis were compared with definitive surgical findings of the presence or absence of anal fistula.ResultsAnorectal abscess with anal fistula was found in 418 patients, and anorectal abscess without anal fistula was found in 96 patients. Microbiological examination showed that Escherichia coli, Bacteroides, Bacillus, and Klebsiella species were significantly more prevalent in patients with fistula (P<0.01), and coagulase-negative Staphylococci and Peptostreptococcus species were significantly more prevalent in patients without fistula (P<0.01). Results of endoanal ultrasonography were concordant with the definitive surgical diagnosis in 421 (94%) of 448 patients studied.ConclusionAcute anorectal sepsis due to colonization of “gut-derived” microorganisms rather than “skin-derived” organisms is more likely to be associated with anal fistula. When the microbiological analysis yields gut-derived bacteria, but no fistula has been found in the initial drainage operation, repeat examinations during a period of quiescence, including careful digital assessment and meticulous endosonography, are warranted to identify a potentially missed anal fistula.

Transient neurologic syndrome in one thousand forty-five patients after 3% lidocaine spinal anesthesia

Recent reports have discussed the potential risk of transient radicular irritation (TRI) after spinal anesthesia with lidocaine.Because we have not encountered such neurologic sequelae with the high incidence reported, we prospectively examined the incidence of TRI after spinal anesthesia with lidocaine. One thousand forty-five adult patients (aged 47 +/- 15 yr) receiving spinal anesthesia with 3% hyperbaric lidocaine (1.0-1.5 mL) for anorectal surgery were consecutively studied. After the induction of spinal anesthesia, all patients were placed in the prone position for surgery. Patients were evaluated for neurologic symptoms in the buttocks, thighs, or lower extremities using a checklist to standardize data collection. Although there was no complaint of neurologic symptoms on Postoperative Day (POD) 1, four patients (0.4%) reported aching, hypesthesia, numbness, or dull pain of both lower extremities and buttocks by the morning of POD 3. In three patients, the symptoms resolved without any treatment by POD 5, whereas in one patient, numbness of the lower extremities lasted until POD 7. We conclude that a combination of lidocaine with surgical position or leg manipulation during surgery might be a major contributing factor in the development of transient neurologic syndrome. Implications: Recent studies have reported the potential risk of transient neurologic syndrome after lidocaine spinal anesthesia. The current study reports a low incidence of such sequelae in 1045 patients undergoing anorectal surgery during the prone position. Other factors, such as surgical position, may be important in the development of this syndrome. (Anesth Analg 1998;86:1023-6)

Endoanal Ultrasonography of Mucinous Adenocarcinoma Arising from Chronic Fistula-in-ano: Three Case Reports

Mucinous adenocarcinoma arising in chronic fistula-in-ano is rare, and diagnosing it at an early stage is difficult. The role of endoanal ultrasonography in diagnosing the condition has not been discussed in the study. Herein, we report three cases of mucinous adenocarcinoma arising from anal fistulas in which endosonography played an important role in diagnosing malignant change. Three male patients with a 5- to 20-year history of anal fistula were referred to our hospital due to perianal induration, progressive anal pain, or mucopurulent secretion. In all three patients, endosonography revealed a multiloculated complex echoic mass with isoechoic solid components communicating with a trans-sphincteric fistula and sonography-guided biopsy under anesthesia revealed mucinous adenocarcinoma. All patients underwent abdominoperineal resection with lymph node dissection. One patient with a local recurrence died 3 years after surgery and two have remained disease-free for >6 years. These observations suggest that endosonography may be a reliable technique for the diagnosis of mucinous adenocarcinoma arising from chronic fistula-in-ano. Sonography-guided biopsy is useful for the definitive diagnosis of malignancy. Therefore, periodic endosonography assessment should be recommended for patients with persistent anal fistula, especially those with progressive clinical symptoms. Once malignancy is suspected, aggressive sonography-guided biopsy under anesthesia should be performed, which may enable an early diagnosis, curative treatment, and favorable long-term results.

Vergleich der Genauigkeit von klinischer Untersuchung und endoanalem Ultraschall zur präoperativen Beurteilung akuter und chronischer Analfisteln

ZusammenfassungFragestellung:Diese Studie wurde zur Überprüfung der Zuverlässigkeit des endoanalen Ultraschalls bei der präoperativen Beurteilung von Analfisteln durchgeführt, insbesondere im Hinblick auf die Unterschiede zwischen akuten und chronischen Fisteln.Patienten und Methodik:Untersucht wurden 401 Patienten, die im Zeitraum von Januar bis Dezember 2005 wegen akuter oder chronischer anorektaler Entzündung kryptoglandulären Ursprungs behandelt worden waren. Bei allen Patienten wurden eine klinische Untersuchung sowie ein endoanaler Ultraschall durchgeführt. Die Übereinstimmungen zwischen den klinischen und endosonographischen Ergebnissen und den tatsächlichen chirurgischen Befunden wurden evaluiert, mit besonderer Berücksichtigung der Klassifikation des Primärtrakts und der Hufeisenausdehnung sowie der Lokalisation der inneren Öffnung. Ebenso wurden die Unterschiede bei der Genauigkeit der endosonographischen Untersuchung zwischen akuten und chronischen Fisteln evaluiert.Ergebnisse:Die Genauigkeit des endoanalen Ultraschalls war signifikant höher als die der klinischen Untersuchung hinsichtlich der Auffindung des Primärtrakts (88,8% vs. 85,0%; p = 0,0287) und der Hufeisenausdehnung (85,7% vs. 58,7%; p < 0,0001) und bei der Lokalisierung der inneren Öffnung (85,5% vs. 69,1%; p < 0,0001). Darüber hinaus war die Lokalisierung der inneren Öffnung durch die Endosonographie bei den chronischen Fisteln signifikant genauer als bei den akuten Fisteln (89,5% vs. 76,8%; p < 0,0001), obwohl sich die Genauigkeit bei der Auffindung des Primärtrakts und der Hufeisenausdehnung nicht signifikant unterschied.Schlussfolgerung:Die endoanale Sonographie ist verlässlich und nützlich bei der präoperativen Untersuchung von Analfisteln, insbesondere zur Auffindung einer Hufeisenausdehnung und zur Lokalisierung der inneren Öffnung. Die endosonographische Untersuchung liefert in den Phasen der chronischen Entzündung eine bessere Darstellung der inneren Öffnung als in den Phasen der Abszessbildung. Bei Patienten mit akuter anorektaler Entzündung könnte eine primäre Drainage mit anschließender Fisteloperation anstelle einer einstufigen Fisteloperation ratsam sein, um eine fehlerhafte Identifizierung der inneren Öffnung zu vermeiden.AbstractPurpose:This study was undertaken to evaluate the accuracy of endoanal ultrasonography for preoperative assessment of anal fistula, with special reference to the difference between acute and chronic fistula.Patients and Methods:The subjects comprised 401 patients treated for acute or chronic anorectal sepsis of cryptoglandular origin during the period January through December 2005. All patients underwent physical examination and endoanal ultrasonography. Agreement between the physical and endosonographic findings and the definitive surgical findings were evaluated with special reference to classification of the primary tract and horseshoe extension and localization of the internal opening. The difference in accuracy of endosonographic assessment between acute and chronic fistula was also evaluated.Results:The accuracy of endoanal ultrasonography was significantly higher than that of physical examination in detecting the primary tract (88.8% vs. 85.0%; p = 0.0287) and horseshoe extension (85.7% vs. 58.7%; p < 0.0001) and in localizing the internal opening (85.5% vs. 69.1%; p < 0.0001). Furthermore, localization of the internal opening by endosonography was significantly more accurate in chronic fistula than in acute fistula (89.5% vs. 76.8%; p < 0.0001), although the accuracy in detecting the primary tract and horseshoe extension was not significantly different.Conclusion:Endoanal ultrasonography is reliable and useful for preoperative assessment of anal fistula, particularly for detecting horseshoe extension and localizing the internal opening. Endosonographic assessment provides clearer depiction of the internal opening during periods of quiescence than during the period of abscess formation. For patients with acute anorectal sepsis, initial surgical drainage and subsequent fistula surgery, rather than one-stage fistula surgery, may be advisable to avoid misidentification of the internal opening.