Philip J. Huber

Comparison of the Costs and Recovery Profiles of Three Anesthetic Techniques for Ambulatory Anorectal Surgery

BackgroundGiven the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting. MethodsNinety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25–100 &mgr;g · kg−1 · min−1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 &mgr;g fentanyl with midazolam, 1–2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5–2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision. ResultsThe mean costs were significantly decreased in group 1 (

Dexamethasone facilitates discharge after outpatient anorectal surgery.

69 ± 20 compared with

Primary colonic lymphoma

104 ± 18 and

Outcome analysis of HIV-positive patients with anal squamous cell carcinoma.

145 ± 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19%vs. 45% for group 3;P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%). ConclusionsThe use of local anesthesia with sedation is the most cost-effective technique for anorectal surgery in the ambulatory setting.

Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons.

Corticosteroids can decrease pain and postoperative nausea and vomiting after ambulatory surgery. Therefore, we designed a study to evaluate if the routine use of dexamethasone would facilitate the early recovery process after anorectal surgery. A secondary aim of the study was to determine if dexamethasone would increase the incidence of postoperative wound complications. Eighty adult outpatients undergoing anorectal surgery with a standardized monitored anesthesia care technique were randomly assigned to receive either dexamethasone 4 mg IV or an equal volume of saline before the start of surgery. All patients were premedicated with midazolam 2 mg IV and received ketorolac 30 mg IV as a preemptive analgesic. A propofol infusion, 50 &mgr;g · kg−1 · min−1 IV, was initiated and subsequently titrated to maintain an observer’s assessment of alertness/sedation score of 2 or 3 (with 5 = awake/alert to 1 = asleep). Fentanyl 25 &mgr;g IV was administered 3–5 min before infiltrating the surgical field with a 30-mL local anesthetic mixture containing 15 mL of lidocaine 1% and 15 mL of bupivacaine 0.25% (with epinephrine 1:200,000 and sodium bicarbonate 3 mL). All patients were fast-tracked directly from the operating room to the step-down recovery area. Even though the incidences of postoperative pain and postoperative nausea and vomiting were small in both treatment groups, the time to “home readiness” was significantly shorter in the dexamethasone group. Importantly, there was no increase in the incidence of wound infections (8% vs 12%) or hematoma formation (3% vs 5%) in the dexamethasone (versus saline) group. We conclude that the administration of dexamethasone, 4 mg IV, shortened the time to home readiness without increasing the incidence of postoperative wound infections in a high-risk outpatient population undergoing anorectal surgery. IMPLICATIONS A single dose of dexamethasone (4 mg IV) decreased the time to “home readiness” without increasing the incidence of postoperative wound complications in an outpatient population undergoing anorectal surgery.

outcome of Hiv-infected Patients With Invasive Squamous-cell Carcinoma of the Anal Canal in the Era of Highly Active Antiretroviral Therapy

The colon is a rare location for gastrointestinal non‐Hodgkins lymphoma (NHL). This study was undertaken to identify risk factors, presentation, treatment, and prognosis for primary colonic lymphoma (PCL) through review of a large tertiary care hospital system experience.

Percutaneous electrical nerve stimulation (PENS): a complementary therapy for the management of pain secondary to bony metastasis.

PURPOSE: With improved antiretroviral therapy, HIV-positive patients are achieving a longer life expectancy. An increased incidence of anal squamous cell carcinomas has been noted in these patients. The purpose of this study was to determine the outcome of HIV-positive patients with anal squamous cell carcinomas. METHODS: We conducted a review based on our tumor registry from 1980 through 1999. We identified 73 patients with anal squamous cell carcinoma treated at the University of Texas Southwestern Medical Center affiliated hospitals; 23 were HIV positive (18 had AIDS). In the HIV-positive group, 9 hadin situ squamous carcinomas and 14 had invasive squamous cell carcinomas. Data collected included age, CD4 count, treatment, complications, and survival; these data were analyzed by Studentst-test. RESULTS: All patients were male. Those with squamous cell cancer of the anus were offered radiation therapy and chemotherapy. Beginning in 1998, all patients received highly active antiretroviral therapy before treatment. Seven of 14 anal squamous cell carcinoma patients had their therapy adjusted owing to toxicity. Morbidity included proctocolitis and diarrhea (n=2) requiring diversion (n=1), hemorrhagic cystitis (n=1), neutropenic fever (n=3), bone marrow suppression (n=1), and urethral stricture (n=1). Mean age was 42 years for anal squamous cell carcinoma patients and 36 years for squamous cell carcinomain situ patients (P=0.05). Mean CD4 count was 222 cells/ml in patients with infiltrating carcinoma and 200 in thein situ patients (P=NS). One-year and five-year mortality rates, respectively, were 40 percent and 80 percent for infiltrating carcinoma patients and 17 percent and 50 percent for thein situ patients. Both of thein situ patients who died had CD4 counts <20 cells/ml at diagnosis, whereas the rest had CD4 counts >100 cells/ml and are currently without anal disease. Mean CD4 count at diagnosis for all patients who died was 133 cells/ml, whereas for those surviving, it was 261 cells/ml (P=0.03). Eight (all with infiltrating carcinoma) of the 10 patients who died had persistent anal disease, but none had metastasis. CONCLUSION: HIV-positive patients within situ carcinomas present at an earlier age than those with infiltrating lesions.In situ patients with CD4 counts as low as 105 cells/ml do well with local excision. A low CD4 count at diagnosis without highly active antiretroviral therapy predicts a poor prognosis. Because these patients appear to succumb to their HIV status and not the anal disease, anal squamous cell carcinoma should be included with cervical squamous cell carcinoma as an AIDS-defining illness. HIV-positive patients, particularly AIDS patients, with invasive anal cancers and without effective antiretroviral therapy obtain little benefit and significant toxicity from current radiation therapy and chemotherapy. Initiation of highly active antiretroviral therapy in HIV-positive patients before radiation therapy and chemotherapy are begun may decrease toxicity and improve survival. Additional clinical trials are warranted to test this theory.

Ketorolac improves recovery after outpatient anorectal surgery.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

The effect of ketorolac on recovery after anorectal surgery: intravenous versus local administration.

PURPOSE:Before the development of highly active antiretroviral therapy for the treatment of HIV infection, HIV patients diagnosed with invasive squamous-cell carcinoma of the anal canal carried a very poor prognosis. This study was designed to determine the outcome in a similar group of patients in the era of highly active antiretroviral therapy.METHODS:HIV-positive patients treated for invasive squamous-cell carcinoma of the anal canal at the University of Texas Medical Center affiliated hospitals from 1980 to 2001 were identified from operative data and cancer registries. We reviewed these records and collected data regarding age, CD4 count, highly active antiretroviral therapy, cancer treatment, complications, and survival. The patients were divided into two groups based on the presence or absence of highly active antiretroviral therapy and compared using a Kaplan-Meier approach.RESULTS:Fourteen patients with HIV and invasive squamous-cell carcinoma of the anal canal were identified. Six were in the prehighly active antiretroviral therapy group and eight in the highly active antiretroviral therapy group. All were considered for treatment with chemotherapy and radiation. In the prehighly active antiretroviral therapy group, one patient refused therapy and three were unable to complete the squamous-cell carcinoma therapy as planned because of complications. Four of eight highly active antiretroviral therapy patients were unable to complete the squamous-cell carcinoma therapy as planned. The prehighly active antiretroviral therapy patients had a mean age of 40 years and a mean CD4 count of 190 at the time of diagnosis. The highly active antiretroviral therapy patients had a mean age of 44 years and a mean CD4 count of 255 at the time of diagnosis. The 24-month survival was 17 percent in the prehighly active antiretroviral therapy group and 67 percent in the highly active antiretroviral therapy group (P = 0.0524). All six patients in the prehighly active antiretroviral therapy group died with active squamous-cell carcinoma vs. two in the highly active antiretroviral therapy group. Four of the remaining six patients had no evidence of active squamous-cell carcinoma at the last follow-up visit.CONCLUSIONS:A review of patients with HIV and invasive squamous-cell carcinoma of the anal canal suggests a trend toward a higher CD4 count at the time of diagnosis and improved survival in patients receiving highly active antiretroviral therapy. In this new era, HIV-positive patients should be on highly active antiretroviral therapy. If not, highly active antiretroviral therapy should be initiated, and standard multimodality therapies for invasive squamous-cell carcinoma of the anal canal are recommended.

Necrotizing soft-tissue infection from rectal abscess

OBJECTIVE To evaluate the use of a novel nonpharmacologic analgesic therapy known as percutaneous electrical nerve stimulation (PENS) in the management of opioid-resistant cancer pain. DESIGN PENS therapy was administered to three cancer patients on three or more occasion using acupuncturelike needle probes that were stimulated for 30 minutes at frequencies of 4-100 Hz. RESULTS Two of the three patients achieved good to excellent pain relief that lasted 24-72 hours after each treatment session. CONCLUSION PENS therapy is a useful supplement to opioid analgesics for the management of pain secondary to bony metastasis in terminal cancer patients.