Intravenous Narcotic Use Research Articles

Ten-year experience of infrainguinal bypass with endoscopic vein harvest.

There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40mmHg (p < 0.0001). Primary bypass patency in the first 30days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0days, with median intravenous narcotic use of 1day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19days), and 83% of patients had freedom from amputation at last follow-up (median 820days). In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.

Open versus thoracoscopic thymectomy for juvenile myasthenia gravis

BackgroundJuvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children. MethodsA retrospective review of all patients younger than 20 years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared. ResultsThirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108 ± 49 and 145 ± 43 min, respectively, p = 0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5 ± 6.0 vs 55 ± 67 ml, p = 0.007), decreased duration of postoperative intravenous narcotic use (5.0 ± 1.5 vs 20 ± 23 h, p = 0.018), and a shorter length of hospitalization (1.7 ± 1.0 vs 2.7 ± 1.1 days, p = 0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups. ConclusionsThoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention. Type of studyClinical research paper. Level of evidenceIII

Management of refractory and super-refractory status epilepticus

If status epilepticus continues despite the use of intravenous antiepileptic drugs or narcotics, it is called "refractory" or "super-refractory" status epilepticus (RSE, SRSE). Prolonged seizure activity is associated with neuronal damage, systemic complications and mortality rates of up to 50%, especially in generalized tonic clonic seizure types. In order to terminate the status, several rescue interventions with drugs and other measures are available. However, their evidence base is low because the effectiveness of the measures was almost exclusively derived from case reports and case series. In individual cases, agood outcome is possible even after several months of ongoing SRSE.

Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary?

BackgroundEnhanced recovery after surgery (ERAS) protocols have improved patient experience and outcomes in a variety of fields, including bariatric surgery. Given the increasing opioid epidemic in the USA, we sought to determine the impact of our own ERAS protocol on narcotic usage following laparoscopic sleeve gastrectomy. MethodsRetrospective chart review was performed on patients undergoing primary laparoscopic sleeve gastrectomy for 6 months before and after implementation of an ERAS protocol. Our protocol strongly discouraged the use of narcotics in the postoperative period. Specific outcomes of interest were postoperative narcotic usage, length of stay, complications, and readmissions. ResultsPatient characteristics were similar in the two groups. ERAS implementation did not correlate with changes in length of stay, complications, or readmissions. However, ERAS implementation was associated with dramatic reductions in the use of intravenous narcotics (100% vs 47%, p < 0.01) and oral schedule 2 narcotics (56% vs 6%, p < 0.01), with an increase in the usage of tramadol (0% vs 36%, p < 0.01). After ERAS implementation, 52% of patients were managed without the use of schedule 2 narcotics (0% pre-ERAS, p < 0.01) and 33% received no narcotics of any kind (0% pre-ERAS, p < 0.01). ConclusionImplementation of an ERAS protocol for laparoscopic sleeve gastrectomy is associated with a dramatic reduction in the use of narcotics in the postoperative period. This has implementation for the usage of narcotics for laparoscopic surgery and potential elimination of narcotics for certain patients and procedures.

Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery.

Perioperative pain, increased sympathetic tone, and peripheral vasospasm may be safely managed with regional nerve blockade during microvascular reconstruction in the lower extremity. Limited reports exist in this setting; therefore, we evaluated our use of peripheral nerve catheters (PNCs) during microvascular limb salvage to determine safety and efficacy for both patient and flap. A single-institution, retrospective review of a prospectively maintained database on all patients with lower extremity free tissue transfers between 2012 and 2017 was completed. Patients were matched into groups based on PNC utilization. The use of intravenous narcotics including patient-controlled analgesia (PCA), oral narcotics, antiemetics, length of stay (LOS), associated pain scores, flap-related performance, and patient morbidity was recorded. Of 48 patients who underwent lower extremity free tissue transfer, 35 satisfied criteria for comparison. Of these, PNC was utilized in 83%. The mean pain score in the immediate postoperative period was 3.84 ± 2.47 (10-point Likert scale). PCA and narcotic use were decreased in the PNC group, and no adverse effects of the catheter were identified. Microsurgical outcomes were not adversely affected in comparison. PNC utilization for lower extremity free flap transfer significantly reduced concurrent narcotic use and attained a shorter LOS. The technique provided for safe analgesia during lower extremity free flap reconstructions satisfying the microsurgeon and the anesthesiologist.

Bridging multimodal pain management provides 48-hour pain control in patients undergoing total shoulder replacement

We report our experience with a bridging multimodal pain management program that provides comprehensive 48-hour pain control in patients undergoing total shoulder replacement (TSR). The study included all patients undergoing unilateral TSR by 1 surgeon between May 2015 and April 2017. There were 62 patients (23 men, 39 women) with an average age of 68 years (range 38-92 years). Of these, 31 underwent standard nonconstrained TSR and 31 underwent reverse TSR. The bridging multimodal pain management protocol included scalene block regional anesthesia using 0.25% bupivacaine enhanced with 4 mg of dexamethasone, application of 20 mg of liposomal bupivacaine diluted with 40 mL of normal saline in the periarticular soft tissues at time of closure, scheduled 24 hours of intravenous acetaminophen and ketorolac, and immediate cryotherapy. Parameters measured included hospital length of stay, postoperative use of intravenous narcotics, and 30-day hospital readmission. The median length of stay was 1 day (range, 1-6; average, 1.5 days). Overall, 41 patients (66%) were discharged on postoperative day 1. Intravenous narcotics were required postoperatively in 22 patients (35.5%). There were no 30-day readmissions. This bridging multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients, even for higher-risk patients with American Society of Anesthesiologists Physical Status Classification III (63%). Of the 62 patients, 64% (n = 40) did not require postoperative intravenous narcotics. For properly selected patients, this program may be considered for performing TSR as an ambulatory procedure.

Does Subcutaneous Infiltration of Liposomal Bupivacaine Following Single-Level Transforaminal Lumbar Interbody Fusion Surgery Improve Immediate Postoperative Pain Control?

Study DesignRetrospective case-control study using prospectively collected data.PurposeEvaluate the impact of liposomal bupivacaine (LB) on postoperative pain management and narcotic use following standardized single-level low lumbar transforaminal lumbar interbody fusion (TLIF).Overview of LiteraturePoor pain control after surgery has been linked with decreased pain satisfaction and increased economic burden. Unfortunately, opioids have many limitations and side effects despite being the primary treatment of postoperative pain. LB may be a form of pre-emptive analgesia used to reduce the use of postoperative narcotics as evidence in other studies evaluating its use in single-level microdiskectomies.MethodsThe infiltration of LB subcutaneously during wound closure was performed by a single surgeon beginning in July 2014 for all single-level lumbar TLIF spinal surgeries at Landstuhl Regional Medical Center. This cohort was compared against a control cohort of patients who underwent the same surgery by the same surgeon in the preceding 6 months. Statistical analysis was performed on relevant variables including: morphine equivalents of narcotic medication used (primary outcome), length of hospitalization, Visual Analog Scale pain scores, and total time spent on a patient-controlled analgesia (PCA) pump.ResultsA total of 30 patients were included in this study; 16 were in the intervention cohort and 14 were in the control cohort. The morphine equivalents of intravenous narcotic use postoperatively were significantly less in the LB cohort from day of surgery to postoperative day 3. Although the differences lost their statistical significance, the trend remained for total (oral and intravenous) narcotic consumption to be lower in the LB group. The patients who received the study intervention required an acute pain service consult less frequently (62.5% in LB cohort vs. 78.6% in control cohort). The amount of time spent on a PCA pump in the LB group was 31 hours versus 47 hours in the control group (p=0.1506).ConclusionsLocal infiltration of LB postoperatively to the subcutaneous tissues during closure following TLIF significantly decreased the amount of intravenous narcotic medication required by patients. Well-powered prospective studies are still needed to determine optimal dosing and confirm benefits of LB on total narcotic consumption and other measures of pain control following major spinal surgery.

Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients

BackgroundMultimodal pain management strategies are used for analgesia following pectus excavatum repair. However, the optimal regimen has not been identified. We describe our early experience with intercostal cryoablation for pain management in children undergoing the Nuss procedure and compare early cryoablation outcomes to our prior outcomes using thoracic epidural analgesia. MethodsA multi-institutional, retrospective review of fifty-two patients undergoing Nuss bar placement with either intercostal cryoablation (n=26) or thoracic epidural analgesia (n=26) from March 2013 to January 2016 was conducted. The primary outcome was hospital length of stay. Secondary outcomes included telemetry unit monitoring time, total intravenous narcotic use, duration of intravenous narcotic use, and postoperative complications. ResultsPatients who underwent intercostal cryoablation had a significant reduction in the mean hospital length of stay, time in a monitored telemetry bed, total use of intravenous narcotics, and the duration of intravenous narcotic administration when compared to thoracic epidural patients. Cryoablation patients had a slightly higher rate of postoperative complications. ConclusionIntercostal cryoablation is a promising technique for postoperative pain management in children undergoing repair of pectus excavatum. This therapy results in reduced time to hospital discharge, decreased intravenous narcotic utilization, and has eliminated epidurals from our practice. Level of evidenceRetrospective study – level III.

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center

BackgroundPostoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative. ObjectiveThe aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients’ pain, satisfaction, and hospital length of stay. MethodsIn a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes. ResultsMean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2 %, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185). ConclusionsUsing IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

Periprosthetic Anesthetic for Postoperative Pain After Laparoscopic Ventral Hernia Repair: A Randomized Clinical Trial.

Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established intervention for ventral hernia, but pain control can be challenging. To determine whether instillation of a long-acting local anesthetic between the mesh and the peritoneum after LVHR reduces pain or narcotic requirements. A prospective, double-blind, randomized clinical trial with data collection during a brief hospital stay in a tertiary care, community teaching hospital over 3 years between December 15, 2011, and March 28, 2014. Of 120 screened patients undergoing LVHR in this intention-to-treat analysis, 99 eligible patients were randomized. Forty-two patients received the study drug, and 38 patients received placebo. Patients with a history of chronic narcotic use were excluded. After mesh placement, a long-acting local anesthetic (bupivacaine hydrochloride, 0.50%) or placebo (0.9% normal saline) was injected between the mesh and the peritoneum. Postoperative pain (on a standard scale ranging from 0 to 10), and narcotic medication use (intravenous morphine equivalents). There were no adverse events. Baseline and operative characteristics were similar except that the treatment group was older (61.8 vs 52.3 years, P = .001). After surgery, pain scores in the recovery room (3.2 vs 4.7, P = .003), interval total narcotic use (6.7 vs 12.5 mg, P = .003 at <4 hours and 0 vs 2.7 mg, P = .01 at 8-12 hours), and total intravenous narcotic use (9.2 vs 17.2 mg of morphine sulfate equivalents, P = .03) were significantly less in the treatment group. Administration of a long-acting local anesthetic between the mesh and the peritoneum significantly reduces postoperative pain and narcotic use after LVHR. clinicaltrials.gov Identifier: NCT01530815.

Avicenna (IbnSina) aspect of Ileus

Dear Editor, Ileusis derived from the Greek word 'eileos,' which means twisting, a prevalent and non- prophylactic consequence in major abdominal operations (Jonson W it occurs post-operatively, ileus (PI) is a delay in the return of a normal bowel movement, which typically lasts 3-5 days dependent on the location, 0 to 24 hours in the small intestine, 24 to 48 hours in the stomach, and 48 to 72 hours in the colon respectively (Ianey2004)(RychterC and creation of wind in the intestine may be accumulated inside muscular tissues, which will be followed by pain and intestinal atony and paralysis (IbnSina 2005 p.262). With deference to the above statements previously discussed, this hypothesis purposes that one of the causes for postoperative ileus is wind. Therefore, those drugs, which remove the produced dense wind in the digestive system, may contribute to the return of intestinal movement (peristalsis) in the post-surgical patient more quickly following the operation. Additionally, this theory could possibly be used and studied as a new method for prophylactic purpose and treatment of the patient’s postoperative ileus (PI) state. We would like to continue further discussions on the aspects of Persian traditional medicinal treatment of ileus in future articles. DOI: http://dx.doi.org/10.3126/ijls.v9i5.12709

Clinical evaluation of a silver-impregnated foam dressing in paediatric partial-thickness burns.

Mepilex Ag, a silver-impregnated foam dressing, was introduced to our institution in 2007 and our outcomes in the treatment of paediatric burns were observed to improve significantly. In order to confirm these observations, we wanted to evaluate the results of using the silver-impregnated foam dressing in partial-thickness paediatric burns. In this retrospective study, the St. Christopher's Hospital burn registry was used to identify subjects, who were otherwise in excellent health at baseline, over an18-month period. Outcomes included length of stay, intravenous narcotic use, and time to healing. No direct comparative studies were performed. This was followed by a non-comparative prospective study involving 22 paediatric patients, aged 1-4 years, with partial-thickness burns. This was a sub-study of a larger randomised controlled trial involving adults with partial-thickness burns, comparing the silver-impregnated foam dressing with Silvadene. In the retrospective part of the study, the silver-impregnated foam dressing was used successfully for the treatment of partial-thickness paediatric burns, with few complications and infections, allowing a shorter hospital stay, fewer dressings, and less pain medication than for historical controls. In the non-comparative prospective study, of 22 paediatric patients 50% healed completely within 1 week of treatment. The mean length of stay was 3.77 days and the mean number of dressings used was 1.64. Although narcotic usage was not assessed, patient surveys showed stinging or burning to be recorded as 'never' in 13 patients, 'rarely' in 8 patients, and 'sometimes' in 1 patient. The silver-impregnated foam dressing is effective and safe for use in partial-thickness paediatric burns, eliminating the need for daily dressings. The study was supported by an educational grant from Mölnlycke Health Care.

Zasadność realizacji programów przesiewowych w zakresie wczesnego wykrywania HCV

The objective of the study was to collect the data on undetected hepatitis C virus (HCV) in the frequently hospitalized residents of the Kujawsko-Pomorskie Voivodeship. The analysis focused on empirical data. The research was conducted in 2013 among 6332 citizens of the Kujawsko-Pomorskie Voivodeship who had been hospitalized at least twice. The blood was tested for the presence of anti-HCV antibodies. The diagnostic survey with an anonymous questionnaire was developed and used for the purpose of the study. For the statistical analysis Statistica 10.0 was used. The hypothesis was verified using the Mann-Whitney U test and Chi2 test of independence. A level of statistical significance was assumed at α = 0.05. The results were considered to be statistically significant if the probability fulfilled the inequality of p < 0.05. Positive anti-HCV antigens were detected in 91 (1.44%) examined individuals. The relationship was found between blood transfusions provided before 1992, the use of intravenous narcotics and doping, and minor surgical procedures and the infection. Asymptomatic infection was detected in 91 citizens of the Kujawsko-Pomorskie Voivodeship. The highest risk of HCV infection occurs during small surgery and usage of intravenous narcotics and doping. The percentage of positive results is slightly higher in the group of people with cosmetic and beauty treatments. Planning screening programs special attention should be paid to this group of risk. Blood and blood products transfusions before 1992 were associated with a higher risk of HCV infection. People with above-mentioned interventions should become a particular group of screening program participants. Occupational medicine service plays an important role in prevention.

Acute urinary retention after cesarean delivery: a case-control study.

This study aimed to identify risk factors for postpartum urinary retention (PPUR) after cesarean delivery (CD). A case-control study design was used. Cases of PPUR after CD were identified using billing codes for CD and "urinary retention" and confirmed by chart review. Matched controls were identified in a 2:1 ratio using an obstetrics database and billing data. Patient demographics, operative, and anesthetic data were collected. Fisher exact tests and Wilcoxon rank sum tests were used to determine differences in medical risk factors, postoperative analgesic use, and catheter management between cases and controls. A modified Poisson conditional multivariate regression with robust error variances was used to estimate the odds ratios (ORs) for significant predictors. Thirty-four confirmed cases of PPUR were matched with 68 controls. The mean ages of cases and controls were 31 and 32 years, respectively. Cases and controls differed in gestational age (P = 0.01), diagnosis of diabetes (P = 0.05), and use of postoperative intravenous and oral narcotics (P < 0.01 and P = 0.03, respectively). In a multivariate model including these factors, increasing gestational age was associated with decreased risk of PPUR [OR, 0.07; 95% confidence interval (CI), 0.01-0.48; P < 0.01], whereas use of postoperative intravenous narcotics (OR, 4.51; 95% CI, 1.09-18.67; P = 0.038) and oral narcotics (OR, 4.99; 95% CI, 1.10-22.65; P = 0.037) were associated with increased risk. After matching for obstetric factors, use of postoperative narcotic analgesia was associated with increased risk of PPUR. Other operative and anesthetic factors had no association. Multicenter prospective studies are needed to investigate this association.

The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy

ObjectiveTo determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use. MethodsThis is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA+transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared. ResultsThe analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p=0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p=0.014; day 1: p<0.0001; day 2: p=0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p=0.046; day 2: p=0.008). ConclusionsThe use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.

Fast-track management is safe and effective after bowel resection in children with Crohn's disease

Background“Fast-track” management (FT) challenges traditional postoperative tenets in order to minimize discomfort and optimize inpatient care. We examined the outcomes of consecutively performed laparoscopic-assisted ileocecectomy for Crohn's disease (CD), with particular focus on FT's effects in patients with underlying bowel inflammation. MethodsWe retrospectively reviewed all patients undergoing isolated laparoscopic-assisted ileocecectomy for CD at our institution between 12/2000 and 12/2010, excluding patients with multiple areas of surgical CD, bladder involvement, or age >18years. ResultsSeventy-one patients aged 8–18years underwent isolated laparoscopic-assisted ileocecectomy for CD, of which 45 met FT criteria. Individual practice patterns primarily determined which patients were FT-managed. FT management led to decreased length of stay (LOS), time to first stool, time to full diet, and intravenous narcotic use. No significant difference in complications or disease progression was observed between the two groups during 2-year follow up. ConclusionsOur results suggest that FT is safe and effective in patients with CD. In a chronically ill population, counseling patients and families to expect early discharge is critical to the success of this strategy. Despite CD-related GI pathology, FT patients realized benefits in terms of LOS, time to bowel function, and narcotic use without any increase in complications.

Complications of Liver Resection: Laparoscopic Versus Open Procedures

Minimally invasive surgery for liver resection remains controversial. This study was designed to compare open versus laparoscopic surgical approaches to liver resection. We performed a single-center retrospective chart review. We compared 45 laparoscopic liver resections with 17 open cases having equivalent resections based on anatomy and diagnosis. The overall complication rate was 25.8%. More open resection patients had complications (52.9% vs 15.5%, P < .008). The conversion rate was 11.1%. The mean blood loss was 667.1 ± 1450 mL in open cases versus 47.8 ± 89 mL in laparoscopic cases (P < .0001). Measures of intravenous narcotic use, intensive care unit length of stay, and hospital length of stay all favored the laparoscopic group. Patients were more likely to have complications or morbidity in the open resection group than in the laparoscopic group for both the anterolateral (P < .085) and posterosuperior (P < .002) resection subgroups. In this series comparing laparoscopic and open liver resections, there were fewer complications, more rapid recovery, and lower morbidity in the laparoscopic group, even for those resections involving the posterosuperior segments of the liver.

Bupivacaine for Wound Infusion

Objective: To determine if preperitoneal placement of continuously infusing bupivacaine catheters via the ON-Q PainBuster System® (I-Flow Corporation, Lake Forest, CA) results in decreased postoperative narcotic use in gynecologic oncology patients. Study Design: An institutional review board–approved retrospective study of all patients who underwent open surgery for gynecologic malignancy was conducted at Thomas Jefferson University Hospital, Philadelphia, PA, between January 2007 and January 2011. Patients were divided into 2 groups: (1) control group (patients who did not have the ON-Q PainBuster System placed intraoperatively) and (2) study group (patients who did have the ON-Q PainBuster System placed intraoperatively). The primary outcome was use of narcotics (in morphine equivalents) during the postoperative period. All statistical analyses were performed using SPSS 17.0; a p-value of <0.05 was considered statistically significant. Results: A total of 200 patients was identified—109 control patients and 91 study patients. Baseline characteristics and intraoperative characteristics did not differ significantly. Study patients used significantly lower amounts of narcotics (total narcotic use, intravenous narcotic use, and oral narcotic use). Study patients reported lower average pain scores, required fewer doses of antiemetics, and had fewer diagnoses of small-bowel obstruction and ileus. Wound toxicity and other postoperative complications did not differ between the two groups. Conclusions: Use of the ON-Q PainBuster System in gynecologic oncology surgery results in decreased postoperative narcotic use, without increasing operative time or increasing wound toxicity. (J GYNECOL SURG 28:202)

Percutaneous vertebral augmentation for painful osteolytic vertebral metastasis: a case report

IntroductionVertebral metastases are associated with significant pain, disability, and morbidity. Open surgery for fracture stabilization is often inappropriate in this population due to a poor risk-benefit profile, particularly if life expectancy is short. Percutaneous vertebroplasty and kyphoplasty are appealing adjunctive procedures in patients with malignancy for alleviation of intractable pain. However, these patients have higher risk of serious complications, notably cement extravasation. Described in this report is a case of a painful osteolytic vertebral metastasis that was successfully treated by a novel percutaneous vertebral augmentation system.Case presentationA 42-year-old Caucasian female presented with a history of metastatic lung cancer unresponsive to radiation and chemotherapy with symptoms inadequately controlled by opiates over the previous 6 months. Magnetic resonance imaging and spiral computed tomography with two-dimensional reconstruction showed an osteolytic vertebral metastasis with complete involvement of the T10 vertebral body, extending to the cortical vertebral wall anteriorly and posteriorly. The patient was treated with percutaneous vertebral augmentation (Kiva® VCF Treatment System, Benvenue Medical, Inc, Santa Clara, CA) utilizing a novel coil-shaped polyetheretherketone implant designed to minimize the risk of cement extravasation. After the minimally invasive procedure, bone cement distribution within the vertebral body was ideal, with no observed cement extravasation. No complications were reported, pain completely resolved within 24 hours, and use of intravenous narcotics was progressively diminished within 1 week. Complete pain relief was maintained throughout 4 months of follow-up.ConclusionThe Kiva System represents a novel and effective minimally invasive treatment option for patients suffering from severe pain due to osteolytic vertebral metastasis.

Single-incision laparoscopic cholecystectomy in children: a feasible alternative to the standard laparoscopic approach

Purpose Our aim was to evaluate the outcomes of the single-incision laparoscopic (SIL) cholecystectomy compared with the standard 4-incision laparoscopic (SL) cholecystectomy. Methods A retrospective chart review of consecutive patients undergoing cholecystectomy using the SIL approach from January 2008 to September 2010 was performed. These patients were compared with a cohort who underwent an SL cholecystectomy from January 2007 to June 2009. Demographics, operative times, length of stay, blood loss, and intravenous narcotic use was obtained from the charts. A nonpaired Student's t test was used to determine statistical significance. Results We identified 40 patients in the SIL group and 68 in the SL group. Main diagnosis was cholelithiasis followed by gallstone pancreatitis and cholecystitis. The mean operative time for SIL cholecystectomies was 79.2 minutes vs 63 minutes in the SL group ( P < .006). The average length of stay was 1.9 days in the SIL group vs 2.3 days in the SL group ( P < .24). The mean intravenous narcotic use was 1 dose in the SIL group vs 2.9 doses in the SL group ( P < .007). There were no intraoperative complications. At 1-month postoperative follow-up, all patients had satisfactory recovery. Conclusion Single-incision laparoscopic cholecystectomy is a safe and feasible alternative to the standard laparoscopic approach in children, even in the setting of acute disease.