Search

Background: Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management. Methods: A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs. Results: Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups ( P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported. Conclusions: This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

Background: The aim of this study is to compare the effects of %4 articaine and %2 lidocaine on inferior alveolar nerve block (IANB) for implant surgery in the posterior mandible.Material and Methods: The patients who have inserted implants in the posterior mandible were divided into 2 groups for IANB: lidocaine and articaine. VAS = visual analog scale, pain during surgery and injection, lip numb-ness time, mandibular canal-implant apex distance, age, gender, bone density, implant number, release incision, adjacent teeth, and duration of surgery were analyzed using t-test, Mann-Whitney U test, Spearman's coefficient, and, Pearson's chi-squared test. This trial followed the recommendations of the Consort Statement for reporting randomized controlled trials. Results: 577 patients were included and 1185 dental implants were analyzed. There was no significant difference between the two groups in terms of injection and surgery VAS values (p>0.05). The lip numbness time of lido-caine was 3.06 +/- 3.22min while articaine was found to be 2.96 +/- 3.09min (p>0.05). Mandibular canal-implant apex distance was found to be 2.28 +/- 0.75mm in the articaine and 2.45 +/- 0.86mm in the lidocaine group (p

Objective Intracordal injection under local anesthesia is widely performed; however, few studies show hemodynamic changes in the heart rate, blood oxygen saturation, and blood pressure during intracordal injection under local anesthesia. This study examined changes in vital signs (heart rate, blood oxygen saturation, systolic blood pressure, diastolic blood pressure) during intracordal injection under local anesthesia among high-risk patients and investigated whether intracordal injection under local anesthesia could be safely conducted. Methods A retrospective chart review was adopted as the research design. We investigated the changes in vital signs (heart rate, blood oxygen saturation, blood pressure) before and after intracordal injection with basic fibroblast growth factor (bFGF) preparations under local anesthesia in 46 patients who visited our institution and developed unilateral vocal cord paralysis after a thoracic aortic aneurysm, thoracic aortic dissection surgery, thyroid disease, esophageal disease, idiopathic disease, etc. Results The average operation time for the high-risk group was 3.67 minutes, with the shortest operating time being 2 minutes and the maximum operating time being 13 minutes. The average operation time for the control group was 3.73 minutes, with the shortest operating time being 1 minute and the maximum operating time being 9 minutes. Results before and after intracordal injection with bFGF preparations under local anesthesia for heart rate, blood oxygen saturation, systolic blood pressure, and diastolic blood pressure had P-values of 0.324, 0.394, 0.215, and 0.508, respectively, in the high-risk group, and no significant differences were found. Conversely, heart rate, blood oxygen saturation, systolic blood pressure, and diastolic blood pressure had P-values of 0.057, 0.232, 0.265, and 0.091, respectively, in the control group, and no significant differences were found. Conclusion Intracordal injection under local anesthesia may be safe, even for patients who require blood pressure management after thoracic aortic disease surgery.

Objective: To evaluate the safety profile, including adverse drug reactions and operative complications, of liposomal bupivacaine (LB) use for local anesthesia during functional septorhinoplasty. S...

Purpose To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). Methods A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a pre-operative ultrasound-guided ACB or peri-articular LIA after surgery. Visual Analog Scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, BMI, graft type, and meniscal treatment. Results are presented as mean(95%CI) unless otherwise indicated. Results There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA 2.6 (2.4-2.8) vs. ACB 2.4 (2.1-2.7), p=0.334) and total MMEs were similar (LIA 17.6 (16.4-18.8) vs. ACB 18.5 (17.2-19.8) (MME), p=0.134). Median time to discharge also did not significantly differ (LIA 137.5 (IQR:116-178) vs. ACB 147 (IQR:123-183) (min), p=0.118). Matched sub-analysis (LIA and ACB, n=94) did not reveal significant differences in VAS pain before discharge (LIA 2.4 (2.1-2.7) vs ACB: 2.7 (2.4-3.0), p=0.134) or total MMEs (LIA 18.6 (17.2-20.0) vs. ACB 17.9 (16.4-19.4), p=0.520). Conclusion The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery.

PURPOSE To investigate the effects in cataract surgery using local anesthesia along with a 30% low-concentration nitrous oxide (N2O) anesthesia compared with local anesthesia only. SETTING Saneikai Tsukazaki Hospital. DESIGN Retrospective, consecutive study. METHODS Patients who underwent bilateral cataracts surgeries were enrolled. 37 patients using room air inhalation (Air group) and 45 patients using 30% low-concentration N2O anesthesia (70% oxygen, total 6 L/min) at the surgery's beginning (N2O group) were retrospectively reviewed. Systolic blood pressure (BPs), diastolic blood pressure (BPd), and heart rate (HR) at the surgery's beginning and end, and mean intraoperative oxygen saturation (% SpO2) were examined. Immediately following surgery, a questionnaire using the Visual Analog Scale score was done to determine intraoperative pain, anxiety, memory, and nausea. RESULTS No systemic symptoms and ocular complications requiring treatment were observed. For the N2O and Air groups, changes in BPs were -5.38 ± 11.07(P = 0.01) and 1.27 ± 13.61 mmHg, and HR were -2.24 ± 6.76 and 0.89 ± 5.18 bpm (P = 0.001), respectively; intraoperative SpO2 was 99.05 ± 0.74% and 97.44 ± 1.31% (P < 0.001), intraoperative anxiety was 21.76 ± 23.2 and 37.17 ± 32.79(P = 0.002), and intraoperative memory was 55.24 ± 36.8 and 68.91 ± 33.81(P = 0.01), respectively. No patients experienced intraoperative nausea. There was no statistically difference in BPd and intraoperative pain. CONCLUSIONS Low-concentration N2O anesthesia may not cause respiratory depression, abnormal vital signs, or nausea in cataract surgery. It can suppress intraoperative anxiety and memory and decrease and stabilize vital signs.

Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia).

Ultrasonography is the best examination to explore the flexor tendons anatomy and disorders from the wrist to the digit. It is the only dynamic and comparative tool easily accessible for the surgeon. Indeed, ultrasonography is always available in all the departments of your hospital. Recent innovations permit to see superficially (high-frequency probes), precisely (smaller probes), and with greater softwares for an effective Doppler mode. Ultrasonography becomes a very important help at the outpatient clinic examination. In the future it can be used in the operating room to perform miniinvasive surgery under local anesthesia to control active motion of the gliding of flexor tendons.

Background Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage. Methods This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline. Results Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4–5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported. Conclusions This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Purpose of review Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization. Recent findings A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP. Summary BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Purpose The aim of this study was to compare the clinical efficacy of injection of 2 long-acting amide local anesthetic agents - bupivacaine and ropivacaine with and without 4 mg dexamethasone in patients undergoing third molar extraction. Methods A prospective randomized double blind controlled trial was conducted among 68 patients with impacted mandibular third molars. Group A and B were the control groups and received 1.8 mL of 0.5% bupivacaine hydrochloride and 0.75% ropivacaine hydrochloride, respectively. Group A1 and B1 were experimental groups and received modified twin mixes which were 1.8 mL of 0.5% bupivacaine hydrochloride + 1mL/4mg dexamethasone and 0.75% ropivacaine hydrochloride + 1 mL/4mg dexamethasone, respectively. Visual analog pain scale, mouth opening measurement and facial swelling were assessed at the time of injection and postoperative days 1, 3, and 7. Results The mean visual analogue scale score for pain on local anesthesia injection was found to be less in both experimental groups- Group A1 (2.94) and B1 (2.41) as compared to control groups- Group A (3.59) and B (3.06). The durations of soft tissue anesthesia were higher as compared to their respective controls for both Group A1 and B1. Patients in both control groups A and B had an increased postoperative swelling, pain and trismus. Conclusions Intraoperative and postoperative comfort in both the experimental groups were higher than those for control groups, thereby establishing the clinical efficacy of both modified twin mixes for use in surgical extraction of mandibular third molars.

Background Transperineal magnetic resonance imaging–transrectal ultrasound fusion guided biopsy (MFGB) is an increasingly popular technique due to increasing rates of biopsy-related infections. However, its widespread implementation has been hampered by the supposed necessity of epidural or general anesthesia. Objective To demonstrate the technique, feasibility, and results of transperineal MFGB under local anesthesia, in an ambulatory setting without the administration of prophylactic antibiotics. Design, setting, and participants This single-center study enrolled consecutive biopsy-naive men with a clinical suspicion of prostate cancer into a prospective database between November 2015 and November 2020. Men with Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores 3–5 underwent transperineal MFGB. Surgical procedure Transperineal MFGB was performed in an ambulatory setting under local anesthesia by a single operator. Measurements Procedure-associated adverse events were recorded. Patient discomfort during both the local anesthesia and the biopsy procedure was determined using a visual analogic scale (0–10). Detection rates of grade group (GG) ≥2 prostate cancer and the proportion of men with GG 1 cancer were assessed. Results and limitations A total of 1097 eligible men underwent transperineal MFGB. The complication rate was 0.73% (8/1097); complications comprised five (0.46%) urinary tract infections including one hospitalization and three (0.27%) urinary retentions. In 735 men, the median pain scores were 2 (interquartile range [IQR] 2–3) for the local anesthesia procedure and 1 (IQR 0-2) for the biopsy. Prostate cancer was detected in 84% (926/1097) of men; 66% (723/1097) had GG ≥2 and 19% (203/1097) GG 1. Conclusions Transperineal MFGB can safely be performed as an outpatient procedure under local anesthesia in an ambulatory setting. The detection rate of clinically significant prostate cancer is high, and biopsy is well tolerated. Although no antibiotic prophylaxis was used, the rate of infectious complications is practicably negligible. Patient summary This article shows how tissue samples (biopsies) can accurately be obtained from suspicious regions seen on prostate magnetic resonance imaging via needles inserted in the perineum (skin between the scrotum and the anus) in men with suspected prostate cancer. This technique appears to be very well tolerated under local anesthesia and has a lower risk of infection without antibiotic prophylaxis than the more common biopsy route through the rectum, with antibiotics.

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and minimal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recommendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia; patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia risks; personnel qualifications for administration; recommended patient monitoring protocols; and general risks of anesthesia in the context of abortion care. The scope of these recommendations is based on limited available evidence and considerably relies on existing professional society guidelines and recommendations developed by content experts and reviewers. Further research to compare the efficacy and safety of different regimens is needed.

Background The management of pain resulting from anesthesia injection, tooth extraction and in the period after extraction is of great importance in pediatric dentistry. Objective The aim of this study was to compare the efficacy of the preemptive administration of ibuprofen or acetaminophen with placebo in reducing the pain during injection, extraction and postoperatively in children undergoing primary tooth extraction. Material and methods A randomized, placebo‐controlled, triple‐blinded clinical trial of cooperative children who needed primary molar extraction by local anesthesia. Sixty‐six children aged between 6 and 8 years were randomly assigned to one of three groups: (a) Acetaminophen syrup (320 mg/10 ml); (b) placebo solution; and (c) ibuprofen syrup (200 mg/10 ml). Each of the three solutions was given 30 min before administration of the local anesthetic agent. The Pain level was assessed using the Wong–Baker faces® pain rating scale after injection, extraction, and postoperatively. The Kruskal–Wallis and Mann–Whitney U test were used to evaluate the pain scores between groups at confidence level of 95%. Results The use of preemptive analgesics showed lower pain scores compared to placebo. Additionally, only ibuprofen significantly reduced pain scores compared to placebo at the points immediately after injection (p = 0.001), immediately after extraction (p = 0.0001) and 5 h after extraction (p = 0.002). Conclusion Preemptive usage of ibuprofen reduces injection pain and relieves both extraction and postoperative pain in children undergoing primary tooth extraction. What this paper or case report adds It adds the knowledge regarding pain relief of injection and extraction in children. Preemptive analgesic medications have a beneficial effect on alleviating postoperative pain following tooth extraction in children. Ibuprofen is an effective analgesic for postoperative pain relief in children undergoing primary tooth extraction. Why this paper or case report is important to pediatric dentists Pediatric dentists may consider preemptive ibuprofen in children before injection and extractions. Identifies that Ibuprofen is an effective method of reducing postoperative pain.

Objective Pulsatile tinnitus (PT) caused by an aberrant artery is rare. We report an unprecedented cause of PT resulting from an aberrant artery coursing the mastoid surface, and qualitatively discuss the pathophysiology of PT. Methods This case study reports a 41-year-old woman who presented with persistent PT at her right retromastoid region. Contrast-enhanced computed tomography revealed an aberrant branch of the artery that coursed over the cortex of the mastoid bone. Surgical ligation of this aberrant artery was performed under local anesthesia. Results Intraoperative findings suggested that PT transmitted via bone-conduction route due to the direct contact of the vascular and mastoid surface. PT was completely resolved upon surgical removal of this causative segment. Ultrasonographic and hemodynamic analysis showed that the turbulent kinetic energy and high regional wall pressure were the major contributory factors causing PT. Spectro-temporal analysis showed that PT fluctuates at frequency 500~2000 Hz, which differs from those of venous PT. Conclusion Judicious preoperative and intraoperative assessments of PT ensure the surgical efficacy of PT. Objective ultrasonographic and computational studies can provide detailed hydroacoustic characteristics of PT.

OBJECTIVES Different anesthesia techniques are used for surgical implantation of paddle lead electrodes for neurostimulation through a laminectomy. We wanted to evaluate the use of dexmedetomidine as sedative for this procedure in a series of patients. Second, we wanted to verify whether the stimulation pattern and position of the electrode had to be changed during the procedure guided by the patient's feedback. MATERIAL AND METHODS Twenty-five consecutive patients received surgical implantation of a spinal cord stimulation electrode under conscious sedation using dexmedetomidine and local anesthesia. We evaluated the effects of the administered drug, the patient comfort, and the adequacy of the stimulation pattern. RESULTS Twenty-four patients completed the procedure with only dexmedetomidine and local anesthetic. Infusion was started on average 55 minutes (sd 29) prior to incision. The mean dose of lidocaine was 430 mg (sd 95). There were no significant hemodynamic changes. Median time to reach Modified Aldrete's score postoperative was 67 minutes (sd 38). In 46% of the patients, the position of the electrode was changed guided by the feedback of the patient. More than half of the patients remember most details of the procedure. Only four patients mentioned substantial discomfort and only three would definitely not want to undergo this procedure again. CONCLUSIONS Implantation of spinal cord stimulation electrodes through a surgical laminectomy using dexmedetomidine is a safe and feasible procedure with adequate comfort for patient and surgeon. This way of working increases the optimal position of the electrode resulting in the most convenient stimulation pattern and avoiding revisions.

While Bartholin gland abscesses are less commonly seen outpatient pathology, prompt diagnosis and treatment are essential to preventing serious complications such as sepsis and rectovaginal fistula. Owing to an unacceptably high recurrence rate, simple incision and drainage is insufficient for primary treatment; preferably, placement of a Word catheter or Jacobi ring device to reepithelize the duct may be done under local anesthesia in an outpatient clinic. Destruction of the gland through silver nitrate application or alcohol sclerotherapy is an alternative. Marsupialization is often reserved for recurrent cases, although can be offered as primary management in some situations.

Introduction This trial aimed to investigate the effectiveness of microosteoperforations (MOPs) in overall time taken for alignment of maxillary anterior crowding and to evaluate the alignment improvement percentage within 6 months between MOPs and control groups. Methods Thirty adult participants (25 females and 5 males; mean age, 22.66 ± 3.27 years) with moderate upper labial segment crowding were randomly assigned into intervention and control groups using block randomization. All participants had first premolar extractions, bonded conventional fixed appliances, and 0.014-in, followed by 0.018-in nickel-titanium archwire placement for initial alignment. The intervention group received a 3-mm deep MOPs procedure under local anesthesia using a Propel device (Propel Ortho Singapore, Pte, Ltd, Winstedt Rd, Singapore) on the labial attached gingivae of maxillary incisors at monthly visits until complete alignment. Little's irregularity index was used to assess the overall changes and measure the change of tooth alignment of the 6 maxillary anterior teeth. Assessor blinding was employed. Results There was no statistically significant difference in the median overall alignment duration between MOPs and control groups (139 days [95% confidence interval, 115.32-161.83] vs 143 days [95% confidence interval, 107.12-179.74]; hazard ratio, 0.829; P = 0.467). The MOPs procedure had no significant effect on the alignment duration (P = 0.657) and no overall significant difference in alignment improvement percentage among 2 groups on the basis of time (F = 2.53; P = 0.124). No harm was encountered. Conclusions The application of MOPs is no more effective in accelerating initial orthodontic alignment than conventional treatment. Trial registration This trial was registered at the ISRCTN registry with the study ID ISRCTN15080404. Protocol https://doi.org/10.1186/ISRCTN15080404 . Funding This work was supported by the Postgraduate Trust Fund, Faculty of Dentistry, Universiti Teknologi MARA .

OBJECTIVES/HYPOTHESIS Evaluation of the clinical outcomes after 6 months of treatment with a novel adjustable implant, the APrevent® Vocal-Implant-System (VOIS), in conjunction with medialization thyroplasty (MT) in patients with unilateral vocal fold paralysis. STUDY DESIGN Prospective case series study at single tertiary referral center. METHODS Preoperative and 1 week, 7 weeks, and 6 months postoperative glottal efficiency (maximum phonation time [MPT]), voice quality (including GRBAS-scores and acoustic parameters) and self-perceived voice-related handicap (voice handicap index [VHI-30]) were measured and analyzed, whereas type of vocal fold closure was evaluated and determined by flexible videolaryngoscopy based on Sodersten and Lindestad classification (Wilcoxon signed-rank test). RESULTS Thirteen patients underwent MT with VOIS under local anesthesia. Six months after surgery, the VHI-30 and MPT had improved from a preoperative mean of 75.0 ± 22.9 and 2.7 ± 2.1 s to a postoperative mean of 20.6 ± 19.7 and 6.3 ± 4.0 s, respectively. The mean GRBAS score improved from preoperative scores of Gpreop = 2.7, Rpreop = 2.6, Bpreop = 2.6, Apreop = 2.2, and Spreop = 2.0 to Gpostop = 0.3, Rpostop = 0.3, Bpostop = 0.2, Apostop = 0.2, and Spostop = 0.3 at 6 months postoperatively. Improved glottal closure was achieved in all patients (n = 13). Five patients received postoperative adjustment for the optimization of voice quality and glottal closure. No intra- or postoperative complications were observed. Significant improvements in acoustic parameters, including percentage jitter, percentage shimmer, and signal-to-noise ratio, were also observed after MT. All results were statistically significant (P .8). CONCLUSIONS APrevent® VOIS-Implantation is a safe procedure with good voice outcomes. Postoperative adjustments can be performed smoothly to optimize voice quality and glottal closure. LEVEL OF EVIDENCE III Laryngoscope, 2021.

Background Digit replantation under wide-awake local anesthesia is a challenging method, and there are only a few works of literature on this procedure. This article describes the authors' clinical experience in finger replantation under wide-awake local anesthesia compared to general anesthesia. Methods Fifty-one patients who received single finger replantation after initial sharp amputation were included in the study of whom 16 received wide-awake local anesthesia and 35 general anesthesia treatment. The indications for wide-awake local anesthesia were sharp amputation injury, estimated operation time less than 3 hours, and cooperative patients. The wide-awake local anesthesia was performed with 1% or 2% lidocaine infiltrated at the volar midpoint of the metacarpophalangeal joint of the affected digit without sedation medications. Demographic data included surgical outcome, waiting time, operation time, and hospital stay. Results A total of 51 consecutive patients were included in this study. There were significantly shorter waiting times and operation times in the wide-awake local anesthesia group. The other parameters showed no significant differences. The overall success rate was 76.47 percent, with a mean overall operation time of 206 minutes. Conclusions In selected patients, finger replantation can be successfully performed under wide-awake local anesthesia, which has lower anesthesia risk and fewer medical expenses than general anesthesia. The method is feasible for single-digit replantation. Therefore, the finger replantation under wide-awake local anesthesia is a practicable alternative to general anesthesia. Clinical question/level of evidence Therapeutic, III.

Background Neonatal curettage of large to giant congenital melanocytic nevi (L-GCMN) is a simple, minimally invasive procedure typically performed within the first 2 weeks of life. Objectives To retrospectively review our experience with serial curettage of L-GCMN in the neonatal period performed under local anesthesia and their long-term outcomes. Methods Curettage was performed by a single pediatric dermatologist on nine neonates with L-GCMN under local anesthetic and with oral analgesia between 2002 and 2016 in Red Deer, Alberta, Canada. Patient charts were reviewed retrospectively to assess patient and procedure characteristics, tolerability, safety, cosmetic and functional outcomes, and malignant transformation. Results Patients were treated with an average of 6 curettage sessions (range 3 to 15) to remove the majority or entirety of the nevus. All patients tolerated local anesthesia well. The most common adverse event of the procedure was transient neutropenia. Two patients developed positive bacterial cultures without clinical signs of infection, treated with antibiotics. All curetted specimens demonstrated benign pathology. Patients were followed annually thereafter, for an average of 6 years. Eight patients with L-GCMN of the trunk had minimal to partial repigmentation with good cosmetic outcome. One patient had recurrence of a facial nevus. None of the patients developed cutaneous malignant melanoma. Conclusions Curettage appears to be a safe and effective treatment option for select cases of L-GCMNs of the trunk. We do not recommend the procedure for face or scalp CMN. This procedure can be performed under local anesthesia with serial curettage to avoid potential risks of general anesthesia.

Objective The purpose of this study is to determine whether a Transversus Abdominis Plane (TAP) block can reduce donor site morbidity among pediatric patients undergoing iliac crest bone grafting for repair of their alveolar cleft. Design This retrospective cohort study was carried out at the Division of Dentistry at the Montreal Children's Hospital. Medical charts of patients who underwent alveolar cleft bone grafting between January 2011 and January 2021 were reviewed and they were divided into two groups, intraoperative TAP block and intraoperative local anesthesia infiltration (control group). The outcomes measured were patients’ post-operative pain at the donor site, in-hospital narcotics requirements and length of stay. Results A total of 66 patients were included. There were no significant differences in pain scale among the TAP group and control group [1.9 (SD 2.5) and 1.3 (SD 2.1), respectively ( p = 0.23)]. The mean length of stay for both groups was 1 day. Interestingly, there was a significant higher proportion of patients who required in-hospital opioids (morphine) in the TAP block group when compared to the control group ( p = 0.03). Conclusions The results of our study suggest there may be no role for a TAP block in reducing pain and improving opioid stewardship.

PURPOSE OF REVIEW Prostate biopsy is a very commonly performed office procedure leading to the diagnosis of the most prevalent solid-organ malignancy in American men. Although the transrectal technique for prostate biopsy remains the gold standard, there is increasing interest in the transperineal approach as it offers a clean, percutaneous approach that significantly decreases the risk for infection. In this review, we discuss emerging developments in transperineal prostate biopsy that may optimize the way biopsies are performed in clinical practice. RECENT FINDINGS Similarly, to transrectal biopsy, the transperineal approach also allows for the performance of systematic and MRI-targeted biopsy cores. As transperineal biopsy obviates the translocation of rectal bacteria to the prostate or bloodstream, in contrast to transrectal biopsy, it is feasible to forgo peri-procedural antibiotics in accordance with professional guidelines. This may attenuate antimicrobial resistance that may be associated with augmented prophylaxis. In addition, although transperineal biopsy may be traditionally performed under general anesthesia using a template grid, it may also be performed freehand under local anesthesia or sedation. Avoiding prophylactic antibiotics and general anesthesia as well as reducing infections/hospitalizations for transperineal biopsy scaled nationally will likely result in significant healthcare savings. SUMMARY Transperineal biopsy with combined systematic and MRI-targeted cores, offers several advantages over conventional transrectal biopsy. Transperineal biopsy under local anesthesia and without periprocedural antibiotic is emerging as a promising method for prostate cancer diagnosis and surveillance.

Background. The presence of opioid receptors around the peripheral nerves offers the possibility of providing postoperative analgesia, thereby encouraging the study of the effect of opioids in combination with local anesthesia (LA). Studies have also reported the efficacy of peripherally administered opioids in achieving adequate analgesia in regions with inflammation. Applying the concept of peripheral opioid receptors, our study aimed to evaluate the effectiveness of opioid analgesia in managing postoperative pain. The split-mouth study was carried out to evaluate the efficacy of buprenorphine added to lidocaine 2% in providing postoperative analgesia after the surgical extraction of the impacted mandibular third molar. Materials and Methods. We conducted a randomized, double-blinded, split-mouth trial among 21 patients with impacted mandibular third molars bilaterally. In all patients, bilateral impacted mandibular third molars were extracted at different periods. The primary outcomes assessed were postoperative analgesia by the VAS score and the number of rescue analgesics consumed by patients at 24, 48, and 72 hours of interval via a questionnaire. Results. There was a statistical significant difference in postoperative analgesia duration at 24 (P = 0.012) and 48 hours (P = 0.024), respectively, between the test and control group. Even though the mean number of rescue analgesics consumed by the test group was less than that of the control group, no significant difference was seen. Conclusion. Buprenorphine added to lidocaine 2% showed a minimal decrease in the pain score and duration of postoperative analgesia with no difference in the frequency of rescue analgesics consumed between the test and control.

In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence.We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia.We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year.The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Background The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. Methods A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. Results Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. Discussion Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors’ experience.

BackgroundThe best anesthetic management strategy for patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains uncertain. Most studies have focused on anterior–circulation stroke caused by large artery occlusion. Nevertheless, limited data are available on the appropriate choice of anesthetic for acute basilar artery occlusion (BAO). We aimed to investigate the effect of anesthetic method on clinical outcomes in patients with BAO undergoing MT.MethodsPatients undergoing MT for acute BAO in the BASILAR registry (Acute Basilar Artery Occlusion Study) were included. We divided patients into three groups according to the anesthetic technique used during MT: general anesthesia (GA), local anesthesia (LA), and conscious sedation (CS). Propensity score matching was performed to achieve baseline balance.Results639 patients were included. GA was used in 257 patients (40.2%), LA was used in 250 patients (39.1%), and CS was used in 132 patients (20.7%). After 1:1 matching, favorable outcome, mortality, and hemorrhagic transformation rates, as well as modified Rankin Scale (mRS) score at 90 days, did not differ between the GA, LA, and CS groups.ConclusionsThe choice of anesthetic strategy, GA, LA, or CS, did not affect the clinical outcomes of patients with acute BAO treated with MT in the BASILAR registry.

Objective There are many adults with cleft lip deformities in developing countries. This is due to the lack of public awareness, social stigma, distance from the health center, and parents' financial condition. Lip repair under local anesthesia is safe, cost-effective and would be beneficial for the underprivileged population. Design A retrospective cohort study with follow-up of 1 to 8 years Setting Academic Hospital. Patients/Participants Cleft lip repair was performed in 252 patients of age more than 12 years from 2012 to 2019. Patients with cleft palate, cardiopulmonary disease, who did not consent for the procedure while awake were excluded. Interventions Cleft lip surgery done under local anesthesia Main Outcome Measures Outcome measures were patients’ self-satisfaction and comments of peer. Results Two hundred fifty-two primary cleft lip operations were done in 168 male and 84 female patients. The mean age was 23.62 years, and the mean weight was 49.66 kg. Unilateral was 227, Bilateral cleft lip 25. The postoperative period was uneventful. No case of wound dehiscence or wound infection was observed. Patients were discharged on the same day, except the ones who traveled a long distance. Conclusion Cleft lip repair in adults under local anesthesia is safe and cost-effective.

PURPOSE The purpose of this study was to report the indications, ocular and systemic comorbidities, and surgical outcomes of corneal transplantation in patients older than 90 years. METHODS A retrospective review was conducted to identify individuals 90 years and older who underwent corneal transplantation surgery at the Bascom Palmer Eye Institute between January 2013 and October 2020. Outcomes included best-corrected visual acuity and graft survival over time. Paired t tests were used to compare visual acuity preoperatively versus postoperatively. Graft survival was evaluated with Kaplan-Meier curves. RESULTS Fifty-eight eyes of 52 consecutive individuals were included. The mean age of individuals was 92 ± 2 years; 26.9% were male; and 48.1% self-identified as non-Hispanic White and 38.5% as Hispanic. Postoperative follow-up was 14.7 ± 12.1 months. Of the 58 eyes, 44.8% (26/58) underwent penetrating keratoplasty, 46.6% (27/58) Descemet stripping automated endothelial keratoplasty, and 6.9% (4/58) keratoprosthesis. All surgeries were performed under monitored local anesthesia, without major complications. Surgical indications included pseudophakic bullous keratopathy (36.2%), glaucoma-associated corneal decompensation (27.6%), Fuchs endothelial dystrophy (25.9%), and perforated corneal ulceration (19.0%). The best-corrected visual acuity improved by 0.32 (95% confidence interval 0.14-0.50; P < 0.01) as early as 1 month postoperatively, and vision gains were sustained for at least 12 months. Graft survival probability at 12 months was 88%. CONCLUSIONS Corneal transplantation is a safe and successful procedure in restoring the visual acuity for patients older than 90 years after careful preoperative evaluation. Further research is needed to evaluate the impact of corneal transplantation on quality of life in patients in the 10th decade of life.

Objective To report our experiences with an extraction technique using a prebent, curved needle placed under deeply located single-rod implants to aid in removal. Study design We conducted a retrospective case series of all patients who were referred for removal of a deeply located or nonpalpable implant to one single specialized center between 2002 and 2019 by screening the database of the private office for “complex implants removals” or “nonpalpable implant” as a result for consultation. After implant-localization via high-resolution ultrasound, we performed a standard incision along the axis of the rod under local anesthesia. We fixed the rod by insertion of a curved needle directly beneath it piercing it through the tissue to the opposite side of the skin. After dissection of the subcutaneous tissue, we palpated the rod above the needle, grasped and removed it. In case of subfascial or intramuscular locations, we applied retractors and opened the fascia along the axis of the device to attempt removal. Results Of 117 referrals, medical records of 95 patients provided sufficient information to be included in our analysis. We could not palpate 81 (85%) devices and questionably palpate 14 (15%) implants. We successfully extracted all implants using this technique with an average removal duration of 30 minutes (SD +/- 6.8). Five (5.3%) patients noted intraoperative discomfort with 3 of them describing transient dysesthesia in the fingers innervated by the median nerve, which disappeared within a maximum of 48 hours. Conclusion Following the described protocol, this novel technique reliably facilitates removal of nonpalpable or deeply located etonogestrel implants. Implications This series of nonpalpable implants, all of which have been removed with the same standardized technique provides evidence that the given protocol permits successful extraction.

Objectives Patients undergoing subcutaneous implantable cardioverter-defibrillator (S-ICD) placement usually experience substantial perioperative pain. The aim of the present study was to investigate the effect of transversus thoracic muscle plane block combined with serratus anterior plane block in patients undergoing S-ICD placement. Design Double-blind, randomized controlled study. Setting First Affiliated Hospital of Nanchang University. Participants Patients aged 18-to-80 years who underwent new S-ICD placement. Interventions A group of 80 patients randomly were allocated to either the regional group (R group) or local group (L group). Measurements and Main Results The primary endpoint was pain during S-ICD placement. The secondary outcome measures included pain intensity at rest and after movement one, three, six, 12, 24, and 48 hours after surgery; the dose of dexmedetomidine and remifentanil during surgery; 24-hour ketorolac administration; postoperative sufentanil dosage; the total duration of hospitalization; intraoperative sedation; and the incidence of hypoxemia. Mean Critical-Care Pain Observation Tool scores were significantly higher during pocket creation, lead tunneling A, and lead tunneling B in the L group compared with the R group. The R group required significantly less intraoperative dexmedetomidine, intraoperative remifentanil, postoperative sufentanil, and ketorolac consumption. Compared with the R group, the L group had higher Numerical Rating Scale pain scores at 24 hours after surgery both at rest and after movement. The intraoperative Ramsay score and the incidence of hypoxemia were significantly higher in the L group compared with the R group. Conclusions Ultrasound-guided transversus thoracic muscle plane block and serratus anterior plane block resulted in lower intraoperative Critical-Care Pain Observation Tool scores and the need for less adjunctive pain medication and sedation compared with local anesthesia in patients undergoing S-ICD placement.

PURPOSE Infiltration techniques are used as an adjuvant to regional anesthesia. In this study, we evaluated the efficacy of the superficial cervical plexus nerve block, as an alternative to local infiltration techniques; in the management of mandibular fractures and peri-mandibular space infections. METHODS A prospective randomized controlled trial was conducted on 24 patients having either mandibular fractures or peri-mandibular space infections; and were scheduled for surgery under regional anesthesia (eg, inferior alveolar nerve block, long buccal nerve block). The control group involved delivering a combination of regional anesthesia along with local infiltration. The experimental group received regional anesthesia with a superficial cervical plexus nerve block. The following parameters were studied: pain, onset and duration of anesthesia, time interval until first analgesic request, pulse rate and blood pressure [at different time intervals]. RESULTS Intergroup comparison was done using unpaired t-test. Intragroup comparison was done using repeated measures ANOVA (for >2 observations), followed by a post hoc test. The superficial cervical plexus nerve block group showed highly statistically significant (P < .01) improvement in terms of intra-operative pain at 30 minutes, duration of anesthesia, intraoperative anesthetic requirement, time interval until first analgesic request and intraoperative diastolic blood pressure at 10 minutes. CONCLUSION It can be concluded that the combination of a regional anesthesia technique with a superficial cervical plexus nerve block is an alternative and safe technique for patients undergoing surgery for mandible fractures and perimandibular space infections, with clear advantages over local infiltration.

Background. Epidural anesthesia used in percutaneous endoscopic lumber discectomy (PELD) has the risk of complete neurotactile block. Patients cannot timely respond to the operator when the nerve is touched by mistake, so the potential risk of nerve injury cannot be avoided. According to pharmacodynamics, with the decrease of local anesthetic concentration, the nerve tactile gradually recovered; however, the analgesic effect also gradually weakened. Therefore, it is necessary to explore an appropriate concentration of local anesthetics that can keep the patients’ nerve touch without pain. By comparing the advantages and disadvantages of 0.4% ropivacaine epidural anesthesia, local anesthesia and intravenous anesthesia on intraoperative circulation fluctuation, the incidence of salvage analgesia and the incidence of nerve non-touch, the feasibility of using low concentration epidural anesthesia in PELD to obtain enough analgesia and avoid the risk of nerve injury was confirmed. Methods. 153 cases of intervertebral foramen surgery from October 2017 to January 2020 were selected and divided into local anesthesia group (LA group), 0.4% ropivacaine epidural anesthesia group (EA group), and intravenous anesthesia group (IVA group) according to different anesthesia methods. The changes of blood pressure and heart rate, the incidence of rescue analgesia and nerve root non-touch were compared among the three groups. Results. The difference of map peak value among the three groups was statistically significant ( P < 0.001 ); pairwise comparison showed that the map peak value of the LA group was higher than that of the EA group ( P < 0.001 ) and IVA group ( P < 0.001 ), but there was no statistical significance between the EA group and IVA group. The difference of HR peak value among the three groups was statistically significant; pairwise comparison showed that the HR peak value of the LA group was higher than that of the EA group ( P < 0.001 ) and IVA group ( P < 0.001 ), but there was no statistical significance between the EA group and IVA group. There was significant difference in the incidence of intraoperative hypertension among the three groups ( P < 0.05 ); pairwise comparison showed that the incidence of intraoperative hypertension in the EA group was lower than that in the LA group ( P < 0.05 ), while there was no significant difference between the IVA group, EA group, and LA group. There was significant difference in the incidence of rescue analgesia among the three groups ( P < 0.01 ); pairwise comparison showed that the incidence of rescue analgesia in the EA group was lower than that in the LA group ( P < 0.05 ) and IVA group ( P < 0.05 ), but there was no significant difference between the LA group and IVA group. Due to the different analgesic mechanisms of the three anesthesia methods, local anesthesia and intravenous anesthesia do not cause the loss of nerve tactile, while the incidence of nerve tactile in 0.4% ropivacaine epidural anesthesia is only 2.4%, which is still satisfactory. Conclusion. Epidural anesthesia with 0.4% ropivacaine is a better anesthesia method for PELD. It not only has a low incidence of non-tactile nerve, but also has perfect analgesia and more stable intraoperative circulation.

OBJECTIVE Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains challenging. Here, we investigated the risk factors for complications after ST by focusing on the application of CAT during ST. DESIGN A retrospective cohort study with medical records from 2009 to 2020. SETTING A single-center study. PARTICIPANTS This study included patients who had undergone ST at the Department of Otolaryngology of our hospital MAIN OUTCOME MEASURES: The primary outcomes were the incidence of complications and blood test results. Secondary outcomes were risk factors for postoperative complications. RESULTS We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly longer activated partial thromboplastin time (p=0.002) and a higher prothrombin time-international normalized ratio (p=0.006) compared to antithrombotic naive patients, no statistically significant intergroup differences were observed for the risk of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p=0.01) and ST for airway emergency (p=0.02) significantly increased the risk of early postoperative complications. CONCLUSION These results suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergencies.

This article is to introduce office-based salvage revision of impending rhinostomy failure after endoscopic dacryocystorhinostomy (EN-DCR), using a microdebrider. The authors conducted retrospective medical chart review of 27 eyes of 26 patients who underwent microdebrider treatment for impending rhinostomy failure in an office setting. After local anesthesia, obstructive soft tissue, interfering with ostium function (granuloma, cicatrization, synechia), was treated with a microdebrider (Osseoduo s120, Bien-Air Surgery, Le Noirmont, Switzerland) within 6 months after primary EN-DCR. Anatomical improvement and functional relief of epiphora were evaluated after revision. The causes of impending rhinostomy failure were granuloma formation (17/27 eyes, 63.0%), cicatrization (8/27 eyes, 29.6%), and synechial formation (2/27 eyes, 7.4%). The surgery did not exceed 5 min in all cases, and partial damage to pre-placed silicone tubes occurred in the first two cases (7.4%). Salvage revision resulted in anatomical success in all eyes, based on patent syringing and a positive functional endoscopic dye test. All cases showed improvement of epiphora after revision surgery. Office-based salvage revision using a microdebrider provided effective management of impending rhinostomy failure during early follow-up period after primary EN-DCR. It enabled prompt management of excessive wound healing interfering with ostium function, while performing the routine postoperative nasal debridement.

Purpose To evaluate the safety and efficacy of percutaneous ultrasound (US)-guided direct puncture of a reconstructed gastric conduit after esophagectomy for performing a percutaneous radiologic gastrojejunostomy. Materials and Methods Between 2014 and 2020, 26 consecutive patients with esophageal cancer (mean age, 70 years ± 8.3) with a total of 27 attempts of percutaneous radiologic gastrojejunostomy for postsurgical enteral feeding at the National Cancer Center Hospital were included in this study. One patient required a repeat procedure because of persistent anorexia after the removal of the first tube. All patients except 1 had a gastric conduit reconstructed via a retrosternal route. All procedures were performed under local anesthesia with moderate sedation and analgesia. A gastric conduit was directly punctured with an 18-gauge needle under ultrasonographic guidance, followed by feeding tube insertion into the proximal jejunum. Technical details of the procedures, technical success (defined as adequate tube placement), procedure-related complications, and clinical outcomes were reviewed. Results The mean procedure time was 25 minutes ± 15, and technical success was obtained in every attempt. Minor complications included mild local pain (n = 7), unintentional tube removal (n = 2), local abdominal wall hematoma (n = 1), and superficial cellulitis (n = 1); no major complications were observed. During a mean follow-up period of 118.3 days ± 85.8, 13 patients resumed oral intake, and the feeding tube could be removed in 4 patients. No procedure-related deaths occurred. Conclusions The US-guided direct puncture technique is feasible for percutaneous gastrojejunal tube insertion in postsurgical patients with esophageal cancer with gastric conduit reconstruction.

Objectives The main study endpoint was tolerance of stapedotomy under local anesthesia with sedation and under general anesthesia using stress and quality of life assessment questionnaires. Secondary endpoints comprised operative time and functional results. Material and method In a consecutive series of stapedotomy patients operated on over a 12-month period, quality of life and perioperative stress were analysed by 3 questionnaires: the Glasgow Benefit Inventory, Cohen's perceived stress scale and the Post-traumatic stress disorder checklist scale. Questionnaire responses and audiometric data were compared between groups treated under local anesthesia with sedation and under general anesthesia. Results Twenty-two patients were included in the local anesthesia with sedation group and 6 in the general anesthesia group. There was no difference between the groups for quality of life, onset of post-traumatic stress, or perceived pre- and postoperative stress. There was also no difference in operative time. The audiometric data confirmed the reliability of stapedotomy. Stapedotomy under local anesthesia with sedation improved air conduction with ≤ 10 dB air-bone gap (ABG), comparable to results under general anesthesia. The rate of ABG ≤ 10 dB was 71.4%; no labyrinthisation was observed. Conclusion Under local anesthesia with sedation, stapedotomy was well tolerated without increasing the stress associated with otosclerosis surgery. By correcting hearing loss, the procedure improves quality of life.

Background The optimal anesthesia modality for umbilical hernia repair is unclear. We hypothesized that using local rather than general anesthesia would be associated with improved outcomes, especially for frail patients. Methods We utilized the 1998-2018 Veterans Affairs Surgical Quality Improvement Program to identify patients who underwent elective, open umbilical hernia repair under general or local anesthesia. We used the Risk Analysis Index to measure frailty. Outcomes included complications and operative time. Results There were 4958 Veterans (13%) whose hernias were repaired under local anesthesia. Compared to general anesthesia, local was associated with a 12%-24% faster operative time for all patients, and an 86% lower (OR 0.14, 95%CI 0.03-0.72) complication rate for frail patients. Conclusions Local anesthesia may reduce the operative time for all patients and complications for frail patients having umbilical hernia repair.

Background The WALANT (wide-awake local anesthesia with no tourniquet) technique was based on local infiltration of lidocaine and epinephrine. This technique has rapidly gained popularity in recent years and can perform most hand operations. This study aimed to investigate the time spent on anesthesia and operation and perform an economic analysis among general anesthesia, wrist block with a tourniquet, and the WALANT technique for the internal fixation of metacarpal fractures. Methods We retrospectively reviewed all the single metacarpal fractures managed with the same procedure, open reduction, and internal fixation with the plate between January 2015 and December 2019. They were divided into three groups according to the method of anesthesia: (1) general anesthesia (GA group), (2) wrist block with a tourniquet (WB group), and (3) WALANT technique (WALANT group). We collected and analyzed patient demographic data, perioperative or postoperative complications, number of hospital days, and postoperative functional recovery assessment. Results A total of 63 patients met the inclusion criteria, including 24 in the GA group, 28 in the wrist block group using a tourniquet, and 11 in the WALANT group. There were no complications during the operation and follow-up in each group. The GA group had an average of 32.8 min of anesthesia time, significantly longer than the other two groups. However, there is no significant difference regarding surgical time among the presenting three groups. The discomfort of vomiting and nausea after surgery occurred in 20 patients in the GA group (38.1%). Nevertheless, there was no postoperative vomiting and nausea present in both the WB and WALANT groups. Most patients achieved full recovery of pre-injury interphalangeal and metacarpophalangeal motion at the final assessment of functional recovery. Conclusions The patients undergoing metacarpal fixation surgery under WALANT or WB had significantly less anesthesia time and postoperative vomiting and nausea. Moreover, there was no difference in surgical time and intraoperative complications. The time-related reduction improved the utilization of the operation room for additional cases. The reduction of the preoperative examination, anesthesia fee, postoperative recovery room observation, and hospitalization can effectively reduce medical costs. Furthermore, the WALANT group is more acceptable because of no tourniquet, which commonly causes discomfort.

Background and objectives We aimed to investigate the effects of two different anesthetic techniques in our patients who underwent transcatheter aortic valve implantation (TAVI). Methods In this study, 303 patients who underwent TAVI procedure with a diagnosis of severe aortic stenosis between January 1, 2012 and December 31, 2018 were retrospectively evaluated. The patients were divided according to the type of anesthesia given during each procedure as; general anesthesia (GA), local anesthesia (LA). Results LA was preferred in 245 (80.8%) of 303 patients who underwent TAVI, while GA was preferred in 58 patients (19.1%). Median ages of our patients who received LA and GA were 83 and 84, respectively. The procedure and anesthesia durations of the patients in the GA group were longer than the LA group (p< 0.00001, p< 0.00001, respectively). Demographic and pre-operative clinical data were similar in comparison between two groups (p> 0.05) except for peripheral artery disease. Hypertension was the most common comorbidity in both groups. While the number of inotrope use was significantly higher in patients who received GA (p< 0.00001), no significant differences were found between LA and GA patients in terms of major complications and mortality (p> 0.05). Intensive care and hospital stays were significantly shorter in the LA group (p= 0.001, p= 0.023, respectively). Conclusion The anesthetic technique of TAVI procedure did not have a significant effect on outcomes including; complications, mortality and success of the procedure. LA provides shorter duration of procedure and hospital stay.

To determine whether intrarectal local anesthesia (IRLA) with heated lidocaine gel provides pain reduction during transrectal ultrasound (TRUS)-guided prostate biopsy. We conducted a randomized-controlled study with 153 participants who underwent TRUS-guided, systematic 12-core prostate biopsy from May 2018 to June 2019. These participants were divided into three test groups. Before prostate biopsy, group A (51 patients) received no local anesthesia, group B (51 patients) received IRLA with 20 mL 2% lidocaine gel stored at room temperature, and group C (51 patients) received IRLA with heated (40 ℃) 20 mL 2% lidocaine gel. Pain was assessed using the 0–10 visual analogue scale (VAS) at three time points: VAS-1: during probe insertion, VAS-2: during biopsy, VAS-3: 30 min after the procedure. Complications during and after the procedure were evaluated. The mean VAS-2 score was significantly lower in group C compared to groups A and B (A, 4.6; B, 4.2; and C, 3.2; p

Background There is a paucity of randomized data regarding the safety and efficacy of the use of intracardiac echocardiography (ICE) from the left atrium (LA) to guide left atrial appendage occlusion (LAAO) procedures under local anesthesia using either of the available devices. Hypothesis The aim of this study was to compare the efficacy and safety of ICE from the LA with transesophageal echocardiography (TEE) for guidance during transcatheter LAAO procedures. Methods Single‐center, cohort study of patients undergoing LAAO with the Amplatzer Cardiac Plug or Watchman device. Procedures were guided by ICE from the LA with local anesthesia (n = 175) or TEE under general anesthesia (n = 49). Efficacy outcomes were procedural success and peri‐device leaks 6 weeks after LAAO. The safety outcome was a composite of procedure‐related complications. Results Procedural success was similar between groups: 100% in the TEE‐guided group, and 98% in the ICE‐guided group. Procedure‐related complications such as death, embolism, migration, or major vascular complications occurred similarly between groups (p = 0.590). The rate and degree of peri‐device leaks or presence of a thrombus on the device did not differ between groups on follow‐up CT. Turnover time in the catheter laboratory and use of contrast agent were reduced with ICE. Conclusions ICE in the left atrium to guide LAAO procedures appears to be as effective and safe as TEE. There was no increase in procedure‐related complications, whatever the device used. ICE resulted in similar procedural success while decreasing procedure time and requiring only local anesthesia.

Purpose To report the outcomes and the patients’ subjective experience of cochlear implantation (CI) performed under local anesthesia (LA). To describe a new form of intraoperative cochlear monitoring based on the patients subjective sound perception during CI. Methods In this retrospective case–cohort study, 117 patients underwent CI under LA with (n = 58) or without conscious sedation (n = 59). Included were primarily elderly patients with elevated risks for general anesthesia and recently patients with residual hearing eligible for electro-acoustic stimulation (EAS) (n = 27), in whom hearing could be monitored during the electrode insertion. A 500 Hz test tone was presented and the patient reported of subjective changes in loudness, leading to a modification of the insertion. A questionnaire was sent to all patients in which they assessed their subjective experience. Results All patients were successfully operated under LA without the need to intraoperatively convert to general anesthesia. 90% of the patients reported that the surgery was a positive experience. The vast majority, 90% of patients were satisfied with the overall treatment and with intraoperative pain management and 84% of the patients would opt for local anesthesia again. Cochlear monitoring by the patients’ subjective sound perception enabled for atraumatic insertions as all EAS patients could hear the test tone up to the end of the surgery. Conclusions CI under LA was well tolerated and recommended by the vast majority of patients. In addition, it offers the possibility to monitor the patients’ hearing during the electrode insertion, which may help to prevent insertion trauma.

Background We identified pain variation according to prostate biopsy sites and compared differences in pain relief according to the site of periprostatic nerve block (PNB). Methods This retrospective study collected data from 312 patients who underwent transrectal prostate biopsies between January 2019 and August 2020. Patients were stratified into two groups according to the site of local anesthesia (base vs. base and apex PNB), with each block achieved with 2.5 cm3 of 2% lidocaine. Pain scores were assessed using the visual analog scale at the following time points: probe insertion, PNB at base, PNB at apex, each of the 12 core biopsy sites, and 15 min after biopsy. The results were analyzed using a linear mixed model. Results The average pain scores were significantly higher in the base-only PNB group than were those in the base and apex PNB group (3.88 vs 2.82, p p p Conclusions The pain scores varied at each site during the prostate biopsy. The provision of a base and apex PNB provided greater pain relief than does base-only PNB during prostate biopsy.

The aim of our study was to compare the clinical results and costs of wide-awake local anesthesia no tourniquet (WALANT), intravenous regional anesthesia (IVRA), and infraclavicular brachial plexus block (IC-BPB). The patients were divided into WALANT, IVRA, IC-BPB groups, each with 50 patients. Demographic information, induction time, use of sedation, number of patients who were converted to general anesthesia, time in postanesthesia care unit (PACU), amount of bleeding during surgery, presence of tourniquet pain, hand motor function during surgery, time to onset of postanesthesia pain, discharge time, complications, and anesthesia costs were compared. Sedation was given to 12 IC-BPB patients, 9 IVRA patients and 5 WALANT patients. Of these patients, 6 undergoing IC-BPB, 5 undergoing IVRA and 4 undergoing WALANT were converted to general anesthesia (p = 0.80). PACU time and anesthesia costs were the least in the WALANT group, followed by the IVRA group (p 0.001, p 0.001). Intraoperative active voluntary movements were best preserved in the WALANT group; however, bleeding was highest in the WALANT group (p 0.001, p 0.001). Tourniquet pain was the higher in the IVRA groups, while postoperative pain in the surgical area developed the fastest in this same group (p = 0.029, p 0.001). Time to discharge was similar in WALANT and IVRA groups, and the longest in the IC-BPB (p 0.001) group. There was no difference among the groups in terms of patient satisfaction (p = 0.085, p = 0.242 for the first and second survey question). In the current study, WALANT appears to be a suitable alternative to IVRA and IC-BPB methods, with better preservation of active intraoperative movement, lower cost, and shorter time spent in PACU at the expense of higher bleeding.

Objective The aim of this study was to assess the effectiveness of Virtual Reality (VR) in reducing anxiety and pain during impacted mandibular third molar extraction under local anesthesia. Methods The study was designed as a prospective clinical study covering 74 respondents over 20 years of age. Surgical extraction of both impacted mandibular third molars was performed in two phases, two weeks apart. In the first phase, surgical extraction of the tooth was performed following the standard procedure (Non VR), and in the second phase (VR), we used VR goggles as an auxiliary tool for distraction during the procedure. Face scale was used to assess the level of pain. Heart rate values were recorded by means of wristbands. After both procedures, the patients filled out a modified post-clinical satisfaction questionnaire. Results During the procedure with VR goggles, the respondents had significantly lower pain values during the application of anesthesia, as well as during the surgical extraction of the third molar. There was no statistically significant difference in the level of pain during both surgical procedures with regard to the gender and age. Heart rate values in both phases of the study were not significantly different before the application of anesthesia. When VR goggles were used, the respondents had significantly lower heart rate values before the procedure, as well as during the procedure. Analysis of answers to the post-clinical questionnaire measuring satisfaction with VR technology shows that over 90% of respondents did not experience any VR-related discomfort during the surgery. Conclusions The VR distraction concept applied during impacted third molar surgery under local anesthesia can help reduce the patients’ anxiety and acute pain levels.

New 3D digital technologies can be applied to implant-supported ear prostheses to restore anatomical structures damaged by cancer, dysplasia, or trauma. However, several factors influence the accuracy of implant positioning using a cranial template. This pilot study describes an innovative navigated flapless surgery for craniofacial implants, prosthetically guided by 3D planning of the ear prosthesis. Laser surface scanning of the face allowed for mapping of the healthy ear onto the defect site, and projection of the volume and position of the final prosthesis. The projected ear volume was superimposed on the skull bone image obtained by cone-beam computed tomography (CBCT), performed with the navigation system marker plate positioned in the patient's mouth. The craniofacial implants were fitted optimally to the ear prosthesis. After system calibration, real-time navigated implant placement based on the virtual planning was performed with minimally invasive flapless surgery under local anesthesia. After 3 months of healing, digital impressions of the implants were made, and the digital manufacturing workflow was completed to manufacture the ear prosthesis anchored to the craniofacial implants. The proposed digital method facilitated implant positioning during flapless surgery, improving the ear prosthesis manufacturing process and reducing operation time, patient morbidity, and related costs. This protocol avoids the need for a reference tool fixed in the cranial bone, as is usually required for maxillofacial surgery, and confirmed that surgical navigation is useful for guiding the insertion of craniofacial implants during flapless surgery.

Background We, herein, propose an algorithm for correction of oral incontinence or/and color/texture mismatch after oromandibular reconstruction, by means of serial excision. To the best of our knowledge, this is the first case series presenting serial excision for complete removal of the free flap skin paddle to improve functional and aesthetic outcomes after free flap reconstruction of oromandibular through-and-through defects. Methods Single-centre retrospective study of all patients who underwent serial excision of the whole skin paddle, for correction of oral incontinence or/and color and texture mismatch after free flap reconstruction, in a 9-year period. We propose a treatment algorithm, based on the lip defect size. Patients with small defects undergo primary commissuroplasty, simultaneously with the free flap reconstruction and, if necessary, subsequent serial excision in local anesthesia for the color/texture mismatch. Patients with large defects undergo secondary commissuroplasty in general anesthesia. They are left to heal and, subsequently, undergo staged excision in 4-6-month intervals in local anesthesia. Results Sixteen patients were analyzed. Thirteen patients (81%) had mild oral incontinence. Eight patients (50%) required two stages of serial excision, six patients (38%) underwent three serial excisions and two patients (12%) had to be operated four times. Skin paddle surface ranged from 4 × 4 cm to 10 × 6 cm. No complications were observed and all patients were satisfied with the final outcome. Conclusion We conclude that the algorithm-based serial excision, can significantly improve the functional and aesthetic outcomes in patients with oral incontinence and color/texture mismatch after free tissue transfer for through-and-through cheek defects, involving the oral commissure.