Extended hepatectomy can be performed with a near-zero operative mortality rate and is associated with long-term survival in a subset of patients with malignant hepatobiliary disease. Combining extended hepatectomy with another intraabdominal procedure increases the risk of postoperative morbidity.

No abstract

The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.

Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia* PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, open forum commentary, and clinical feasibility data. This update includes data published since the "Practice Guidelines for Obstetrical Anesthesia" were adopted by the American Society of Anesthesiologists in 1998; it also includes data and recommendations for a wider range of techniques than was previously addressed. Methodology A. Definition of Perioperative Obstetric Anesthesia For the purposes of these Guidelines, obstetric anesthesia refers to peripartum anesthetic and analgesic activities performed during labor and vaginal delivery, cesarean delivery, removal of retained placenta, and postpartum tubal ligation. B. Purposes of the Guidelines The purposes of these Guidelines are to enhance the quality of anesthetic care for obstetric patients, improve patient safety by reducing the incidence and severity of anesthesia-related complications, and increase patient satisfaction. C. Focus These Guidelines focus on the anesthetic management of pregnant patients during labor, nonoperative delivery, operative delivery, and selected aspects of postpartum care and analgesia (i.e., neuraxial opioids for postpartum analgesia after neuraxial anesthesia for cesarean delivery). The intended patient population includes, but is not limited to, intrapartum and postpartum patients with uncomplicated pregnancies or with common obstetric problems. The Guidelines do not apply to patients undergoing surgery during pregnancy, gynecologic patients, or parturients with chronic medical disease (e.g., severe cardiac, renal, or neurologic disease). In addition, these Guidelines do not address (1) postpartum analgesia for vaginal delivery, (2) analgesia after tubal ligation, or (3) postoperative analgesia after general anesthesia (GA) for cesarean delivery.

Comparative data concerning the effects of topical anesthetics in man are not available. A technique with the use of electrical stimulation which permitted such a study was developed by the authors. The tip of the tongue is the most sensitive area in the body to this type of stimulation. Over 40 drugs with topical activity were studied with the tip of the tongue as the test site. The most potent and effective compounds are tetracaine, cocaine, dibucaine, lidocaine, and dyclonine. With the exception of dyclonine, these are toxic systemically if used in excess. The addition of vasoconstrictors, detergents, demulcents, cations, hyaluronidase, and other often suggested potentiating agents, does extend the period of activity. Need for a controlled studyNo wholly satisfactory technique has been available for studying topical anesthesia in man. Therefore, clinically significant data of a comparative nature are sparse. The efficacy of topical anesthetics is usually established by observing their ability to suppress the corneal or laryngeal reflexes. 6 , 8 The effects on the laryngeal reflex have been used as a basis for study in man. However, this technique has drawbacks because the responsiveness is variable and the reflex is obtunded after repeated stimulation. The need for a better method of study was obvious. After a num-