A 19-year-old woman presented with nausea. vomiting and bilateral loin pain of increasing intensity and duration which was unresponsive to antispasmolytic agents. Two months prior to admission the pain was predominantly localized to the right lumbar region and was associated with several episodes of painless haematuria, pyrexia, elevated blood glucose and 20 kg weight loss.Physical examination revealed severe cachexia, tenderness and pain on palpation of the right lumbar region. A large ill-defined mass was palpable. Abdominal ultrasonography showed an extensive tumour mass involving the right hdney. Hepatomegaly , splenomegaly and pancreatic enlargement were also identified.An intravenous urogram showed a right spaceoccupying lesion with distortion of the pelvicalyceal system. Renal arteriography revealed hypertrophied venous vessels but no hypervascularization. Computed

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Introduction:Postoperative ileus is one of the most common early complications appearing in up to 30% in patients undergoing radical cystectomy and is the major cause of prolonged hospital stay (l). Underlying pathogenetic factors are type of surgery as well as the degree of the systemic inflammatory response (surgical stress response). Multimodal approaches including sympathicolysis by postoperative analgesia like thoracic epidural analgesia (TEA) with local anaesthetics (and epidural opioids) in contrast to intravenous opioid analgesia can attenuate or prevent this surgical stress response. The purpose of this study was to evaluate the impact of TEA and patient controlled intravenous analgesia (PCIA) on incidence and duration of post-operative ileus as well as the start of uncomplicated oral intake of fluids and solid diet in patients undergoing radical cystectomy Methods: In 1994 a collaborate clinical pathway was introduced including standards for surgery, anaesthesia and perioperative care. All patients were offered continuous TEA for postoperative pain relief. Patients with contraindications or refusal received PCIA with piritramide. Pain relief was individually adjusted so in all patients a VAS-score Ͻ4 during mobilisation and & # 8804; 2 at rest was intended. Hence, the records of all consecutive patients undergoing radical cystectomy for bladder cancer between 1994 were reviewed regarding incidence and duration of post-operative ileus with respect to the analgetic regimen. Absence of bowel sounds and defecation longer than 4 postoperative days was considered to be postoperative ileus (1). Results:The records of 302 out of 314 patients were eligible for analysis. Continuous TEA with local anesthetics (buivacaine/ ropivacaine) and lipophilic opioid (sufentanil) was performed in 198 patients and PCIA with piritramide in 104 patients. Groups did not differ regarding demographic data, comorbidity, kind of urinary diversion and quality of analgesia at rest. Duration until first defecation was shorter in the TEA group (2.4Ϯ1.4d vs. 4.1Ϯ1.6d (pϽ0.0005)). Postoperative ileus was significantly reduced in TEA (2.5% vs 10%, pϭ0.001). First uncomlicated oral intake was also faster in TEA group (2.9Ϯ0.96d vs. 4.3Ϯ1.6d; pϽ 0.01). Cardiopulmonary complications tended to be less in TEA without reaching significance. Conclusion:Despite comparable quality of analgesia there was a striking benefit in the TEA group regarding normalisation of gastrointestinal function and time to first oral intake indicating TEA to be more than just analgesia. These early results despite not fulfilling actual fast track regimen implicate the integration of the method of postoperative analgesia within multimodal strategies aiming in the future in effective and fast rehabilitation.Introduction: Prolonged gastrointestinal dysfunction is a common early complication in patients receiving major abdominal surgery, resulting in delayed rehabilitation and prolonged hospital stay. Multimodal collaborate clinical pathways can implement sympathicolytic m...

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