This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

clinicaltrials.gov Identifier: NCT00465829.

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Background The risks of bariatric surgical procedures must be balanced against their benefits and require further characterization. Methods Longitudinal Assessment of Bariatric Surgery-1 (LABS-1) was a prospective, multi-center observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States (2005-2007). A composite endpoint of 30-day major adverse outcomes (death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; no discharge) was evaluated among patients undergoing first-time bariatric surgery. Results There were 4776 patients (mean age 44.5 years, 21.1% male, 10.9% non-white, median BMI of 46.5 kg/m2) who had a first-time procedure. Over half had at least two comorbid conditions. Roux-en-y gastric bypass was performed in 3412 (87.2% laparoscopic) and laparoscopic adjustable gastric banding in 1198. The 30-day mortality rate for Roux-en-y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; 4.3% of participants had at least one major adverse outcome. A history of deep vein thrombosis or pulmonary embolus, obstructive sleep apnea, and functional status were each independently associated with increased risk of the composite endpoint. Extreme values of BMI were significantly associated with an increased risk of the composite endpoint, while age, sex, race, ethnicity and other co-morbid conditions were not. Conclusion The overall risk of death and adverse outcome after bariatric surgery was low, varying considerably with patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the longer term effects of bariatric surgery and the risk of living with extreme obesity.

Epidural analgesia with bupivacaine and morphine provided the best balance of analgesia and side effects while accelerating postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program.

Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.

IMPORTANCE In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. OBJECTIVE To evaluate whether there is an association between time and perforation after patients present to the hospital. DESIGN, SETTING, AND PARTICIPANTS Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. MAIN OUTCOMES AND MEASURES The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. RESULTS A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance. CONCLUSIONS AND RELEVANCE There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.

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