SUMMARY The aim of this study was to determine whether patients' tolerance of upper gastrointestinal endoscopy is related to the dose of lignocaine spray used for oropharyngeal anaesthesia and to measure plasma concentrations at these doses. Sixty consecutive patients undergoing routine upper gastrointestinal endoscopy with sedation were randomized to receive lignocaine spray 50 mg (Group A), 100 mg (Group B) or 200 mg (Group C). Patient, endoscopist and endoscopy nurse were unaware of the variation in dose used. Each patient's tolerance of the intubation and of the remainder of the gastroscopy was assessed independently by the patient, endoscopy nurse, and endoscopist using a visual analogue scale. Plasma lignocaine concentration was measured at 20, 40, 60 and 80 min after administration of the spray. Fifty (83 %) patients were unable to recall either the intubation, or the procedure. On the endoscopy nurse's assessment, the patients in Group B tolerated the intubation better than those in Group A, and Groups B and C tolerated the remainder of the gastroscopy better than those in Group A. On the endoscopist's assessment, Groups B and C tolerated the remainder of the gastroscopy better than Group A. There were fewer gags per min in Groups B and C compared to Group A. Mean plasma Lignocaine concentrations showed a dose—dependent absorption of the spray, but none exceeded the potentially toxic level of 5 mg/L.
Abstract Introduction Transanal endoscopic microsurgery (TEM) is an accepted way of excising rectal adenomas with low morbidity and mortality, avoiding major resectional surgery. However, there are no agreed criteria for surveillance following TEM. The purpose of this study was to identify criteria to guide surveillance programmes, thus reducing the surveillance burden for those patients at low risk of recurrence. Patients and methods Patients who had undergone TEM for rectal adenomas were identified, and a retrospective review of patient, pathological and histological parameters was performed. Results Seventy‐five (40 male) patients were identified; median age 70 years (39–85). There were seven tubular, 33 tubulo‐villous and 35 villous adenomas. All were considered completely excised by the operating surgeon. Forty‐seven (62.7%) were reported as being completely excised histologically. There was no significant association between recurrence at 6 months and sex, age, type or position of adenoma, height above the anal verge, or degree of dysplasia. Recurrence rates at six months were 0% for the completely excised adenomas and 21.4% for the incompletely excised ones; this was statistically significant (Pearson χ 2 , P < 0.001). In all there were 12 recurrences, 10 in the incompletely excised group at a median follow up of 31 (6–80) months ( P < 0.001). In addition, a significant association for large adenomas to recur was noted at median follow up (Armitage Trend test, P = 0.019). Conclusions Histological assessment of completeness of excision of rectal adenoma and size of adenoma are important predictors of early recurrence and have potential to guide follow‐up strategies after TEM.
Haemorrhoids are a common complaint with estimates suggesting a prevalence of 4% of the adult population. Treatments such as rubber band ligation (RBL), sclerotherapy and excisional surgery have been in use for many years, and recently stapled haemorrhoidopexy, or procedure for prolapsing haemorrhoids (PPH) has gained acceptance. However, there have been consistent reports of severe sepsis, including a number of deaths. The purpose of this review was to assess the scale of the problem, and identify any predisposing factors, common presenting features, and treatment options in those who suffer these complications.Twenty-nine papers were identified, reporting 38 patients. Of these, 17 had undergone RBL, three had sclerotherapy, one had cryotherapy, 10 had excisional surgery and seven had PPH. Ten died as a result of their sepsis. The cases included 16 with perineal sepsis, seven with retroperitoneal gas and oedema, and six with liver abscesses. Common presenting features were urinary difficulties, fever, severe pain, septic shock and leucocytosis. Most were managed by means of surgery, although a minority survived having received conservative therapy. With the exception of two patients (one of whom was human immunodeficiency virus positive and the other had a drug-induced agranulocytosis) all were well prior to surgery.Although extremely uncommon, severe sepsis does occur post-treatment for haemorrhoids and all surgeons who treat such patients should be aware of the potential complications and alert to their presenting features. Early presentation without evidence of tissue necrosis may be managed conservatively, although most cases are managed by means of surgery.
Many variables influence the treatment course and outcome of desensitization under relaxation. 1) Relaxation is a significant aspect of desensitization. The optimum degree of relaxation necessary to this technique is unknown. 2) Hypnosis and suggestibility play a nebulous role, influencing speed of progress, relaxation and imagery. 3) The ability to evoke anxiety to imagined stimuli is essential to in vitro desensitization. 4) Interview-induced emotional responses, although demonstrated to have a significant affect upon desensitization, are not essential. 5) Interpretation, confrontation and insight are not significant aspects of psychotherapy by reciprocal inhibition. 6) Patients with a history of a conditioning process, a specific stimulus antecendent for anxiety and minimal free-floating anxiety, benefit most from desensitization. 7) The positive influence an understanding of the reciprocal inhibition theory has on patients' motivation, attitude and expectancy may be related to primary suggestibility.
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