Use of local anesthetic does not influence postoperative opioid requirements or patients' subjective report of pain following laparoscopic colorectal procedures managed within enhanced recovery care pathways.

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endograft within a thrombosed aneurysm sac leading to sac expansion and rupture. Case Report: The patient is a 68-year-old woman with a past medical history significant for hypertension, known 4.5-cm thoracic aortic aneurysm, and severe emphysema on home oxygen who underwent an endovascular aneurysm repair 6 years before at an outside hospital. Repair was complicated intraoperatively by thrombosis of the contralateral limb and conversion to an aortouni-iliac graft with a femoral-femoral bypass. Three years later, she presented to our hospital with an ischemic left leg. Computed tomography angiography (CTA) was performed, demonstrating complete thrombosis of the aortic endograft and aneurysm sac with an infected thrombosed bypass graft. A left axillary-femoral bypass was performed with excision of the infected femoral-femoral bypass. On followup 17 months later, computed tomography scan demonstrated aneurysm sac growth to 5.1 cm, sac and endograft thrombosis, and no evidence of endoleaks, with stable endograft position. The patient elected surveillance. Six months later, repeated CTA again demonstrated growth of the aneurysm sac to 5.6 cm. Aortic duplex ultrasound at the time detected motion in the thrombus surrounding the endograft. Aortography was then performed, with no evidence of any endoleaks but with downward migration of the endograft by 5 mm. The patient again elected observation. Another CTA 6 months later showed thrombosed sac growth to 6.1 cm and further downward migration of the thrombosed endograft with infrarenal aortic neck dilation to 3.6 cm. After extensive discussion with the patient regarding a high-risk open repair, given her severe emphysema, or a technically challenging endovascular rechanneling of her thrombosed endograft with proximal aortic extension and aortic anchors, the patient elected not to proceed with intervention. She presented 2 months later with a ruptured aneurysm. The patient's family elected comfort care. Conclusions: Despite thrombosis of the aortic sac and endograft, persistent aortic pressure and neck dilation can contribute to endograft migration, sac expansion, and ultimately rupture. Continued surveillance is critical even with a thrombosed endograft.