Efficacy of Repeated Intraperitoneal Administration of Levobupivacaine in Pain and Opioid Consumption After Elective Laparoscopic Cholecystectomy: A Prospective Randomized Placebo-controlled Trial.

PURPOSE: To estimate the effect of intraperitoneal levobupivacaine on postoperative pain and analgesic requirements, during the first 24 hours after elective laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: In this prospective, randomized, placebo-controlled study, 73 consecutive patients scheduled for LC were randomized into 2 groups. In the local anesthetic group 36 patients received 10 mL of 0.5% levobupivacaine intraperitoneally at the end of the LC and at 4 hours postoperatively, whereas in the placebo group 37 patients received 10 mL of 0.9% normal saline. Visual analog scale pain scores, analgesic consumption, side-effects, and vital signs were recorded for 24 hours postoperatively. RESULTS: In the local anesthetic group lower visual analog scale pain scores were observed postoperatively, both at rest and at movement (P-values compared with placebo, 0.012 and <0.001, respectively). Fentanyl consumption was greater in the placebo group (P-value <0.001). CONCLUSIONS: Intraperitoneal administration of 10 mL 0.5% levobupivacaine after LC is effective in reducing postoperative pain and decreasing opioid consumption.

Granisetron versus tropisetron in the prevention of postoperative nausea and vomiting after total thyroidectomy.

BACKGROUND: Postoperative nausea and vomiting (PONV) are frequently encountered after thyroidectomy. For PONV prevention, selective serotonin 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are considered one of the first-line therapy. We report on the efficiency of granisetron and tropisetron, with that of placebo on the prevention of PONV in patients undergoing total thyroidectomy. METHODS: One hundred twenty-seven patients were divided into three groups and randomized to receive intravenously, prior to induction of anesthesia, tropisetron 5 mg, or granisetron 3 mg, or normal saline. All patients received additionally 0.625 mg droperidol. All episodes of postoperative PONV during the first 24 h after surgery were evaluated. RESULTS: Nausea visual analogue scale (VAS) score was lower in tropisetron and granisetron groups than the control group at all measurements (P<0.01) except for the 8-h measurement for tropisetron (P=0.075). Moreover, granisetron performed better than tropisetron (P<0.011 at 4 h and P<0.01 at all other points of time) apart from the 2-h measurement. Vomiting occurred in 22.2%, 27.5%, and 37.5% in granisetron, tropisetron, and control groups, respectively (P=0.43). CONCLUSIONS: The combination of the 5-HT3 antagonists with droperidol given before induction of anesthesia is well tolerated and superior to droperidol alone in preventing nausea but not vomiting after total thyroidectomy.

Sugammadex, a promising reversal drug. A review of clinical trials.

According to published data, sugammadex, rapidly reverses (2-5 min) shallow and profound NM block induced by rocuronium and vecuronium, without being connected with serious adverse events. It is accepted that in order to reverse shallow block, the suggested dose of sugammadex comes up to 2 mg/kg. Profound level of NM block demands 4 mg/kg in order to defy few responses at the post titanic count. Doses of sugammadex lower than 1 mg/kg may lead to rebound of rocuronium's effect. Higher doses of sugammadex (12 16 mg/g) are used in rescue reversal. In children and adolescents the 2 mg/kg dose is both effective and well tolerated, while, to date, data regarding infants are scarce. In patients with renal failure, 2 mg/kg of sugammadex resulted in a mean time to recovery of TOF ratio to 0.9 in 2 min, which was quicker than the time of reversal by acetylcholinesterase inhibitors. Investigations in cardiac patients undergoing noncardiac surgery suggest that 2 and 4 mg/kg of sugammadex are both safe and effective. Compared with neostigmine, sugammadex has no need to use muscarinic antagonists and therefore is not associated with variations in heart rate. Trials indicate that sugammadex acts faster than edrophonium and neostigmine. Sugammadex is a promising, well tolerated agent that enables fast reversal in different depths of NM block -shallow and profound- and in different patients populations. After completion of trial probation and settlement of issues concerning estimated cost and cost impact, it is believed to play a leading part in future anesthesiology.

Primary cavernous hemangioma of the thyroid gland.

A 78-year-old euthyroid patient presented for evaluation of a symptomatic, slowly growing neck mass. Ultrasound scan revealed a multinodular goiter and a hypoechoic nodule of the right thyroid lobe. Total thyroidectomy was performed and the lesion was completely excised. Definite diagnosis was obtained after histological examination of the surgical specimen. Cavernous hemangiomas of the thyroid gland are infrequent lesions which may escape diagnosis preoperatively. An effort should be made not to rupture these lesions in order to ensure a bloodless procedure.

Undifferentiated giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation: a case report and review of the literature.

INTRODUCTION: Undifferentiated gallbladder carcinoma is a rare entity. Among unusual types of undifferentiated gallbladder carcinoma, giant cell type carcinoma is infrequent and, moreover, very few cases of such neoplasms with osteoclast-like giant cells have been documented. We report a case of undifferentiated gallbladder carcinoma presenting an unusual immunophenotype that was shown to be of giant cell type with sarcomatoid dedifferentiation infiltrated by osteoclast-like multinucleated cells. CASE PRESENTATION: An 84-year-old Greek man presented with right upper quadrant pain, high fever, rigors, anorexia and weight loss during the past month. Clinical examination revealed tenderness in the right upper abdominal quadrant and a palpable gallbladder. Blood tests showed elevated white blood-cell count and transaminases. Abdominal ultrasound and computed tomography demonstrated a markedly distended gallbladder, measuring 16 cm x 8 cm, with oedema and pericholecystic fluid, consistent with gallbladder empyema. After an open cholecystectomy and an uneventful recovery, the patient was discharged on the 4(th) postoperative day. On cut surface, a 2cm solid mass was identified, obstructing the lumen in the neck of the gallbladder. Histopathology and immunohistochemistry offered the diagnosis of an undifferentiated, giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation infiltrated with osteoclast-like giant cells. CONCLUSIONS: Undifferentiated, giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation infiltrated with osteoclast-like giant cells is a very infrequent neoplasm. Controversy exists over its nature, as related knowledge remains incomplete. Thorough histopathological and immunohistochemical evaluation is imperative for diagnosis. Due to their rarity, the biological behaviour and prognosis of these tumours remain unclear.

Lymphocyte apoptosis after major abdominal surgery is not influenced by anesthetic technique: a comparative study of general anesthesia versus combined general and epidural analgesia.

STUDY OBJECTIVE: To examine the influence of abdominal colectomy with combined general anesthesia and epidural analgesia versus general anesthesia on apoptosis of circulating lymphocytes. DESIGN: Prospective, randomized, clinical comparison study. SETTING: Tertiary-care general hospital. PATIENTS: 40 ASA physical status I and II patients undergoing elective open colectomy for nonmetastatic colon carcinoma. INTERVENTIONS: Patients were randomly allocated to two groups to receiver either general anesthesia alone (Group G) or general anesthesia combined with epidural analgesia (Group C). Group C comprised 21 patients while 19 patients constituted Group G. All patients underwent median longitudinal laparotomy. MEASUREMENTS: Blood samples were collected preoperatively and 24 hours postoperatively for measurement of lymphocyte apoptosis, serum cortisol, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). MAIN RESULTS: There were no differences between the two groups in age, weight, or duration of surgery. No significant alterations in total lymphocyte counts, as well as in lymphocyte subpopulations (early apoptotic, late apoptotic, viable, and necrotic), were observed between the general and combined anesthesia groups. Cortisol, ESR, and CRP were significantly increased postoperatively in both groups. Group C presented with lower serum cortisol levels postoperatively than Group G (b = -5.38, CI95%: -8.72 to -2.05, P = 0.002). CONCLUSIONS: Epidural block could not suppress postoperative lymphocyte apoptosis, increases in cortisol, CRP, or ESR compared with general anesthesia.

Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Postoperative pain, however, can prolong hospital stay and lead to increased morbidity. In the context of a multimodal approach to analgesia, intraperitoneal local anesthetic administration optimizes analgesia and facilitates early postoperative recovery, and it may be associated with a decreased risk of side effects. METHODS: A total of 71 patients was randomized to receive either intraperitoneal analgesic (IPA group) or not (controls). At the completion of cholecystectomy, 10 mL of levobupivacaine 0.5% were infused intraperitoneally in the IPA group and 8 h postoperatively, whereas in the controls, 10 mL of 0.9% NaCl were administered in the corresponding points of time. Differences in pain scores between groups were the primary endpoints. Opioid consumption and adverse effects were the secondary endpoints. RESULTS: The 2 groups were homogenous in respect to age, sex, body mass index (BMI), and duration of operation. No conversion, complication, or mortality was recorded. The IPA group had a lesser visual analog scale score at rest and at movement compared with controls at all points of time measured. Moreover, fentanyl consumption in the recovery room was significantly greater in the control group, and the consumption of meperidine and the percentage of the patients that requested rescue analgesia in the ward was significantly greater in the control group. Local analgesic intraperitoneal injection as well as parecoxib for postoperative analgesia had no significant adverse effects. CONCLUSION: Our study showed that 2 separate doses of intraperitoneally administered levobupivacaine significantly decreased postoperative pain and the need for opioids compared with placebo. This technique is simple, safe, and without adverse effects.

Detection of epithelial cells by RT-PCR targeting CEA, CK20, and TEM-8 in colorectal carcinoma patients using OncoQuick density gradient centrifugation system.

BACKGROUND: The detection of epithelial-specific mRNA correlates well with the presence of cancer cells in the peripheral blood and provides a rational explanation for subsequent metastasis. MATERIAL AND METHODS: Forty-two, patients with colorectal cancer and 14 controls were included in our study. Peripheral blood samples were acquired at 24 h before and 48 h after laparotomy. Tissue samples were also acquired from the primary lesion. All samples were examined for the expression profile of CEA, CK20, and TEM-8. RESULTS: Tissue samples expressed CEA in every specimen, CK20 in 30, and TEM-8 in 41. CEA and CK20 were not identified in the control blood samples while TEM-8 was detected in 4. CEA was detected in 17, CK20 in 28 and TEM-8 in 23, of the preoperative blood samples. CEA mRNA expression in preoperative blood sample and TNM stage were found independently associated with increased tumor size. Positive CEA, CK20, and TEM-8 signals were found in 25, 25, and 23 of the postoperative blood samples respectively. CONCLUSIONS: CK20 and CEA are significantly more frequently detected in colon cancer patients than in healthy controls and can serve as markers. Cancer cell mRNA is commonly detected in the preoperative and postoperative peripheral blood samples. Tumor size was independently associated with the preoperative detection of CEA mRNA. Although TEM-8 mRNA detection in the peripheral blood showed no specificity for cancer patients or correlation with clinical stage, identification and validation of genes and proteins implicated in metastatic process needs to be further investigated.

Successful use of recombinant activated factor VII for postoperative associated haemorrhage: a case report.

BACKGROUND: Coagulopathy is a major contributing factor to bleeding related mortality even after achieving adequate surgical control of the haemorrhage in trauma and surgical patients. CASE PRESENTATION: A 65 years old Greek man was admitted in our ICU with critical haemorrhage following renal biopsy. Despite surgical exploration the patient continued to bleed resulting in a vicious cycle of transfusion, coagulopathy and re-bleeding. After all standard management options were exhausted, the patient was given rFVIIa (total dose 4,8 mg). Clinical improvement was noted without adverse thrombotic complications. One month later the same patient was operated on for a suspected retroperitoneal infected collection that it was assumed to be the cause of persistent pyrexia. After abdominal washout, he suffered haemorrhagic shock with postoperative coagulopathy. Standard transfusion therapy was again unsuccessful. The patient was given rFVIIa again resulting in an immediate reduction in coagulopathic haemorrhage accompanied by a significant improvement in laboratory measurements and reduction in blood products requirements. CONCLUSION: Published clinical experiences for the use of rFVIIa in trauma patients are limited to small series and case reports. However, in trauma patients, administration of rFVIIa appears to be effective in addition to prompt surgical intervention as an adjunctive haemostatic measure to control life threatening bleeding in appropriately selected patients.

A case of polymyositis associated with papillary thyroid cancer: a case report.

Differentiated thyroid cancer is rarely associated with paraneoplastic events. Polymyositis, an autoimmune inflammatory myopathy, can be manifested as a paraneoplastic syndrome (PS). We report a case of a young woman who developed progressive proximal muscle weakness one and a half year after a total thyroidectomy for papillary thyroid cancer. Clinical features, laboratory results and muscle biopsy led us to the diagnosis of polymyositis, possibly related to her previous malignancy. A search for recurrence of the thyroid carcinoma or other underlying malignancy was fruitless. The patient improved slowly but almost completely after about 6 months of immunosupressive therapy, which she is still receiving.

Results using the AO hook plate for dislocations of the acromioclavicular joint.

The AO Hook plate has been used for stabilization of acromioclavicular joint dislocations. We present our experience of this newly introduced device in a general hospital, since there are not many papers in the literature reporting on this. A total of 16 patients were treated with the AO Hook plate between November 2001 and November 2003 at Princess Alexandra Hospital in Harlow, UK. For functional assessment 6 months after removal of the plate, the constant score and the pain visual analogue score were used. The pain visual analogue score ranged from 0 to 6 (mean: 0.87) and the constant score ranged from 78 to 100 (mean: 96.4). In one instance, a patient developed instability after removal of the plate. The use of this device results in excellent functional outcome for the treatment of acromioclavicular joint dislocations.

A symptomatic cyst of the ligamentum teres of the liver: a case report.

Cysts of the liver ligaments are extremely rare and cysts of the ligamentum teres of the liver have been sporadically reported in the literature during the last century. The present report describes a case of a symptomatic patient with a cyst of the ligamentum teres of the liver. The patient presented with right upper quadrant pain and indigestion during the last 2 years. Ultrasound and computed tomography scans revealed a water-density mass attached to the anterior abdominal wall, but definite diagnosis could not be reached. The cyst was completely excised during laparotomy. Cysts of the ligamentum teres of the liver, although infrequent, may produce clinical symptoms and require excision. Ultrasound and computed tomography scan preoperatively cannot rule out malignancy, thus exploratory laparotomy and total resection of these lesions are necessary.

Splenic rupture as the presenting manifestation of primary splenic angiosarcoma in a teenage woman: a case report.

INTRODUCTION: Primary splenic angiosarcoma is a rare neoplasm of vascular origin carrying a very poor prognosis, partly due to its high metastatic potential. This disease presents frequently with splenic rupture and hemorrhage. We report the case of a 17-year-old woman who presented with rupture of a primary splenic angiosarcoma. CASE PRESENTATION: The patient presented with diffuse abdominal pain and distention. Clinical examination revealed severe tenderness in the left upper abdominal quadrant, a palpable abdominal mass, and hemodynamic instability with a systolic arterial blood pressure of 75 mmHg and heart rate of 135 beats per minute. Blood tests revealed anemia (hemoglobin 7.0 g/dl) and thrombocytopenia (platelets 70 x 109/liter). After initial fluid resuscitation and stabilization, abdominal ultrasound and computed tomography were performed, revealing a large quantity of intraperitoneal free fluid, an enlarged spleen, and a heterogeneous low-density signal within the splenic parenchyma, which showed varying degrees of contrast enhancement. At laparotomy a huge (weight 1530 g, diameter 19 cm) actively bleeding spleen was identified and splenectomy was performed. Histopathology showed a primary splenic angiosarcoma. After an uneventful recovery, the patient was discharged on the sixth postoperative day. CONCLUSION: Primary splenic angiosarcoma is rare. Although this malignancy is usually encountered in advanced age, there have been a few reported cases among younger patients. The case reported here presented with splenic rupture, was treated by laparotomy and splenectomy, and the patient is disease free 16 months after surgery.

Lipoma induced jejunojejunal intussusception.

Intussusception in adults is rare. The clinical picture of intussusception in adults is subtle and the diagnosis is, therefore, elusive. The presence of a structural abnormality in the great majority of the adult cases mandates high clinical suspicion. Gastrointestinal lipomas are rare benign tumors and intussusception due to a gastrointestinal lipoma constitutes an infrequent clinical entity. The present report describes a case of jejunojejunal intussusception in an adult with a history of severe episodes of hematochezia and colicky upper abdominal pain. The diagnosis was suspected preoperatively but computed tomography scan could not rule out malignancy. Exploratory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with segmental intestinal resection.

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature.

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

Primary gastric melanoma: a case report.

Melanoma accounts for 1-3 per cent of all malignant tumors. Except cutaneous, other less common melanomas include, among others, those in the GI tract. However, their primary or secondary nature is often difficult to establish. Referring to the stomach, scattered cases of primary melanomas have been reported in the literature. We report a case of a man with an ulcerated sub-mucosal mass at the antrum of the stomach, manifested with dull upper abdominal pain, nausea, vomiting, fatigue and anemia. This lesion was histologically proved to be melanoma. A detailed clinical and laboratory investigation revealed no primary site elsewhere. To our knowledge, very few cases of primary gastric melanoma have been reported. Our case is the fourth ever published and the first located at the antrum of the stomach. The debate upon the primitive nature of such lesions still persists. Thus, specific diagnostic criteria have been proposed.