Post-laparoscopic cholecystectomy pain: effects of intraperitoneal local anesthetics on pain control--a randomized prospective double-blinded placebo-controlled trial.

Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.

Management of gallstones.

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four to six hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliative and are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay.

Small bowel necrosis related to enteral nutrition after duodenal surgery.

Nutritional support is the key to the successful recovery of any patient. Small bowel necrosis is described in patients being fed with enteral nutrition after surgery. Five patients with small bowel necrosis after surgery will be discussed and an etiology proposed. A retrospective review of patient data was performed. Data was collected on the type of surgical procedures performed, the enteral nutrition given to the patient, basic laboratory data, the length of stay, and discharge status. A total of five patients' charts were reviewed. Three patients had pancreaticoduodenectomy for a pancreatic mass and two required pyloric exclusion secondary to gunshot wounds. All five patients were fed with a fiber-based enteral nutrition. All patients subsequently had small bowel necrosis requiring reoperation. Four of the five patients had inspissated tube feeding within the necrotic small bowel. Two patients died and three survived with prolonged hospital courses. We propose that the combination of duodenal surgery and fiber-based enteral nutrition contribute to the development of small bowel necrosis postoperatively.