Cholecysto cholangiography versus cystic duct cholangiography in laparoscopic cholecystectomy: a prospective controlled randomized trial.

This study evaluated the safety and effectiveness of cholecysto-cholangiography (CCC), an extremely rapid and easy way of imaging the biliary tree during laparoscopic cholecystectomy and a viable alternative to cystic duct cholangiography in the era of minimal invasive surgery. Sixty patients with symptomatic gallbladder stones were studied in this series, 30 were evaluated for cholecysto-cholangiography and other 30 for transcystic-cholangiography. The success rate in cholecysto-cholangiography approached 80% with excellent quality films obtained. Delineation of anatomy approached 85%; 75% for cholecysto-cholangiography and transcystic cholangiography respectively. Exposure time to radiation compares favourably with cystic duct cannulation with a mean time 2.4 min. Cholecysto-cholangiography added less than 11 mins to the procedure; mean 10.4 mins, while transcystic cholangiography added an extra 30 mins; mean 31 mins. There were no cholangiogram related complications or false positive findings with a smooth for two months follow up.

Modified endocystectomy versus pericystectomy in echinococcus granulosus liver cysts: a randomized controlled study, and the role of specific anti-hydatid IgG4 in detection of early recurrence.

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries (level IV evidence, grade C recommendation). So, there is a need for accurately designed randomized trials with precise goals to compare pericystectomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-operative blood loss, complications and long-term recurrence and to test the role of anti-hydatid IgG4 in diagnosis and detection of early recurrence. 60 patients with 131 liver cysts of E. granulosus fulfilling the study criteria were randomly divided to two groups. GI: 32 patients with 69 cysts treated by modified endocystectomy and GII: 28 patients with 62 cysts treated by closed total pericystectomy. GIa included 40 cysts >5 cm in diameter (mean 6.86, SD+/-0.809) & GIb 29 cysts < or = 5 cm in diameter (mean 4.17 SD+/-0.83). GIIa included 37 cysts >5 cm in diameter (mean 7.01 SD+/+0.79) & GIIb 25 cysts < or = 5 cm in diameter (mean 4.04 SD+/-0.93). Preoperative evaluation included history taking, clinical examination, blood tests, specific anti-hydatid IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood transfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early recurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24-90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients (GII) had blood transfusion. The intraoperative bleeding in GI was <500 ml/ patient, and 18 patients (GII) each bled >500 ml. No intraperitoneal seedling during the follow up. 5 of 55 patients (9%) were serologically suspected of relapse or incomplete cure. One (GII) showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.

Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy.

INTRODUCTION: Intraabdominal CO(2) gas after laparoscopic cholecystectomy causes postoperative shoulder-tip pain. Many methods of analgesia have been used to reduce this pain, including analgesic drugs, intraperitoneal local anesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas, and nitrous oxide pneumoperitoneum. The aim of this study was to evaluate the efficacy of combined low-pressure CO(2) pneumoperitoneum and intraperitoneal infusion of normal saline in reducing the incidence of postoperative shoulder-tip pain. METHODS: Altogether, 109 patients undergoing elective laparoscopic cholecystectomy were randomized prospectively into three groups. Patients in group A (n = 34) underwent laparoscopic cholecystectomy with 14 mmHg CO(2) pneumoperitoneum; patients in group B (n = 37) underwent laparoscopic cholecystectomy with 10 mmHg CO(2) pneumoperitoneum; and those in group C (n = 38) underwent laparoscopic cholecystectomy with 10 mmHg CO(2) pneumoperitoneum in addition to intraperitoneal normal saline infusion in the right hemidiaphragmatic area. Shoulder-tip pain was recorded on a verbal rating scale 2, 6, 12, 24, and 48 hours after operation. RESULTS: Twelve patients in group A (35.2 percent), six in group B (16.2 percent), and seven in group C (18.4 percent) complained of shoulder-tip pain. Hence, there was a significant decrease in the frequency of shoulder-tip pain in groups B and C in relation to group A, but there was no significant difference between groups B and C. The postoperative shoulder-tip pain scores were significantly reduced in group C at 6, 12, and 24 hours. The number of patients who required additional analgesics was also reduced in group C. CONCLUSIONS: Low-pressure CO(2) pneumoperitoneum reduces the number of patients complaining of shoulder-tip pain and the intensity of the pain after laparoscopic cholecystectomy. The addition of intraperitoneal normal saline infusion to low-pressure CO(2) pneumoperitoneum seems to reduce the intensity but not the frequency of shoulder-tip pain after laparoscopic cholecystectomy.