Irrigation with Bupivacaine at the Surgical Bed for Postoperative Shoulder Tip and Abdominal Pain Relief after Laparoscopic Cholecystectomy.

Gallstones in western countries are primarily composed of cholesterol. However, mixed or pigment stones, which contain a higher proportion of bilirubin, are more frequently seen in developing nations and Asia than in western countries. Abdominal and shoulder tip pains (STPs) are common complaints following the standard laparoscopic cholecystectomy procedure. To date, all pain management modalities have proven variable outcomes. This prospective randomized study included 82 patients who underwent elective laparoscopic cholecystectomy. The control group received 20 mL of normal saline, whereas the study group received a 20-mL instillation of 0.5% bupivacaine at the gallbladder bed after surgical resection. The Visual Analog Scale (VAS) was used to analyze abdominal pain and STP. The mean age ranged from 20 to 80 years. Abdominal VAS at 6, 12, 18, 24, 30, 36, and 48 hours were statistically insignificant. The majority were discharged on postoperative day 1 (32 studies, 37 control). Follow-up VAS after 1 week for STP VAS and abdominal pain VAS in both groups were statistically insignificant. Even with small numbers of a well-conducted randomized trial, we demonstrated that bupivacaine irrigation at the gallbladder bedpost laparoscopic cholecystectomy does not affect pain relief.

Intra-operative pathological diagnosis of chronic ulcerative colitis in the two stage ileal pouch anal anastomosis.

OBJECTIVE: The definitive diagnostic biopsy for chronic ulcerative colitis (CUC) is the colon itself. Simultaneous colectomy and ileal pouch anal anastomosis (IPAA) means that the colon only becomes available for pathological assessment intra-operatively. We examined the role of intra-operative pathological assessment including frozen section in distinguishing between CUC and Crohn's colitis, inpatients undergoing simultaneous colectomy and IPAA. METHOD: Prospective study of 13 patients undergoing simultaneous colectomy and IPAA between Jan 1992 and April 1999. Resected colon was sent for pathological assessment intra-operatively in all 13 patients. Comparison was made between final histology and frozen section. Patient outcome and pouch function was recorded prospectively. RESULTS: Thirteen patients, M:F 5:8, mean age 41 years (range 20-56). Intra-operative pathological assessment including frozen section diagnosed CUC in nine patients, Crohn's disease in two patients and indeterminate colitis in two patients. The two Crohn's patients had subtotal colectomy and ileostomy. The nine CUC patients and two indeterminate colitis patients underwent IPAA. There was complete agreement between intra-operative assessment including frozen section and the final histopathology. At a median follow up of 31 months (8-58 months) all pouches were intact with good function. There has been no evidence of Crohn's disease on subsequent pouchoscopy and pouch biopsy. CONCLUSIONS: Pathological assessment, including frozen section of the colon, intra-operatively is a useful adjunct to surgical decision making in those patients undergoing simultaneous colectomy and IPAA.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.