Randomized clinical trial comparing two different techniques of local anesthesia (subcutaneous versus subcutaneous & deep infiltration) for postoperative pain in patients undergoing open appendecectomy.

This study compared the postoperative analgesic effect of local anesthetic (LA) injected subcutaneous (SC) alone versus local anesthetic injected both SC and deep in patients undergoing open appendecectomy operations. Sixty patients ASA class I-II undergoing open appendecectomy for presumed acute appendicitis will be randomly assigned into three groups. After routine monitoring, anesthesia induction was performed with propofol, fentanyl and, cis-atracurium; later, maintenance was continued with isoflurane. GA received local infiltration of the skin prior to incision with bupivacaine 0.25% (10 ml), GB received received half the bupivacaine infiltrated into the skin and other half deep-to external oblique prior to incision to create a local nerve field blockade & GC received half dose of saline subcutaneous & half deep to external oblique muscle prior to incision. Postoperative pain was assessed using visual analogue score (VAS) at 1, 4, 8, & 24 hours post extubation. Pethidine 1 mg/kg was given if VAS is ≥ 4. All patients in GA (SC) and Control required postoperative analgesics, compared to only 60% of the patients in GB (SC+deep). Time for the first analgesic requirement was prolonged in GB compared to other groups (P < 0.01). VAS scores were significantly lower in patients of GB in the first 8 hr. postoperative compared to GA &GC (P < 0.01).

The effect of portal vein branch plus heterochronous hepatic artery branch ligation on liver regeneration (experimental study).

The proliferative capacity of non-ligated liver lobes was designned experimental study on dogs in which portal vein and hepatic artery ligation was done either simultaneously or heterochronously. Dogs were divided into four groups: G I (control G); laparotomy was performed without vascular ligation, G II; dogs were subjected to ligation of the right lateral and median branches of portal vein alone, G III, dogs were subjected to hepatic artery branches ligation 48h after portal vein branches ligation. G IV, dogs were subjected to ligation of the same branches of the portal vein and hepatic artery simultaneously. Dogs from each group were subjected to a liver biopsy before and 24, 48, 72, & 168h (one week) after surgery. Standard serum liver functions were tested before ligation, 72 hs and one week after ligation. Hepatic regeneration in the non-ligated lobe was assessed through histo-pathological study, DNA quantitation of the hepatic nuclei by the computerized image analysis system and estimation of proliferation marker in hepatic tissue. In this study, the labeling index of the nuclear factor NF Kappa B (P105), a novel monoclonal antibody specific for P105 protein, was determined immunohistochemically. Results showed induction of the NK kappa B (P105) labeling index showed maximum levels G III. Quantitative determination of serum glutamic-oxalacetate transaminase (GOT) showed peak levels in G IV at 24h after surgery. Our finding for this index that heterochronous partial portal vein and hepatic artery ligation (i.e., G III) is effective, because this procedure leads to an increase in the compensatory hypertrophy of the non-ligated liver lobes that depends on the regenerative capacity of the lobes themselves. In contrast, in G IV (i.e., synchronous ligation of portal vein and hepatic artery branches) liver regeneration did not occur due to the severe systemic damage induced by infectious necrosis in the ligated lobe. The serial changes in liver function in G III indicate that the use of this technique may minimize dysfunction in the remaining hypertrophied liver lobes, similar to findings in G II. So, the PVBL plus heterochronous HABL procedure is safer and more effective than PVBL alone, or PVBL plus simultaneous HABL. A better knowledge of the events following such heterochronous ligation should improve the clinical outcome of hepatic resection for liver diseases.