Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) on pain after laparoscopic cholecystectomy. DESIGN: A prospective, randomized, placebo-controlled, double-blind study. SETTING: A university hospital. PATIENTS: Fifty-two patients with cholelithiasis but without known allergy to one of the study drugs, history of bleeding, peptic ulcer disease, known cardiac, lung or renal disease, abnormal liver function or use of opiates or NSAIDs within 2 weeks before operation. Patients were assigned to one of three groups and treatment was randomized by placing the drugs in sealed, numbered envelopes. INTERVENTION: Administration of the NSAIDs ketorolac, intramuscularly, or indomethacin, rectally, before laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Postoperative pain scored on a a visual analogue scale and by nurse assessment, total dose of fentanyl citrate given, and nausea or emesis. RESULTS: Patients in the placebo group reported significantly more pain than either NSAID group (p<0.05) and were reported as having significantly more pain by the nurses (P<0.05). These patients were subsequently treated with a higher mean postoperative dose of fentanyl citrate than either NSAID group (p<0.05). Furthermore, the placebo group reported more nausea and emesis (p<0.05). There was no significant difference in any of the parameters measured between the ketorolac or indomethacin group. CONCLUSIONS: The data demonstrate that the NSAIDs ketorolac and indomethacin, administered preoperatively, decrease early postoperative pain and nausea after laparoscopic cholecystectomy and are equally efficacious in producing these results.

Thoracoscopic transthoracic dorsal sympathectomy.

The authors report on the three patients who underwent thoracoscopic transthoracic dorsal sympathectomies by the techniques of minimal-access surgery learned from laparoscopic cholecystectomy. All three had histologic confirmation of removal of the sympathetic chain and have had an encouraging early postoperative result. The authors believe that thoracoscopic transthoracic dorsal sympathectomy can be accurately and safely performed and will become the method of choice for dorsal sympathectomy.

Ultrasonographic and radiologic evaluation of patients after laparoscopic cholecystectomy.

The first 30 patients scheduled to undergo laparoscopic cholecystectomy at the Kingston General Hospital, Kingston, Ont., were studied by abdominal ultrasonography and abdominal roentgenography 24 hours after the procedure. The ultrasonogram appeared normal in 21 of the 29 patients in whom laparoscopic cholecystectomy was successful. In six of the eight patients with an abnormal ultrasonogram a tiny collection of fluid was identified in the gallbladder fossa; in two patients retained intraperitoneal stones were identified (one of these patients also had a small fluid loculus); and one patient had a small amount of free fluid in Morrison's pouch. This last patient was subsequently found to have a retained common-bile-duct stone, which required endoscopic removal. Plain films showed moderate to large amounts of retained gas intraperitoneally in only three patients. Colonic distension was recorded in 23 of the 28 patients studied, suggesting a partial colonic ileus. Residual pneumoperitoneum and colonic distension did not correlate with any untoward clinical findings. This study demonstrates that most patients have complete reabsorption of their pneumoperitoneum within 24 hours of laparoscopic cholecystectomy and that small amounts of fluid in the gallbladder fossa and mild to moderate colonic distension are not significant in terms of operative complications.

Laparoscopic cholecystectomy in a patient with situs inversus viscerum: a case report.

A patient with known situs inversus viscerum of the abdomen and congenital heart disease presented with symptomatic cholelithiasis in a left-sided gallbladder. Laparoscopic cholecystectomy was carried out successfully, despite the reversed anatomic relationships, and the patient made a smooth recovery. This is the first case report of a successful laparoscopic cholecystectomy in a patient with a left-sided gallbladder.

Human lymphocyte responsiveness is not enhanced by relief of biliary obstruction: an in-vitro study.

Imparied cell-mediated immunity has been described in obstructive jaundice and has been attributed to depressant serum factors or to depressed intrinsic T-cell function. The authors studied lymphocyte responsiveness to phytohemagglutinin stimulation, the in-vitro correlate of T-cell function, in 11 patients with biliary obstruction. Peripheral-blood mononuclear cells and serum were obtained before (mean serum bilirubin level 302 mumol/L) and after (mean serum bilirubin level 23 mumol/L) treatment of the biliary obstruction. Simultaneous cell culture of all samples disclosed no evidence of a serum depressant factor in patients with obstructive jaundice, and crossover incubation studies failed to suggest that there is a depression of intrinsic T-cell responsiveness that can be reversed by biliary drainage.

Isolated endometriosis of the small bowel presenting as acute small bowel obstruction.

Although endometriosis is a common disease, small bowel involvement is unusual. We recently treated a patient in whom the diagnosis of endometriosis was made only after histological examination of a solitary lesion, which was obstructing the distal ileum and had the clinical appearance of a malignant tumour.

Volvulus of the gallbladder: a case report.

Torsion of the gallbladder is a surgical emergency that occurs predominantly in the elderly and whose presentation is indistinguishable from acute cholecystitis. If patients being treated conservatively for acute cholecystitis fail to improve promptly, laparotomy is indicated, because the diagnosis of gallbladder torsion cannot be excluded. Cholecystectomy before the onset of gangrene and rupture of the gallbladder is curative.

Intra-abdominal sepsis after hepatic resection.

One hundred and thirty hepatic resections performed over an 8-year period were reviewed for evidence of postoperative intra-abdominal sepsis. Of 126 patients who survived for more than 24 hours after operation, 36 developed culture positive intra-abdominal collections (28.6%). Significant independent variables associated with the development of intra-abdominal sepsis were diagnoses of trauma or cholangiocarcinoma, and the need for reoperation to control hemorrhage during the postoperative period. Before 1984, infected fluid collections were treated predominantly by operative drainage, but this has largely been replaced by percutaneous methods, which have proven effective in most cases. Eighteen (50%) of the infections were caused by a mixed bacterial culture, with Streptococcus faecalis, Staphylococcus epidermidis, Staphylococcus aureus and Escherichia coli being the most common isolates. Six patients with clinical signs of sepsis had a sterile fluid collection drained with complete relief of symptoms. This review suggests that intra-abdominal sepsis is a frequent complication after hepatic resection, and can often be managed successfully by nonoperative percutaneous drainage.

Combined endoscopic and percutaneous stent insertion to overcome a problem of percutaneous stent insertion.

Non-operative stent insertion is a well-accepted means of palliating malignant biliary obstruction. The endoscopic approach is often considered the procedure of choice, with the percutaneous technique reserved for endoscopy failures. We recently encountered a patient in whom both techniques proved unsuccessful initially, and in whom palliation was finally achieved by means of a combined endoscopic and percutaneous transhepatic procedure.

Silastic catheter separation due to subcutaneous suture.

The development of large-bore, double-lumen Silastic catheters for introduction into the superior vena cava has made it possible for patients with renal failure to receive immediate dialysis while awaiting maturation of an arteriovenous fistula. Although infections and thrombotic complications have been well documented, separation of Silastic cannulas has seldom been described and is poorly explained. The authors report two such cases. In one the catheter was clearly sheared off due to snaring by a subcutaneous suture. In the second case, awareness of the possibility of such a complication allowed the authors to explore the catheter at the level of the venotomy. By dividing the suture under direct vision, they were able to remove the snared catheter before it became transected.

Misdiagnosis using endoscopic retrograde cholangiopancreatography in a patient with postcholecystectomy pain.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential tool to investigate patients with the postcholecystectomy syndrome. A normal cholangiogram usually rules out the presence of biliary tract disease, and further investigations are directed towards other organ systems. We present a case in which a normal ERCP caused a significant delay in reassessing the biliary tree in a patient who eventually presented with choledocholithiasis. A repeat ERCP should be considered in patients with persistent biliary tract pain, even if the initial ERCP shows no abnormality.

Histologic sequelae of endoscopic sphincterotomy: a canine experiment.

Concern for the late formation of strictures at the site of an endoscopic sphincterotomy has delayed the acceptance of this procedure as treatment for choledocholithiasis in otherwise healthy patients. The authors addressed this issue by comparing the biochemical and histologic sequelae of sphincterotomy in 23 dogs with those in 10 sham-operated controls. Twenty-four hours after sphincterotomy, hemorrhagic, edematous mucosa surrounded the incision. Microscopically, there was an acute inflammatory exudate bridging the mucosal surfaces. Mucosal regeneration was sufficient after 1 week to cover the defect caused by the cautery, although some inflammatory changes were still evident. A widely patent sphincterotomy orifice was seen in 15 dogs followed up for 10 weeks. In three dogs, the fibres of the papilla had reunited below the incision, resulting in a choledochoduodenal fistula. Histologically, complete healing of the mucosal surface had occurred with no evidence of scar formation or chronic inflammation. Serum bilirubin and liver enzyme measurements did not show evidence of biliary obstruction due to the sphincterotomy. From the results of our study, there is no evidence to suggest that an endoscopic sphincterotomy is predisposed to late stenosis.

Diagnosing papillary stenosis by technetium-99m HIDA scanning.

The diagnosis of papillary stenosis, occasionally seen after cholecystectomy, is confirmed by endoscopic retrograde cholangiopancreatography (ERCP), which demonstrates delayed emptying of contrast material into the duodenum for more than 45 minutes. The authors assessed 2,6-dimethyl phenyl carbamoyl methyl iminodiacetic acid labelled with technetium-99m (99mTc HIDA) as a less invasive procedure in these circumstances by comparing it with the findings from ERCP. Twenty-six patients who had pain after cholecystectomy were studied by continuous 1-hour scintigraphy after injection of 99mTc HIDA. Biliary flow was estimated by measuring uptake and clearance of the entire liver and common bile duct. Volunteers who had no pain after cholecystectomy served as controls. Of the 26 study patients, all 99mTc HIDA scan findings were within the control range in 11. Of these, 10 had normal biliary drainage confirmed by ERCP. The one patient with delayed drainage did not improve after endoscopic sphincterotomy. Two patients demonstrated pooling of 99mTc HIDA in cystic dilatations of the biliary tree, while the other 13 patients had obstruction of the distal common bile duct and impaired flow demonstrated on the 99mTc HIDA scan. All 13 of these patients had papillary stenosis proven by ERCP. The authors conclude that 99mTc HIDA scanning is a valuable, minimally invasive method of diagnosing papillary stenosis.