Management of traumatic liver injuries without a valid trauma system.

INTRODUCTION: Despite a global increase in conservative treatment of blunt liver injuries, the number of surgically treated traumas in one major trauma center in Iran has increased. The aim of this study was to unveil the reasons behind this increase in operative management by studying 228 consecutive patients at this regional center. HYPOTHESIS: The increased number of liver injuries operated upon is due to the lack of a solid, well-defined trauma system. METHODS: A retrospective review of all patients admitted for liver trauma at Bahonar Hospital, Kerman, Iran, from March 2001 until March 2006 was conducted. Patient data were collected, studied and statistically processed with regard to demographics, clinical and laboratory findings, surgical procedures, complications, and mortality. RESULTS: All patients who were admitted between 30-360 minutes after injury were included. Twelve hemodynamically stable patients were treated conservatively in an ordinary surgical ward. The remaining 216 patients, 153 of whom had blunt injuries, were hemodynamically unstable. A total of 70 patients were in hemorrhagic shock at the time of arrival. Hemodynamically unstable patients with either the suspicion of associated injuries and/or who displayed clinical deterioration and could not be observed in an ordinary surgical ward were treated surgically. The majority of patients who were operated upon in this series had a grade-II liver injury. The total mortality rate in surgically treated patients was 18.1%. None of the patients treated conservatively died. CONCLUSIONS: Despite the low grade of their liver injuries, the high number of surgically treated patients in this series was due to the absence of a valid trauma system. This result should encourage the authorities to review current trauma systems and trauma surgical guidelines.

Effect of intercostals neural blockade with Marcaine (bupivacaine) on postoperative pain after laparoscopic cholecystectomy.

BACKGROUND: Postoperative pain experienced by patients who undergo laparoscopic cholecystectomy may aggravate surgical complications, prevent early discharge, and cause readmission. This study aimed to evaluate the effectiveness of an intraoperative intercostals neural blockade for the control of postoperative pain after laparoscopic cholecystectomy. METHODS: In a prospective, double-blinded, clinical trial, 61 patients classified as American Society of Anesthesiology (ASA) 1 and 2 undergoing laparoscopic cholecystectomy were randomized to receive only general anesthesia (control group, n = 30) or general anesthesia plus intraoperative intercostals neural blockade using 0.5% bupivacaine-adrenaline at the right side (intercostals group, n = 31). Postoperative pain was assessed according to a pain severity score using a subjective analog visual scale (VAS) 6, 12, and 24 h after the surgery. Systemic narcotic injection was available to all surgically treated patients postoperatively according to their demand. The history, pain severity score, and all postoperative data were recorded for each patient. RESULTS: The pain severity score was significantly higher in control group than in the intercostals group (p < 0.001), suggesting that patients who received intercostals neural blockade had less pain postoperatively than the control group. CONCLUSION: Intercostals neural blockade may safely be used to reduce the postoperative pain after laparoscopic cholecystectomy.