Prospective randomized controlled trial comparing standard analgesia with combined intra-operative cystic plate and port-site local anesthesia for post-operative pain management in elective laparoscopic cholecystectomy.

BACKGROUND: Various mechanisms, including somatic and visceral nociceptive stimulation, have been suggested as a cause for pain after laparoscopic cholecystectomy (LC). We therefore conducted a prospective randomized controlled trial (PRCT) to evaluate whether somatovisceral pain blockade reduces pain after LC. HYPOTHESIS: Analgesic efficacy of multimodal analgesia is superior to standard analgesia for patients undergoing elective LC for symptomatic cholelithiasis. Specifically, topical cystic plate and port-site injection with 0.25 % bupivacaine significantly reduces pain after LC. DESIGN: This study was designed as single-blinded PRCT. SETTING: This study was conducted in an academic medical center. PATIENTS AND METHODS: Between February and May 2010 we randomly assigned 63 patients with symptomatic cholelithiasis in a 1:1 ratio to non-opioid/opioid analgesic combinations (Control Group, n = 32) and non-opioid/opioid analgesic combinations plus topical 0.25 % bupivacaine onto the cystic plate and local 0.25 % bupivacaine port-site injection, post-LC (Study Group, n = 31). Primary endpoint was patient-reported pain 1, 4, 6, 12, 24 h and 1 week post-LC using the Visual Analog Scale (VAS 0-10). RESULTS: Study groups were comparable clinicopathologically. There were no adverse events. A statistically significant reduction in mean pain score was apparent in Study Group patients in comparison with Control Group (mean VAS 4.83 ± 2.33 vs. 6.80 ± 1.87; p < 0.001) at all early (1-6 h) post-operative time points following LC. CONCLUSION: This PRCT shows significantly improved pain control with somatovisceral pain blockade over non-opioid/opioid analgesic combinations following LC for symptomatic cholelithiasis. For centers not utilizing adjunctive local anesthetic for LC, this topical use of bupivacaine may improve patient comfort during recovery. This trial was registered on www.ClinicalTrials.gov NCT# 01972620.

Rare solitary fibrous tumor of the stomach: A case report.

INTRODUCTION: Solitary fibrous tumors are rare soft tissue tumors of submesothelial origin and variable malignant potential. The most common localization is pleural, whereas only 0.6% are of extrapleural localization. Solitary fibrous tumor of the peritoneum, especially of gastric serosa is an extremely rare form of this tumor. CASE REPORT: We presented a 65-year-old female patient with solitary fibrous tumor of the stomach. Histopathological analysis of removed tissue showed the presence of tumor tissue built of spindle cells, elongated nuclei with moderately abundant cytoplasm. Cells were in a noncohesive arrangement, in smaller areas distributed in the form of palisade. There were amounts of hipocellular connective tissue, hyalinised, with small foci of dystrophic calcification. Mitoses were rare (less than 3/10 HPF). Blood vessels surrounded the connective tissue. Reviewed material did not contain elements of the parent organ. Immunohistochemically there were positivity on CD34 and vimentin, and negativity to S100, SMA, CD117, dezmin, and Ki-67 is < 2%. The change was diagnosed as a solitary fibrous tumor. CONCLUSION: Considering that benign solitary fibrous tumors of extrathoracic localizations are extremely rare neoplasms with unpredictable biological behavior and the possibility of recurrence, a long-term clinical and endoscopic follow-up on yearly basis of patients with this disease is recommended.

The role of duodenogastric reflux in formation of precarcinogenic gastric lesions--an experimental study.

INTRODUCTION: Duodenogastric reflux, commonly encountered as an aftermath of gastroenteroanastomosis, with or without gastric resection (Billroth I, Billroth II), vagotomy and pyloroplastic surgery, is known to cause inflammatory-dystrophic-metaplastic lesions of gastric mucosa. Our objective was to determine the effects of surgery-induced duodenogastric reflux on the development of precarcinogenic lesions or carcinoma in correlation with the reflux duration. MATERIAL AND METHODS: The experiment was performed on three groups of Wistar rats with 1) Billroth II-induced reflux surgery, 2) resection of the Rouxr-en-Y type reconstruction, and 3) control group with no resection. The aim of the experiment was to study the effects ofduodenogastric reflux on the rat gastric mucosa in correlation with two different types of gastroenteroanastomosis 8, 16 and 24 weeks after the surgery. RESULTS: In Billroth II group, hyperplastic changes were observed as early as in week 16. Statistically significant results were recorded in week 24, with 6.7% of metaplastic alterations, including dysplasia of all three degrees, dominantly severe dysplasia in 66.67%, early carcinoma in 20% and gastric carcinoma in 6.67%. In the Roux-en-Y group, gastric mucosa remained predominantly normal (60%), with somewhat increased frequency ofgastritis and dysplasia in week 24. In the control group, the finding of normal gastric mucosa was constant. CONCLUSION: The experiment confirms that direct contact of duodenal juice with gastric mucosa associated with Billroth II resection causes precarcinogenic lesions. Development of adenocarcinoma caused solely by duodenogastric reflux, excluding a carcinogenic agent is possible 20 weeks after the experiment--earlier than suggested by previous researchers.

[Role of surgical resection in treatment of pancreatic adenocarcinoma].

INTRODUCTION: Pancreatic adenocarcinoma is the fifth leading cause of death from malignant diseases. The total five-year rate is bellow 5%, but in patients who underwent pancreatic resection, the five-year rate may be up to 20%. Surgical resection is still the only therapeutic option that offers the possibility of cure. In recent decades, the perioperative mortality rate has been significantly reduced in the institutions performing a number of these operations per year and has become less than 5%. Postoperative morbidity remains high. MATERIAL AND METHODS: The results of surgical resection in the treatment of pancreatic adenocarcinoma have been analyzed. A retrospective study included the patients operated at the Department for Abdominal, Endocrine and Transplantation surgery, Clinical Center of Vojvodina. RESULTS: In the period from February 1st 1998 to February 1st 2007 a total of 67 patients with pancreatic adenocarcinoma underwent resection. The average age of patients was 58.81 +/- 1.42 years. There were 44 (65.7%) male and 23 (34.3%) female patients. The most common locations of cancer were the head, then the body and the tail of the pancreas and they were found in 57 (85.1%) cases, 7 (10,4%) cases and 3 (4,47%) cases, respectively. The postoperative mortality appeared in 3 (4.47%) cases and postoperative morbidity in 21 (31.3%) cases. The average survival was 22.89 +/- 3.87 months, the median being 9.0 +/- 2.18 months. The five-year survival rate was 13.5%. CONCLUSION: For patients with pancreatic cancer, surgical resection still remains the only chance of cure. These procedures are performed with acceptable postoperative mortality and morbidity rate. The percentage of cured patients is still unsatisfactorily low.

Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy.

BACKGROUND: Information-based scoring systems predictive of outcomes of midline laparotomy are needed; these systems can support surgical decisions with the aim of improving patient outcomes and quality of life, and reducing the risk of secondary surgical procedures. STUDY DESIGN: All study subjects were followed for a minimum of 6 months after operation. Numerous demographic, clinical, treatment, and outcomes-related perioperative factors were recorded to determine statistical association with the primary end point: incisional hernia development. The first analysis was designed to establish the statistical model (scoring system) for estimating the risk of incisional hernia within 6 months of midline laparotomy. Univariate and multivariate analyses were performed. A simple additive model was constructed using stepwise logistic and linear regression. The second part of the study analysis was validation of the scoring systems developed initially. RESULTS: A logistic linear minimum regression model was developed based on four covariates independently predictive of incisional hernia: Body mass index (BMI) > 24.4kg/m(2); fascial suture to incision ratio (SIR) < 4.2; deep surgical site, deep space, or organ infection (SSI); and time to suture removal or complete epithelialization >16 days (TIME). The hernia risk scoring system equation [p(%) = 32(SIR) + 30(SSI) + 9(TIME) + 2(BMI)] provided accurate estimates of incisional hernia according to stratified risk groups based on total score: low (0 to 5 points), 1.0%; moderate (6 to 15 points), 9.7%; increased (16 to 50 points), 30.2%; and markedly increased (>50 points), 73.1%. CONCLUSIONS: A statistically valid, straightforward, and clinically useful predictive model was developed for estimating the risk of incisional hernia within 6 months of midline laparotomy. Prospective independent validation of this model appears indicated.