Narcotic Analgesic Requirements Research Articles

Ultrasound-Guided Techniques for Postoperative Analgesia in Patients Undergoing Laparoscopic Sleeve Gastrectomy: Erector Spinae Plane Block vs. Quadratus Lumborum Block

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a common bariatric surgery. Regional anesthetic techniques decrease postoperative pain, narcotic analgesic requirements, and opioid-related adverse effects in patients scheduled for bariatric surgery. OBJECTIVES: The research team conducted this clinical trial to assess the effects of bilateral ultrasound (US)-guided erector spinae plane block (ESPB) on postoperative pain scores and postoperative analgesics consumption compared with bilateral US-guided quadratus lumborum block (QLB) in the first 24 hours following LSG. STUDY DESIGN: A randomized, double-blind, prospective, single-center study. SETTING: Ain-Shams University Hospitals. METHODS: Patients: One hundred twenty morbidly obese patients were scheduled for LSG. Intervention: Were randomly assigned to 3 groups (40 each): bilateral US-guided ESPB, bilateral US-guided QLB, or control (C) group. Measurements: The time to first rescue analgesia (ketorolac) was considered as a primary outcome. The time to perform the block, the duration of anesthesia, the time to first ambulation, the visual analog scale (VAS) at rest, VAS at movement, the total nalbuphine consumption (mg), the total requirements of rescue analgesia (ketorolac) over the first 24 hours after surgery and the study safety profile were considered as secondary outcomes. RESULTS: The time to perform the block and the duration of anesthesia were higher in the QLB group compared to other groups, with significant differences between ESPB and C groups (P < 0.001, P < 0.001, respectively). The ESPB and QLB groups were superior to the C group as regards the time to first rescue analgesia, the total dose of rescue analgesia, and the total nalbuphine consumption (P < 0.001, P < 0.001, P < 0.001, respectively). In the C group, VAS-R and VAS-M readings were higher in the first 18 hours after surgery (P < 0.001, P < 0.001, respectively). In the rest 6 hours of 24 hours after surgery, the QLB group had lower VAS-R and VAS-M readings than the C group (P < 0.001, P < 0.001, respectively). More patients in the C group had higher incidences of nausea and vomiting (P = 0.011, P = 0.002, respectively). In the C group, the time to first ambulation, the length of PACU stay, and the hospital stay were higher in comparison to the ESPB and QLB groups (P < 0.001, P < 0.001, P < 0.001, respectively). More patients in the ESPB and QLB groups were satisfied with postoperative pain management protocol (P < 0.001). LIMITATIONS: The lack of postoperative respiratory assessment (e.g., spirometry) precluded the identification of either ESPB or QLB effects on pulmonary functions in such patients. CONCLUSION: Bilateral ultrasound-guided erector spinae plane block and bilateral ultrasound-guided quadratus lumborum block provided adequate postoperative pain control and reduced postoperative analgesic requirements for morbidly obese patients scheduled for laparoscopic sleeve gastrectomy with priority to bilateral erector spinae plane block. KEY WORDS: Obesity, bariatric surgery, ultrasound, erector spinae plane block, quadratus lumborum block, postoperative, pain, analgesia

Investigation of the Effect of Local Anesthesia Application on the İncision Line on Patient Comfort in Patients Who Underwent Pfannestiel İncision-Prospective Case-Control Study Article Sidebar

AİM: It was aimed to investigate the effect of local anesthetic application on the Pfannenstiel incision line on patient comfort. METHODS: The study was carried out between 2021 and 2022. It was performed on 240 patients. The patients were categorized as Group 1 in which a local anesthetic was administered and Group 2, which was not administered a local anesthetic. It was performed on 120 hysterectomy cases operated under general anesthesia. 5 mg 0.5% bupivacaine was used as a local anesthetic. The patients were evaluated in terms of postoperative pain score, gas-gaita release time, postoperative mobilization, narcotic analgesic requirement, post-operative home comfort, daily return to basic work, and feeling like they used to be. For statistical analysis, SPSS Version 28.0.1 program was used. RESULTS: A statistically significant decrease was observed in postoperative 2nd-hour pain scores in Group 1 patients compared to Group 2 (p=0.007). A statistically significant decrease was found in the need for narcotic analgesics in Group 1 patients (p=0.04). Gas-stool release time was shorter in Group 1 patients compared to Group 2, and it was statistically significant (p=0.038). Mobilization was easier in the 1st group of patients and it was found to be statistically significant compared to the 2nd group (p=0.004). In other parameters, there was no difference between the two groups. CONCLUSİON: Applying local anesthesia to the incision site reduces pain in the first 2 hours postoperatively, earlier gas-gaita output, comfortable mobilization, and a decrease in the need for narcotic analgesics.

Comparison between open and laparoscopic appendectomy: A systematic review

Introduction: Open appendectomy (OA) has been the treatment of choice for acute appendicitis since its introduction by Mc-burney in 1884. Laparoscopic appendectomy (LA) though widely practiced, has not gained universal approval. LA was first described in 1983. Some early studies showed equivocal results about benefit of LA. Recent studies showed overall benefit in favour of LA. So, we decided to do this study with a view to evaluate the therapeutic benefit of LA by comparing with conventional OA. Materials and methods: We collected data of 100 appendectomies done in Chamarajanagara institute of medical sciences & hospital from for a period of 15 months. Out of them 50 had conventional OA and 50 had LA. We compared the mean operation time, time of first oral feeding, narcotic analgesic requirement, and duration of post-operative hospital stay. Results: We found that mean operation time was 33±5.8 minute and 37±7.5 minute in LA and OA respectively. Duration of post-operative hospital stay was 1.2 days shorter in Laparoscopic group. LA required 1.1 shots of less analgesic than OA. Oral feeding was resumed 21 hours earlier following LA compared to OA. Laparoscopic appendectomy was safely performed in paediatric patient without any adverse effect. We also found that, in female patient, concurrent ovarian cysts, tubal pregnancy and endometriosis can be diagnosed and managed laparoscopically in the same sitting. Conclusion: Our study found that laparoscopic appendectomy is an effective and safe procedure irrespective of age and sex of the patient. LA has added advantage of early return of bowel movement, less post-op hospital stay and less requirement of narcotic analgesic.

Does previous abdominal surgery adversely affect perioperative and oncologic outcomes of laparoscopic radical cystectomy?

BackgroundLaparoscopic radical cystectomy (LRC) has been shown to have less estimated blood loss (EBL), transfusion rate, narcotic analgesic requirement, earlier return of bowel function, and shorter hospital stay. The aim of this study was to investigate the feasibility, peri-operative and oncologic outcomes of laparoscopic radical cystectomy (LRC) in patients with previous abdominal surgery (PAS).MethodsWe retrospectively reviewed 243 patients undergoing open radical cystectomy (ORC) or LRC with bilateral pelvic lymph node dissection and urinary diversion or cutaneous ureterostomy at a single center from January 2010 to December 2015. Demographic parameters, intra-operative variables, peri-operative records, pathologic outcomes, and complication rate were reviewed to assess the impact of PAS on peri-operative and oncologic outcomes.ResultsPatients in both ORC and LRC subgroups were homogeneous in terms of demography characteristics including age, gender, BMI, ASA score, and comorbidity. Estimated blood loss (EBL) was higher in patients with PAS undergoing ORC compared to those with no PAS (P = 0.008). However, there was no significant difference of EBL among patients undergoing LRC with or without PAS (P = 0.896). There was no statistical difference in peri-operative parameters and pathological outcomes. Patients with PAS undergoing ORC and ileal conduit had a higher vascular injury rate (P = 0.017). Comparing patients with PAS performed by LRC and ORC, the number of patients with the vascular injury was higher in ORC groups regardless of the type of diversion (ileal conduit, P = 0.001, cutaneous ureterostomy, P = 0.025). There is no significant difference in other complications.ConclusionThe presence of adhesions from PAS is not a contraindication to LRC. Patients with PAS may benefit from LRC with lower estimated blood loss, fewer transfusion rates, and vascular injuries. Furthermore, the overall oncologic outcomes and complication rate are similar between LRC and ORC patients with PAS.

Endoscopic resection of gastric gastrointestinal stromal tumors originating from the muscularis propria layer in North America: methods and feasibility data.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. In recent years, endoscopic procedures such as endoscopic enucleation (EN) and endoscopic full-thickness resection (EFTR) have been used to resect GISTs. This study aimed to investigate the clinical efficacy, safety, and feasibility of endoscopic resection of GISTs in a North American population. A total of 25 patients with gastric submucosal lesions (SML) underwent endoscopic resection from December 2014 to April 2016. Data from cases with histologically proven GISTs originating from the muscularis propria layer (MP-GIST) were collected. The main outcome measures were complete resection rate, operative time, postoperative complications, length of hospital stay, narcotic analgesic requirement, and follow-up outcomes. Surveillance was performed with CT abdomen, and/or EGD along with oncology follow-up at 6- to 24-month intervals. Out of 25 gastric SML, there were 12 histologically proven MP-GIST. Five endophytic MP-GIST were removed by EN, and seven exophytic MP-GIST were removed by EFTR. All lesions were removed en bloc except for one hard to localize exophytic lesion which was completely removed piecemeal. The mean removal time was 79.7min (range 17-180min). Nine out of twelve patients required inpatient admission for observation with a mean length of stay of 2.08days (range 1-4days). No complications were noted and no narcotic analgesics were required. Pathology reports showed that one GIST was intermediate risk but all others were low-risk lesions. No recurrence has been noted thus far. Endoscopic removal of MP-GIST by a trained endoscopist appears to be safe and feasible in North American population. Further studies with greater sample size are necessary to compare endoscopic versus surgical resection of MP-GIST. Comparison of outcomes may support wider use of endoscopic techniques for GIST removal.

Preemptive Analgesia with Pregabalin: It’s Effect on Postoperative Analgesia after Abdominal Hysterectomy

Background: Preemptive administration of single dose pregabalin reduces postoperative narcotic analgesicconsumption after abdominal hysterectomy under sub-arachnoid block. Objectives: The present study was designed to evaluate the effect of pregabalin as a preemptive agent toreduce postoperative pain. Methodology: This randomized double-blind placebo-controlled clinical trial was conducted in theDepartment of Anesthesia, Analgesia and Intensive Care Medicine at Banghabandhu Sheikh Mujib MedicalUniversity, Dhaka from July 2010 to June 2012 for a period of two years. Women aged between 40 to 60years scheduled for abdominal hysterectomy under sub-arachnoid block were selected as study population.A total of one hundred and twenty women were randomly allocated into two equal groups by cardsampling. 120 cards, 60 for each group were prepared by another person who was not aware of the study.Group A was known as study group who were received 300mg oral pregabalin one hour before performanceof SAB and group B was known as control group who were received matching placebo one hour beforeSAB.Pain in the postoperative period was assessed on visual analogue scale and managed with PCAusing morphine. Patients were visited by the investigators at ½, 1, 2, 4, 12, and 24 h after operation. Ateach visit, outcomes were measured in the following order: heart rate, mean arterial pressure, respiratoryrate, SpO2, and VAS pain score, sedation score, and any side effects which would develop. Finally, totalamount of morphine administered in 24 hour was recorded. The time since spinal anaesthesia to firstdose of analgesic was also recorded. Result: The mean 24hrs morphine consumption was 13.3 (±1.5) mg in Group-A, whereas in Group-B was29.1(±2.1) mg. The Group-A showed a significant reduction in morphine consumption then the Group-B(P<0.001). The time interval of first dose of analgesic was 5.2(±0.4) hrs in the Group-A, whereas in theGroup-B was 2.3(±0.2) hrs.The difference was significant (P<0.05).It was seen that side effects like respiratorydepression more in Group-B, dizziness and somnolence was more in Group-A than Group-B.Sedationscore was higher in Group-A than Group-B. Incedence of nausea/vomotting was same in both groups. Conclusion: It is demonstrated that preemptive use of Pregabalin led to significant reduction in narcoticanalgesic requirement and thereby a significant reduction in morphine related side effects. Beside this,pregabalin caused increased levels of sedation which may be beneficial for certain patients in earlypostoperative periods. JBSA 2017; 30(2): 66-74

Preoperative intravenous ibuprofen does not influence postoperative narcotic use in patients undergoing elective hernia repair: a randomized, double-blind, placebo controlled prospective trial

IntroductionInguinal and umbilical hernia repairs are among the most common surgical procedures performed in the US. Optimal perioperative pain control regimens remain challenging and opioid analgesics are commonly used. Preoperative nonsteroidal anti-inflammatory drug (NSAID) administration has been shown to reduce postoperative narcotic requirements. This study sought to evaluate the efficacy of perioperative intravenous (IV) ibuprofen on postoperative pain level and narcotic use in patients undergoing open or laparoscopic inguinal and/or umbilical hernia repair.MethodsA single center, randomized, double-blind placebo-controlled trial involving patients ≥18 years undergoing inguinal and/or umbilical hernia repair was performed. Patients were randomized to receive 800 mg of IV ibuprofen or placebo preoperatively. Outcomes assessed included postoperative pain medication required and visual analog scale (VAS) pain scores.ResultsForty-eight adult male patients underwent inguinal and/or umbilical hernia repair. Patients receiving IV ibuprofen used more oxycodone/acetaminophen (32% vs 13%) and IV hydromorphone (12% vs 8.7%), and fewer combinations of pain medications (44% vs 65.2%) in the first two postoperative hours compared to placebo (p=0.556). The IV ibuprofen group had more patients pain free (28% vs 8.7%, p=0.087) and lower VAS scores (3.08±2.14 vs 3.95±1.54, p=0.134) at 2 hours postoperatively, compared to the placebo group, however, this was not statistically significant. Similar pain levels at 1, 3, and 7 days, postoperative and similar use of rescue medications in both groups were observed.ConclusionPreoperative administration of IV ibuprofen did not significantly reduce postoperative pain among patients undergoing elective hernia repair. Considerable variability in postoperative narcotic analgesic requirement was noted, and larger scale studies are needed to better understand the narcotic analgesic requirements associated with IV ibuprofen in inguinal/umbilical hernia repair patients.

Comparative Efficacy of Bilateral Thoracoscopic Splanchnicectomy for Intractable Pain Secondary to Pancreatic Cancer vs Chronic Pancreatitis

Splanchnicectomy has been evaluated for treatment of chronic pain in both pancreatic cancer and chronic pancreatitis patients, although its efficacy has not been compared in these 2 patient populations. This study aimed to compare bilateral thoracoscopic splanchnicectomy in treatment of abdominal pain secondary with pancreatic cancer and chronic pancreatitis. A University of Louisville database was evaluated from July 1998 to March 2016 for patients undergoing bilateral thoracoscopic splanchnicectomy for intractable pain secondary to pancreatic cancer (n= 48) or chronic pancreatitis (n= 75). Patients were evaluated pre- and postoperatively with regard to abdominal pain and related symptoms, narcotic analgesic requirements, and hospital admissions. Narcotic use was quantified using the Kentucky All Schedule Prescription Electronic Reporting system. After bilateral thoracoscopic splanchnicectomy, 28% of pancreatic cancer patients continued to experience abdominal pain compared with 57% of chronic pancreatitis patients. Daily narcotic dose decreased for 74% of pancreatic cancer compared with 32% of chronic pancreatitis patients (p < 0.001). Sixty-seven percent of pancreatic cancer patients discontinued pain medications completely compared with 14% of chronic pancreatitis patients (p<0.001). Hospitalizations decreased significantly in both groups (p < 0.001; p= 0.001), although mean number of postoperative hospitalizations was lower for pancreatic cancer (0.5) compared with chronic pancreatitis patients (2.80) (p < 0.001). Mean follow-up was significantly shorter for pancreatic cancer patients than for chronic pancreatitis patients (8months vs 32 months; p < 0.001). Bilateral thoracoscopic splanchnicectomy safely, effectively, and durably relieves abdominal pain in patients with both pancreatic cancer and chronic pancreatitis. However, it is more effective in providing pain relief and preventing pain-related hospitalizations in patients with pancreatic cancer compared with those with chronic pancreatitis.

PostOperative Pain Level and Narcotic Analgesic Medication Requirement Amongs Adults Undergoing Orthognathic Surgery

Bimaxillary osteotomy comprising bilateral sagittal split osteotomy and LeFort I osteotomy is one of the most common major maxillofacial operations, and has the highest reported postoperative pain scores.1 Due to the severity of this post-surgical pain, rapid onset and prolonged pain relief is ideal in this acute setting. Narcotic analgesics like Oxycodone have become successful for treating this acute postoperative pain as they have shown to provide a more rapid analgesic effect compared to most other non-opioid analgesic medications. Unfortunately, this rapid onset of opioid analgesics like Oxycodone has been shown to be a contributing factor to narcotic addiction potential.2 Identifying clinical variables that help predict narcotic medication requirements in the acute setting can potentially direct prescribing practices and thus limit overmedication of narcotics and addiction.

Comparison of Clinical Effects of Dexketoprofen and Paracetamol Used for Analgesia in Endoscopic Retrograde Cholangiopancreatography.

This study aimed to compare 50 mg dexketoprofen vs. 1 g paracetamol that were parenterally administered before endoscopic retrograde cholangiopancreatography (ERCP) under sedoanalgesia with comparable anaesthesia depth regarding haemodynamic, pain, narcotic analgesic requirement, recovery and post-procedural cognitive functions. Overall, 80 ASA I-III patients aged 18-75 years who were undergoing scheduled ERCP were randomly assigned into three groups. In all patients, the mini-mental test (MMT) was conducted before the procedure. No drug was administered to controls (Group C; n=26); patients were transferred to ERCP unite 30 min after parenteral dexketoprofen (50 mg) in group D (n=27) and paracetamol (1 g) in group P (n=27). The standard monitoring was applied. After intravenously administering loading doses of midazolam (0.02 mgkg) and propofol (1 mg kg(-1)), propofol infusion was administered at a dose of 2-4 mg kg(-1) h(-1) to maintain a bispectral index value of 50-70. Fentanyl (0.05 μg kg(-1)) was intravenously administered when patients experienced pain. Haemodynamic effects, additional analgesic requirement, adverse effects during procedure, time to reach Aldrete score of 9 and satisfaction of an endoscopist and patient were recorded. MMT was repeated 3 h after completing the procedure. Fentanyl requirement during the procedure was significantly low in group D (p<0.05). Apnoea during the procedure and nausea after the procedure were least common in group D while significantly lower than group C (p<0.05). There was no significant difference with respect to MMT scores and endoscopist's satisfaction, while patient satisfaction was greater in group P. Parenterally administered dexketoprofen provided better haemodynamic effect and pain control, thereby decreasing incidence of adverse events by reducing the requirement for narcotic analgesics.

Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after laparoscopic Roux-en-Y gastric bypass

BackgroundIntravenous (IV) acetaminophen has the potential to reduce postoperative narcotic analgesic requirement but this has not been reported in bariatric surgery. As lower dosages could reduce undesirable narcotic side effects, we investigated the opioid-sparing effect of concomitant IV acetaminophen in bariatric surgery. MethodsWe performed a retrospective review of our electronic medical records of laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed for severe obesity between 2011 and 2013. We identified 183 patients that received scheduled IV acetaminophen in addition to morphine sulfate (MSO4) patient-controlled analgesia (PCA). A cohort of 229 patients from the preceding 2 years who were treated with MSO4 PCA but not acetaminophen was used as a historical control. Patient demographic characteristics and narcotic use data were extracted from electronic medical records. Student’s t test or linear regression was used as appropriate (P< .05). ResultsDuring the first 24-hour postoperative period after LRYGB, narcotic analgesic demand (total PCA demand including nondelivery of narcotic due to lock-out) was reduced by 25% with the concomitant use of IV acetaminophen (40.5 versus 30.9 average pushes; P<.05). During the same period, narcotic analgesic dosage requirement was cut down by 20% in the study group (average of 29.9 versus 24.1 mg of MSO4; P<.05). Linear regression analysis confirmed that these changes were independent of age, gender, and body mass index distribution, or type 2 diabetes mellitus. ConclusionScheduled IV acetaminophen reduces the demand for and the requirement of narcotic analgesia after LRYGB. We provide new evidence in support of the routine use of multimodal analgesia that includes scheduled IV acetaminophen in the initial 24-hour period after bariatric surgery.

Laparoscopic vs Open Appendectomy : A Comparative Study

Backgraound: Open appendectomy (OA) has been the treatment of choice for acute appendicitis since its introduction by Mc-burney in 1884. Laparoscopic appendectomy(LA) though widely practiced, has not gained universal approval. LA was first described in 1983. Some early studies showed equivocal results about benefit of LA. Recent studies showed overall benefit in favour of LA. So far no such a large study was done in any Bangladeshi hospital. So, we decided to do this study with a view to evaluate the therapeutic benefit of LA by comparing with conventional OA.Materials and methods: We collected data of 763 appendectomies done in Jahurul Islam medical college hospital from July 2007 to June 2012 for a period of 5 years. Out of them 448 had conventional OA and 315 had LA. We compared the mean operation time, time of first oral feeding, narcotic analgesic requirement, duration of post operative hospital stay.Results: We found that mean operation time was 33±5.8 minute and 37± 7.5 minute in LA and OA respectively. Duration of post operative hospital stay was 1.2 days shorter in Laparoscopic group. LA required 1.1 shots of less analgesic than OA. Oral feeding was resumed 21 hours earlier following LA compared to OA. Laparoscpic appendectomy was safely performed in paediatric patient without any adverse effect. We also found that, in female patient, concurrent ovarian cysts, tubal pregnancy and endometriosis can be diagnosed and managed laparoscopically in the same sitting.Conclusion: Our study found that laparoscopic appendectomy is an effective and safe procedure irrespective of age and sex of the patient. LA has added advantage of early return of bowel movement, less post-op hospital stay and less requirement of narcotic analgesic.

Comparison of surgical and functional outcomes of open, laparoscopic and robotic pyeloplasty for the treatment of ureteropelvic junction obstruction.

To compare the surgical and functional outcomes of open, laparoscopic and robotic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO). Between 2007 and 2012, a total of 56 patients underwent conventional open (Group 1; n=25), laparoscopic (Group 2; n=16), and robotic (Group 3; n=15) dismembered pyeloplasty operations. Preoperative evaluation was performed using urinalysis, urine culture, blood biochemistry, urinary ultra-sound, intravenous pyelogram (IVP) (optional) and Mercaptoacetyltriglycine (MAG-3) renal scan. The mean operation time, estimated blood loss, drain removal time, narcotic analgesic requirements, length of hospital stay and functional outcomes were compared among groups. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) v. 20 (IBM, Armonk, NY, USA) software, and statistically significant differences were determined using a p value <0.05. The mean age of the patients was 30 years in Group 1, 34.3 years in Group 2 and 32.9 years in Group 3. The mean operation time was 127, 130 and 114 min (p=0.32), and the estimated blood loss was 105, 31 and 28 mL, respectively (p=0.001). The drain was removed after 4.36 (±1.3), 2.33 (±0.6) and 1.8 (±0.6) days after surgery (p<0.001), and the mean hospital stay was 4.14 (±1.8), 2.8 (±0.75) and 2 (±1) days, respectively (p<0.001). Narcotic analgesic requirement was significantly higher in Group 1 compared with Groups 2 and 3 (p=0.02). The radiographic and symptomatic success rates were 96% in Group 1, 93.75% in Group 2 and 93.3% in Group 3. Laparoscopic and robotic pyeloplasty are feasible, effective, reliable and minimally invasive treatment approaches for the treatment of UPJO as compared with open dismembered pyeloplasty.

Surgical Site Infection (Ssi) In Open Vs Laparoscopic Appendicectomy In Case Of Complicated Appendicities: A Retrospective Study

Appendicectomy is one of the most common surgical procedures in day to day practice in Bangladesh. Although it is considered a safe operation, a potential complication developed in complicated appendicitis. Surgical site infection is one of those noticeable complications. Infection of wound still remains one of the main postoperative morbidities and as a result, prolonged hospitalization in those undergoing open appendicectomy(OA).Laparoscopic appendectomy (LA) has been widely practiced for uncomplicated appendicitis. The role of laparoscopy in management of complicated appendicitis remains undefined. Complicated appendicitis is associated with a significant risk of postoperative morbidity, making the value of the minimally invasive approach is superior. This is a retrospective study comparing SSI in laparoscopic appendicectomy versus open appendicectomy. The study was performed on 120 patients which were clinically and after investigation diagnosed as a case of complicated appendicitis from January 2008 to June 2011. Out of them 60 patient were done by laparoscopically and 60 patients by open method. Complicated appendicitis includes perforated appendicitis, gangrenous appendicitis and appendicular abscess or early lump found intra-operatively. Patients were excluded if the diagnosis of appendicitis was not clinically established and if they had a history of symptoms for more than 5 days and/or a palpable mass in the right lower quadrant. The conversion rate, operative time, SSI (postoperative abdominal and wound infections), the return to oral intake, and the length of hospitalization were analyzed .The aim of this study is to compare the SSI between LA and OA for complicated appendicitis. In 60 patients of laparoscopic appendectomy for complicated appendicitis there were 35 patients with perforated appendicitis, 12 patients with gangrenous appendicitis and 13 patients with early appendicular lump or abscess. There were 42 males and 18 females, mean age 24 yrs (range, 18 to 32), The average operating time was 65 minutes. The average length of hospitalization was 3.2(2-5) days. The post operative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.33%). Four (6.6%) had post operative complications (diarrhea). Nine patients developed (15.00%) developed wound (port) infection. SSI . No statistically significant differences in operative time (P0.13) There was no mortality in the current series. Laparoscopic appendectomy is a safe and feasible treatment option in complicated appendicitis. It is advantageous than open surgery because of less wound infection, less morbidity, less hospital stay and early return to work and not associated with increased risk of septic postoperative complications. JCMCTA 2013; 24 (1):53-57

Tackling of Complicated Appendicitis by Laparoscopy: Is it Safe and Feasible?

Background: Laparoscopic appendectomy has been widely practiced for uncomplicated appendicitis. Various reports demonstrated its merits in reducing postoperative pain, analgesic requirement, incidence of wound infection, and hospital stay. The role of laparoscopy in management of complicated appendicitis remains undefined. Complicated appendicitis is associated with a significant risk of postoperative morbidity, making the value of the minimally invasive approach is superior. Methods: This is a retrospective study done in Chittagong Medical College Hospital and various private hospitals in Chittagong from January 2008 to June 2011. Sixty patients with complicated appendicitis included perforated appendicitis, gangrenous appendicitis, and appendicular abscess or lump found intra-operatively. The conversion rate, operative time, postoperative abdominal and wound infections, the return to oral intake, and the length of hospitalization were analysed. Laparoscopic appendectomy was done by three trocar techniques in all cases. Results: During the study period, 60 patients underwent laparoscopic appendectomy for complicated appendicitis. There were 35 patients with perforated appendicitis, 12 patients with gangrenous appendicitis, and 13 patients with early appendicular lump or abscess. The average operating time was 65 min. The average length of hospitalization was 3.2 (2–5) days. The postoperative narcotic analgesic requirement was minimal. Laparoscopy was converted to open surgery in two patients (3.33%). Four (6.6%) had postoperative complications (diarrhoea). Three patients developed (5%) wound (port) infection. There was no statistically significant difference in operative time (P 0.13). There was no mortality in the current series. Conclusions: Laparoscopic appendectomy is a safe and feasible treatment option in complicated appendicitis. It is advantageous than open surgery because of less wound infection, less morbidity, less hospital stay, early return to work, and not associated with increased risk of septic postoperative complications. DOI: http://dx.doi.org/10.11593/bje.2013.0102.0010 Bangladesh Journal of Endosurgery Vol.1(2) May 2013: 11-14

Tubeless percutaneous nephrolithotomy is effective and safe in short- and long-term urinary drainage

We aimed to investigate the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL) with ureteral catheter or double-J stent in comparison with standard PCNL in our study. We retrospectively evaluated 707 of 1,469 patients with stone area under 800mm(2) and only one subcostal nephrostomy access that was underwent PCNL between March 2004 and October 2011 in our clinic. Patients with 14F nephrostomy tube (Malecot or Re-entry catheter), with ureteral stent and with antegrade double-J stent were included into Group 1 (n=180), Group 2 (n=148) and Group 3 (n=120), respectively. The mean hospitalization time of patients in Group 1 was significantly longer. The mean VAS was significantly higher in Group 1. On the other hand the mean fluoroscopy and operation time of patients in Group 2 were significantly shorter in comparison with other groups. Number of patients with postoperative transfusion requirement was significantly higher in Group 1. The number of patients with postoperative narcotic analgesic requirement was also significantly higher in Group 1. The most frequent complication in our study was prolonged drainage. The postoperative complications were seen more frequently in Group 1. Both ureter catheter and double j stent were more comfortable, effective and safe in urinary drainage following PCNL with single sub-costal access. On the other hand, double-J stent has a disadvantage as requirement additional cystoscopy for removal. We suggest ureter catheter or double-J stent to preserve short- and long-term urinary drainage.

Evaluation of Open and Laparoscopic Radical Cystoprostatectomy Combined with Orthotopic Neobladder: A Single-Surgeon Experience

Aim: To compare the outcomes of laparoscopic (LRCP) and open radical cystoprostatectomy (ORCP) with orthotopic urinary diversion for muscle-invasive organ-confined bladder cancer by a single surgeon. Patients and Methods: Prospectively documented 15 LRCP and 15 ORCP patients, followed for at least 3 years, were included in our study. The demographic parameters of patients, preoperative radiologic staging, previous operations, surgical outcomes, complications, oncologic results and intermediate-term follow-up, postoperative chemotherapy and follow-up periods were recorded and evaluated. Results: The mean oncologic follow-up was 3 years. Transfusion rate, estimated blood loss, oral intake and narcotic analgesic requirement were statistically less in the LRCP group (p < 0.05). However, operation time and hospital stay were similar in both groups. The complication rates were not significantly different between the two groups. The mean number of dissected lymph nodes was 20.0 ± 1.7 in the ORCP and 22.6 ± 2.0 in the LRCP group. One patient in each group had a margin positive for bladder cancer. Conclusions: The laparoscopic approach may be feasible for muscle-invasive organ-confined bladder cancer. Furthermore, LRCP provides less blood loss, early oral intake and postoperative pain management. Additionally, continence and sexual function may be provided by LRCP as with ORCP.

The Role of Pre-induction Ketamine in the Management of Postoperative Pain in Patients Undergoing Elective Gynaecological Surgery at the University Hospital of the West Indies

To determine if a single preoperative dose of ketamine hydrochloride reduces the narcotic analgesic requirements and/or pain scores reported by patients in the first 24 hours postoperatively. A single-centred, prospective, case-control study was conducted on 84 patients aged 18-65 years, American Society of Anaesthesiologists (ASA) I and II, undergoing elective gynaecological procedures at the University Hospital of the West Indies (UHWI). Patients were randomly assigned to one of two treatment groups: (a) ketamine group, where patients received intravenous ketamine 0.15 mg/kg pre-induction of anaesthesia; and (b) placebo group, patients received normal saline. The anaesthetic technique was standardized. Postoperatively, patients were interviewed at 15-minute intervals for the first hour then at 2, 4, 6, and 24 hours to determine their pain scores and any side effects. Timing and dose of opioid analgesics were also recorded. The mean cumulative morphine dose over the first 24 hours postoperatively was 29.6 +/- 10.8 mg for the ketamine group and 31.9 +/- 11.2 mg for the placebo group (p = 0.324). There was also no significant difference in pain intensity measured by the visual analogue scale (VAS) between the groups. Patient age and the type of surgery performed were not found to influence pain intensity. The most common adverse effects were nausea and vomiting (32.5%), dizziness (42.2%), drowsiness and sedation (45.8%) with no significant difference between groups. Both groups had an average in-hospital stay of three days postoperatively, however, the patients in the ketamine group reported higher satisfaction scores than those in the placebo group (p = 0.039). Despite no significant reduction in postoperative narcotic requirements or pain intensity, more patients who received ketamine reported higher levels of satisfaction with their pain management.

Topical Metronidazole can Reduce Pain after Surgery and Pain on Defecation in Postoperative Hemorrhoidectomy

Topical metronidazole (10 percent) has been previously demonstrated to decrease postoperative pain after hemorrhoidectomy. The aim of this study was to evaluate the effect of topical metronidazole (10 percent) in reducing postoperative and after-defecation pain of hemorrhoidectomy. A double-blind, randomized trial was conducted to compare posthemorrhoidectomy pain with use of topical metronidazole (10 percent) vs. placebo carrier, applied to surgical site. Forty-seven patients were randomly allocated to receive metronidazole (n=25) or placebo (n=22). Pain was assessed using a visual analog scale preoperatively and on postoperative hours 6 and 12 and at days 1, 2, 7, and 14. The use of narcotic, additional analgesics, and complications were recorded. (Pain scores were calculated and compared with baseline values and control group (t test, SPSS ver.10). Patients in the topical metronidazole group had significantly less postoperative pain than those in the placebo group up to day 14 (P <or= 0.04). There was no significant difference in narcotic analgesic requirements between groups, except on hour 12 (P<0.05). In the metronidazole group, after-defecation pain was ranked significantly lower at day 2 (P=0.016) and patients required fewer additional analgesics postoperatively on days 2 and 7 (P <or= 0.04). These finding indicate that topical 10 percent metronidazole significantly reduce posthemorrhoidectomy discomfort, and postoperative defecation pain is reduced compared with that of the placebo control group.

META‐ANALYSIS OF NON‐RANDOMIZED COMPARATIVE STUDIES OF THE SHORT‐TERM OUTCOMES OF LAPAROSCOPIC RESECTION FOR COLORECTAL CANCER

Laparoscopic resection remains to be established as the procedure of first choice for operable colorectal cancer. The aim of the study was to conduct a systematic review of non-randomized comparative studies of laparoscopic resection for colorectal cancer. Published work in English was searched for relevant articles published by the end of 2003. The MOOSE statement was used to conduct the meta-analysis. Study quality was assessed by two investigators using the MINORS tool and the analysis was conducted using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA). One thousand two hundred and twenty abstracts were reviewed and 398 articles examined in detail. Out of 108 articles reporting the results of relevant studies, 75 were reports of 64 non-randomized comparative studies. Fifteen studies were excluded. Analysis of the outcomes of 6438 resections showed that the conversion rate was 13.3% with a statistically significant difference between studies with more than 50 versus those with 50 or less attempted resections (11.7 vs 16.5%; P<0.001). Laparoscopic resection took 27.6% (41 min) longer to carry out than open resection. There was no significant difference between the two groups in early mortality rates (1.2 vs 1.1%; P=0.787) or likelihood of re-operation (2.3 vs 1.5%; P=0.319). Laparoscopic resection was associated with a lower morbidity rate (24.05 vs 30.80%, odds ratio (95% confidence interval)=0.77 (0.63-0.95); P=0.014, n=4111, random-effects model). Time until passage of first flatus, passage of a bowel motion, tolerating oral fluids and a solid diet was 1.2-1.6 days (26 to 37%) shorter, measurements of pain and narcotic analgesic requirements were 16-35% lower and hospital stay was 3.5 days (18.8%) shorter following laparoscopic resection compared with open resection. The two approaches were 99% similar in terms of adequacy of oncological clearance. Meta-analysis of non-randomized comparative studies favours laparoscopic over open resection for colorectal cancer. The results were remarkably similar to those of a contemporaneous meta-analysis of randomized controlled trials published by the end of 2002.