Post-laparoscopic Cholecystectomy Research Articles

Effects of Footbath on Pain, Anxiety, Sleep, and Comfort Levels in Patients With Postlaparoscopic Cholecystectomy: A Randomized Controlled Study.

The aim of the study is to determine the effect of of hot footbaths on the pain, anxiety, sleep, and comfort levels of patients who underwent laparoscopic cholecystectomy. The study is a randomized controlled designed. This study was conducted in surgery clinic of a university hospital between January 2022 and November 2022. The research was completed with 54 patients in the experimental group and 54 patients in the control group. The mean state anxiety score and VAS-Sleep score of the patients in the experimental group 120 minutes after the application was 31.07±4.70 and 612.62±82.37, respectively, which was statistically significantly lower than that of the patients in the control group ( P <0.05). On the other hand, at the 120th minutes after the application, the mean VAS-Comfort scores of the patients in the experimental group were statistically significantly higher than those of the patients in the control group ( P <0.05). A positive relationship was found between the mean VAS-Pain and VAS-Sleep scores of the patients in the experimental group, and a significant negative relationship was found between the mean VAS-Comfort and state anxiety scores. Foot bath is effective in reducing the pain and anxiety levels of patients undergoing laparoscopic cholecystectomy surgery.

Retained gallstone found in a remnant gallbladder post-laparoscopic cholecystectomy using point of care ultrasound.

Retained gallstone found in a remnant gallbladder post-laparoscopic cholecystectomy using point of care ultrasound.

Financial Performance Analysis And Stock Valuation of PT Kimia Farma Tbk.

Laparoscopic cholecystectomy is the surgical method of choice for gallbladder removal. Enhanced Recovery After Surgery (ERAS) is a program designed to accelerate patient recovery after surgery by reducing length of stay, pain, and accelerating initial mobilization. This study aims to evaluate the effectiveness of the ERAS nursing program on pain levels, initial mobilization, and length of hospitalization of post-laparoscopic cholecystectomy patients at Pluit Hospital Jakarta. A total of 65 patients undergoing laparoscopic cholecystectomy were sampled, with 40 patients in the ERAS group and 25 patients in the control group. Data were collected using questionnaires and observation sheets, and analyzed using the ANCOVA test. The results showed that the ERAS group had lower numerical scale scores for pain (1.87 vs 5.72, p &lt; 0.001), earlier mobilization (3.45 hours vs 9.12 hours, p &lt; 0.001), and shorter length of stay (27.13 hours vs 74.84 hours, p &lt; 0.001) compared to the control group. The implementation of the ERAS nursing program has proven to be effective in reducing pain levels, accelerating initial mobilization, and reducing the length of stay of patients after laparoscopic cholecystectomy at Pluit Hospital Jakarta. This study supports the use of ERAS protocol to improve the quality of surgical care in Indonesia.

Migration of the Plastic Clips of the Cystic Ducts to the Bile Duct Post-Laparoscopic Cholecystectomy: A Case Report

Introduction: Migration of the cystic duct clip into the common bile duct is a rare but significant complication following laparoscopic cholecystectomy. This condition can cause biliary obstruction, cholangitis, and gallstone formation. Case presentation: A 60-year-old man presented with symptoms of cholangitis. His medical history included laparoscopic cholecystectomy with choledochoscopy and intraoperative cholangiography. MRCP showed stones and sludge in the common bile duct (CBD), but did not identify a migrated clip. Endoscopic retrograde cholangiopancreatography (ERCP) successfully extracted the migrated clip causing the obstruction. Conclusion: Migration of the clip into the common bile duct should be considered in the differential diagnosis of biliary obstruction following laparoscopic cholecystectomy. Early identification through careful imaging and ERCP can facilitate appropriate management and prevent further complications.

Immediate Effect of Breath Stacking and Buteyko Breathing on Physiological Parameters in post Laparoscopic Cholecystectomy Patients: A Research Protocol of a Randomised Controlled Trial

Introduction: Laparoscopic cholecystectomy is frequently performed in acute, chronic, symptomatic, and asymptomatic cholelithiasis. It is simple, safer, and requires less recovery time than open cholecystectomy, which is why this procedure is increasingly utilised for various abdominal surgeries. Patients may experience postoperative pulmonary problems during the recovery phase and as per available literature there is a noticeable decline in the vital capacity of the patient. It was observed that Buteyko breathing and breath stacking breathing techniques has a good impact on the physiological parameters and vital capacity of patients with hypertension, asthma, Chronic Obstructive Pulmonary Disease (COPD), and other respiratory conditions. Need of the study: Buteyko breathing and breath stacking breathing techniques are effective in different conditions like hypertension, asthma, and cardiac surgery. The need of the study is to compare both techniques and find out which one is more effective and implement that with the standard exercises in the patients to help them improve their quality of life, reduce hospital stay, and improve lung capacity. Aim: To compare the effects of the Breath Stacking Technique (BST) and Buteyko Breathing Technique (BBT) on the physiological parameters of patients undergoing laparoscopic cholecystectomy. Materials and Methods: This will be a randomised controlled trial in which 140 patients will be included using purposive sampling via block randomisation. The study will be conducted in Surgery Intensive Care Unit (SICU) of Maharishi Markandeshwar Medical College and Hospital, Kumarhatti, Solan, from December 2023 to May 2024. Patients in Group-A will perform the BBT and Group-B will perform the BST. Each cycle of breathing consists of five repetitions with five sets and 30 seconds of rest in between. Outcome measures will be taken at baseline and after intervention on Postoperative Day 1 (POD). The normality of the data will be checked by KolmogorovSmirnov test. A paired t-test will be used if the data is normal, and the Wilcoxon Signed Rank test will be used if the data is non-normal. A p-value &lt; 0.05 will be considered significant.

Post-laparoscopic cholecystectomy pancreatitis

Laparoscopic cholecystectomy is one of the commonest operations performed on the biliary system. Acute pancreatitis following Lap-chole is quite uncommon. Whether pancreatitis is a complication or a sequalae to surgical treatment of gall stone disease continues to be a debatable issue. A 37-year-old lady underwent laparoscopic cholecystectomy for incidentally diagnosed gall stones. Early post-operative course was uneventful. The patient presented 3 weeks after surgery with severe excruciating abdominal pain and was diagnosed as acute pancreatitis by ultrasound evaluation. Liver function tests were altered with raised bilirubin, serum lipase and amylase. MRCP revealed a normal biliary tract. Pancreas showed changes of acute interstitial pancreatitis. Patient responded to conservative line of treatment. Acute pancreatitis could be a known complication following laparoscopic cholecystectomy. What causes pancreatitis continues to be a matter for debate. MRCP is the investigation of choice. Interventional endoscopy (ERCP) is indicated in cases of impacted gallstone in the CBD. While if the CBD is clear of stones, aggressive conservative management will suffice.

ThTP6.8 Incidence and management of non-resolution of Biliary Colic or Right Upper Quadrant pain Post Laparoscopic Cholecystectomy

Abstract Background The pathogenesis and risk of chronic pain after laparoscopic cholecystectomy are not well understood. Post-cholecystectomy syndrome describes persistence of biliary colic or right upper quadrant pain with a variety of GI symptoms, similar to features prior to cholecystectomy. It is attributed to biliary (retained stone, biliary stricture), extra-biliary (pancreatitis, gastritis, IBS) and psychiatric or neurological disorders. Aim To find out (1) the incidence of post laparoscopic cholecystectomy pain. (2) if patients were counselled on non-resolution of pain during consenting for surgery. (3) if patients were investigated for non-resolution of pain. Methodology Retrospective cohort study was performed by interviewing patients undergoing laparoscopic cholecystectomy from April2022-October2022. Direct telephone consultation to enquire about non-resolution of pain. Digital case notes were reviewed for subsequent admissions. Results A total of 50 cases met the audit inclusion criteria over the period of 7months. Mean age of the selected population was 47.98 years (SD 15.47). Male:female ratio was 11:39. 24%(n=12) patients were reported non-resolution of pain post-op. 48%(n=24) patients were counselled on non-resolution of pain while consenting for surgery. Discussion The study suggested a significant number of patients experience non-resolution of pain post-cholecystectomy. However, less than half of the study population were counselled during consenting. Limitations include low number of patients and risk factors like urgent surgery like ‘hot gallbladders’ and choledochotomy could not be assessed. To improve clinical practice, non-resolution of pain should be mentioned during consenting. Additionally, a potential follow-up system should be introduced to review non-resolution of pain and guidelines on investigation of the residual pain should be produced.

Evaluation of role of peri portal infiltration of ropivacaine in post laparoscopic cholecystectomy pain management: a randomized controlled double-blind study

Background: Laparoscopic cholecystectomy is considered as the treatment of choice for symptomatic cholelithiasis. The present study was conducted to assess the role of peri-portal infiltration of ropivacaine in post laparoscopic cholecystectomy pain management. Methods: A total of 100 eligible cases undergoing laparoscopic cholecystectomy were randomly allocated in two groups: group A (received infiltration of total 20 ml of 0.5% ropivacaine, 5 ml in each port site after removal of trocar, and group B (received placebo i.e., 20 ml normal saline). Postoperative pain was assessed using Wong Baker facial pain scale at 6, 12 and 18 hours and use of rescue analgesics were noted. Results: Group I comprised of 27 males and 23 females and group II had 25 males and 25 females. The mean heart rate in group I was 85.4 and in group II was 86.2. Respiratory rate was 14.2 cycles/minute in group I and 15.2 cycles/minute in group II. The mean blood pressure was 134.2/74.6 mmHg in group I and 136.4/75.2 mmHg in group II and oxygen saturation was 99.2% in group I and in group II was 99.5%. The mean VAS scores were significantly lower in group A cases as compared to group B, throughout the study follow up (p&lt;0.01). 70% in group A and 90% in group B required 1 dose and 10% in group II required 2 doses. Duration of rescue analgesia was 21.49 minutes in group A and 17.3 minutes in group B. Conclusions: Peri-portal infiltration of ropivacaine is effective in reducing post laparoscopic cholecystectomy pain. Mean duration of analgesia was significantly more and requirement of rescue analgesics were significantly less in cases managed by peri-portal infiltration of ropivacaine as compared to control group (using NSAIDs).

Retaining the epigastric trocar, until rest all ports closed decreases post-operative shoulder pain in laparoscopic cholecystectomy patients

Background: Laparoscopic cholecystectomy has become the mainstay of treatment for gallstone disease cases due to its lower morbidity and pain compared to open techniques. Unfortunately, the use of carbon dioxide to insufflate the abdomen is the main contributor to post-operative shoulder pain. Aims and Objectives: The aim of the study was to evaluate the effectiveness of retaining the epigastric port trocar in position until rest all ports closed after completion of lap cholecystectomy in decreasing the post-operative shoulder pain. Materials and Methods: A prospective, randomized, and clinical trial was done in AIIMS hospital, Bhubaneswar, on 102 patients who have undergone laparoscopic cholecystectomy. The patients were alternatively selected, one in the study group (52) and the other in the control group (50). For those patients in the study group, after the completion of the surgery, the epigastric port trocar is retained in position until the rest of all ports were closed. In the control group, all trocars were removed and port closure was done. The patients were evaluated for the next 24 h for post-operative shoulder pain. A numerical rating scale (NRS) was used to assess shoulder pain on patient arrival to the ward, at 4, 6, 12, and 24 h postoperatively. One hundred and two patients were included in the final data analysis. Results: NRS pain scores were significantly lower in the study group at 6, 12, and 24 h post-laparoscopic cholecystectomy compared to the control group with no additional requirement of IV analgesics. Conclusion: Retaining the epigastric trocar in position is an easy way that is beneficial in reducing post-operative shoulder pain post laparoscopic cholecystectomy surgery.

Comparison of metoclopramide–dexamethasone combination and metoclopramide alone for prophylaxis of postoperative nausea vomiting in laparoscopic cholecystectomy

BACKGROUND &amp; OBJECTIVE: Post operative nausea and vomiting (PONV) is an important concern in laparoscopic surgeries. Aim of this study is to identify the role of metoclopramide dexamethasone combination for prophylactic management of post laparoscopic cholecystectomy nausea and vomiting in comparison to metoclopramide alone.&#x0D; METHODOLOGY: The study group comprised of 150 patients. These were the patients with symptomatic gallstones for whom elective laparoscopic cholecystectomy was planned. Study was conducted from 15-04-2018 to 15-07-2019. Non-probability consecutive sampling technique was used.Two groups were generated by simple random method. Group M was given injection metoclopramide only, whereas patients in Group D+M were injected with both dexamethasone and metoclopramide, intravenously, before induction of anesthesia. Parameters observed for 24 hours during postoperative period included; nausea, episodes of vomiting, requirement for rescue antiemetic drugs and total duration of hospital stay after the surgical procedure.&#x0D; RESULTS: In Group D+M (dexamethasone+metoclopramide), out of total 75 patients, 8% developed nausea while 5.33% had both nausea along with emesis. While in group M (metoclopramide), 16% out of the total 75 patients had nausea only but 18.7% patients had complaints of nausea and emesis. Three patients out of 75, that is 4% from group (D+M) had extended duration of in hospital admission (&gt; 24 hours), while in groupM, this percentage was 13.33% (n=10) patients.&#x0D; CONCLUSION: A combination of metoclopramide with dexamethasone for prophylaxis against PONV in laparoscopic cholecystectomy patients is preferred to metoclopramide alone.

Migration of Metallic Clip in to the Common Bile Duct after Laparoscopic Cholecystectomy – A Case Report

Cholecystectomy is now-a-days done mostly by laparoscopy rather than open procedure. Post- cholecystectomy complications are not uncommon but somewhat it seems post laparoscopic cholecystectomy complications are not fewer in comparison to open. Among various complications, post-cholecystectomy clip migration is one of the rare ones. It can happen anytime but mostly occurring around 2 years of operation. Clinical presentation varies, as described in literatures but mostly presents with choledocholithiasis. Here we present such a case in a 25-year-old lady who was a bit challenging due to unusual presentation and long course of illness.

Post operative effect of bile spillage in laparoscopic cholecystectomy

Background: Most common disease of gall bladder and biliary tree is cholelithiasis. Laparoscopic cholecystectomy is now gold standard treatment. Gall bladder contents can be spilled during both in open and laparoscopic cholecystectomy, but these contents are eliminated usually through direct removal, copious irrigation and mopping in open operations. Right shoulder tip pain is a common short term complaint. Aims and objectives were to study right shoulder tip pain, its duration and severity in post-operative period of patients having spillage versus non spillage of gall bladder contents. Method: It is a hospital based prospective comparative study was conducted in KPC medical college and hospital, Jadavpur, Kolkata. Time frame was April 2021- July 2022. Sample size was 100. Result: Our study showed that, less number of patients had right shoulder tip pain (in numerical rating scale) and requirement of rescue analgesia in case compared to control group. Conclusions: Right shoulder-tip pain, which may occur post-laparoscopic cholecystectomy, is variable in duration, severity and character and is more in spillage group.

Surgicel® fibrillar as an innovative analgesic reservoir for post-laparoscopic cholecystectomy pain management: Randomized double-blind trial

ABSTRACT Background Strong analgesia is still needed after laparoscopic cholecystectomy (LC). Surgicel® is a haemostatic agent, capable of absorbing fluids several times its volume, although pain is lower than after open surgeries. We hypothesized that Surgicel® could function as an innovative carrier for sustained-release postoperative analgesia. Methods Ninety patients (18–65 years) scheduled for LC were randomized to receive a mixture of 20 ml bupivacaine 0.5%, 10 ml lidocaine 2%, epinephrine 5 µg/ml, and morphine 0.1 mg/kg instilled at hepatic fossa, trocar sites, and under the right copula of the diaphragm (Group-I). Group-II received similar mixture to soak Surgicel® applied at the hepatic fossa and trocar sites. Group-III received normal saline to soak Surgicel® at the same locations. Visual analog scale at 1, 2, 4, 6, 12, and 24 h postoperatively was the primary outcome, while the secondary outcomes included Verbal rating scale, time to first rescue analgesia, total 24-h analgesia, time for the return of bowel function, patients’ satisfaction, and adverse effects. Results Group-II showed the lowest pain scores (p > 0.05), the longest time before requesting analgesia (p = 0.004), used least extra analgesia (p ≤ 0.001), maintained highest satisfaction scores (p ≤ 0.001), and lowest complications (p = 0.048). Group-I showed better results regarding pain control compared to group-III after 2 h (p = 0.02) with prolonged time to first analgesia (p < 0.001) and less analgesic consumption (p < 0.001). Conclusion Application of Surgicel® as a reservoir of analgesics at the potential pain generating sites following laparoscopic cholecystectomy, resulted in superior and extended postoperative analgesia with better patients’ satisfaction, and no serious adverse effects.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial.

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively. We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption. This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours. Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively). A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

TH4.9 Patient Reported Outcome Measures (PROMs) – A Key to Understanding Laparoscopic Cholecystectomy Outcomes?

Abstract Aims Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient reported outcome measures PROMS in laparoscopic cholecystectomy. Methods A PROSPERO registered (ID: CRD42021261707) systematic review was undertaken of English language articles, published from January 1st, 2011 to June 2nd, 2021, and underwent MINORS grading, using PubMed version of Medline, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards including key words: laparoscopic cholecystectomy AND patient outcome OR patient reported outcome OR patient reported outcome measure OR PRO OR PROM. Results A total of 4960 individual articles were reviewed, 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy. 21 articles spanning 19 countries and 4 continents were included in the qualitative data synthesis. There was significant heterogeneity in PROMs, with eight different PROM tools used in 21 studies. Wide variation in the time points at which PROMs were recorded. Fourteen of twenty-one studies recorded PROMs pre- and post-operatively, seven of twenty-one recorded PROMs post-operatively only. Follow up periods ranged from 3 days to 2 years post-operatively. All PROMs detected changes in quality-of-life over time. Conclusions This study identified that while post laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. EuroQOL EQ-5D provides a simple platform for the modern digital era.

Umbilical bleeding during menstruation in status post laparoscopic cholecystectomy of unknown/ambiguous aetiology

Although umbilical endometriosis is a possible cause of cutaneous manifestation of retrograde menstruation during cyclical bleeding in status post laparoscopic surgery patient, Here in this case we presumed a diagnosis of endometriosis on the basis of its symptoms which couldn’t be proven in biopsy and on immune-histo-chemistry and casted a query that now what is the next possible aetiology which is responsible for umbilical bleeding specifically during menstruation in the patient with status post laparoscopic surgery. We report a case of presumed secondary umbilical port scar endometriosis in a 25-year-old lady nulliparous woman following laparoscopy-assisted cholecystectomy 6 months ago. Remarkably patient complained of peri umbilical pain and menstrual bleeding through umbilicus (retrograde) soon after surgery which was remarkably noticed only during her periodical cycle. History and clinical examination, haematology, ultrasound, computed tomography and MRI of abdomen and pelvis performed to rule out any primary lesions which all were found unremarkable. After counselling the patient about the presumptive causes and treatment options the umbilicus with its surgical scar mark excised and the tissue was sent for histopathological examination which was found inconclusive with no evidence of endometriosis at all. Remarkably it was further scrutinized by immune-histo-chemistry but remained fruitless. Fortunately, patient relieved her symptoms of retrograde menstrual bleeding after total excision of the umbilicus with scar mark post operatively but still left a diagnostic stigma for surgeons.

Patient-reported outcome measures (PROMs) after laparoscopic cholecystectomy: systematic review

BackgroundHealthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy.MethodsA PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included.ResultsA total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery.ConclusionsThis study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era.

202 VTE Prophylaxis Post-Laparoscopic Cholecystectomy

Abstract Introduction VTE refers to a clot that causes stenosis or blockage of the blood flow in a vein. VTEs are classified as hospital-acquired if they occur within 90 days of hospital admission. Recent hospitalisation and associate immobilisation are well-acknowledged risk factors also included in Well’s score, which is used as part of the diagnostic work up. NICE guidelines state that patient over 16 years old must be offered VTE prophylaxis either in the form of LMWH or fondaparinux for at least 7 days after an abdominal surgery. The aim of the audit is to explore whether NICE guidelines regarding the VTE prophylaxis post-laparoscopic cholecystectomy are followed. Method The data from all the patients who had laparoscopic cholecystectomy in a two-month period was collected and discharge summaries and TTOs were reviewed to identify whether thromboprophylaxis was prescribed for 7 days following the operation. A second cycle was completed after results of first cycle presented to the surgical team. Results Increased in compliance with VTE prophylaxis guidelines observed, although though still suboptimal. 14% of patients received prophylaxis in first cycle, and 34% in the second. Conclusion Increased compliance with VTE guidelines observed, however the second cycle only included a small sample of patients which limited reliability. Furthermore, as highlighted by the surgical team, NICE guidelines are vague. There is no clarification regarding types of abdominal operations. No VTE incidences are yet to be identified post-operatively. Medico-legal aspects were also considered.

Magnesium Sulphate as an Adjuvant to Ropivacaine in Bilateral Transversus Abdominis Plane Block for Laparoscopic Cholecystectomy: A Randomised Double-blind Clinical Study

Introduction: Magnesium sulphate has the potential to treat and prevent pain by acting as an antagonist at N-methyl-DAspartate (NMDA) receptors. Many researchers found that magnesium sulphate as adjuvant to local anaesthetics reduces analgesic requirements in the postoperative period. Aim: To evaluate magnesium sulphate as an adjuvant to ropivacaine in ultrasound guided bilateral Transversus Abdominis Plane (TAP) block with respect to postlaparoscopic cholecystectomy pain. Materials and Methods: The present randomised doubleblind clinical study was conducted in the Department of Anaesthesiology, SKIMS Medical College, Srinagar, Jammu and Kashmir, between January 2022 and June 2022. Total 80 patients of American Society of Anesthesiologists (ASA) grade I and II were divided into two groups. Group A (n=40) patients received ropivacaine with magnesium and group B (n=40) patients received ropivacaine only. Pain was measured using the Visual Analogue Scale (VAS). Total rescue analgesia consumption during 24 hours, time to first request of rescue analgesia, postoperative nausea vomiting, sedation score and patient satisfaction score were recorded. Mann-Whitney U test was used for VAS score and patient satisfaction score. Results: Mean age of patients was higher in group A (47.95±13.853 years) than group B (46.45±11.940 years). Group A had 12 males and 28 females while in group B, there were 11 males and 29 females in group B. Group A showed better analgesic profile in the form of lower mean VAS, which were statistically significant (p-value&lt;0.05). However, time to first request of rescue analgesia (743.5±58.214 minutes in group A vs 668.50± 214.375 minutes in group B; p-value=0.162) and total dose of rescue analgesia consumption were comparable in both groups (p-value&gt;0.05). Also the sedation score (2.325±0.2529 in group A vs 2.295±0.2562 in group B; p-value=0.600) and patient satisfaction score (PSS) between the two groups (81.05±8.638 in group A vs 80.53±7.517 in group B; p-value=0.665) were statistically not significant. Incidence of postoperative nausea and vomiting was comparable in both groups (p-value=0.924). Conclusion: Addition of magnesium sulphate to ropivacaine in ultrasound guided bilateral TAP block significantly reduced pain scores in patients undergoing laparoscopic cholecystectomy.

Early Enteral Nutrition in Septic Shock Patient with Postoperative Bile Duct Injury Bismuth Type 4: A Case Report

Introduction: Early enteral nutrition (EEN), despite preventing sepsis, its supplementation is challenging in upper gastrointestinal surgery due to serious complications, particularly sepsis. Method: We present a 33-year-old septic shock patient with BDI Bismuth type 4 post-laparoscopic cholecystectomy for bile duct stone, an open laparotomy, hepaticojejunostomy Roux en Y, and jejunojejunostomy side to side. EEN was given after a clinically severe malnutrition diagnosis. The patient had a history of severe obesity and unintentional weight loss of 22.7 kg (33%) with reduced >50% intake in 4 months. The patient become sepsis postoperatively and developed septic shock at postoperative day (POD) 2 with blood lactate level 2.8 mmol/L and norepinephrine 0.25 mg/kg BW/min. The patient was nil per os at POD 1, and EEN was initiated in 48 hours with clear fluid 30 mL/h, intermittently for 2 days. At POD 3, septic shock was resolved and the patient become more stable. To meet the energy requirements of 20 kcal/kg BW/day, 3-chamber parenteral nutrition was delivered. Parenteral nutrition was fully weaned at POD 4. After POD 5, a hospital low lactose milk 50 mL/h, intermittently, was prescribed to the patient. Micronutrients consisting of zinc sulfate 1x20 mg, vitamin B complex 3x1 tablet, vitamin C 2x50 mg, and folic acid 1x0,5 mg were given. Results: Enteral nutrition was well tolerated. The patient was discharged from ICU and hospital at POD 6 and 19 days consecutive treatment at the ward. Conclusion: EEN can improve clinical outcomes in septic shock patient with postoperative BDI Bismuth Type 4