Ghattas Khoury

A comparison of epidural tramadol and epidural morphine for postoperative analgesia

The present study compared epidural tramadol with epidural morphine for postoperative analgesia in 20 patients undergoing major abdominal surgery. Intraoperatively, the patients were anaesthetized by a balanced technique of general anaesthesia combined with lumbar epidural lidocaine. In ten of the patients 100 mg tramadol diluted in 10 ml normal saline was also injected epidurally, while 4 mg epidural morphine was used in the other ten patients. In all patients, the visual analogue pain score, PaO2, PaCO2 and respiratory rate were monitored every hour for the first 24 hr postoperatively. In both the tramadol and morphine groups, the mean hourly pain scores ranged from 0.2 ± 0.6 to 1.4 ± 2.5 throughout the period of observations. However, the mean PaO2 was decreased postoperatively in the epidural morphine group, while no change was observed in the epidural tramadol group. The maximal decrease of PaO2 in the epidural morphine group was observed at the tenth hour postoperatively, when it decreased to 72.8 ± 10.3 mm Hg. This was not associated with any increase in PaCO2 or a decrease of respiratory rate, suggesting that hypoxaemia rather than hypercarbia or decreased respiratory rate may be an earlier indicator of respiratory depression in patients breathing room air without oxygen supplementation. The absence of clinically relevant respiratory depression following epidural tramadol compared with epidural morphine may be attributed to the different mechanisms of their analgesic action. The results suggest that epidural tramadol can be used to provide prolonged postoperative analgesia without serious side effects.RésuméCette étude compare le tramadol à la morphine donnée par voie épidurale pour l’analgésie postopératoire de 20 patients subissant une chirurgie abdominale majeure. Les patients sont anesthésiés par une technique balancée, combinée à une épidurale lombaire à la lidocaïne. Chez dix des patients, tramadol 100 mg dilué de 10 ml de liquide physiologique est également injecté par voie épidurale, tandis que morphine épidurale 4 mg est injectée aux autres patients. Chez tous les patients, une échelle visuelle analogue de la douleur, la PaO2, la PaCO2 et la fréquence respiratoire sont mesurées chaque heure pendant les 24 premières heures postopératoires. Autant dans le groupe tramadol que dans le groupe morphine, la valeur moyenne de l’évaluation de la douleur se situé de 0,2 ± 0,6 à 1,4 ± 2,5 pendant toute la période d’observation. La PaO2 moyenne est cependant diminuée en postopératoire dans le groupe épidurale à la morphine tandis qu’aucun changement n’est observé dans le groupe épidurale au tramadol. La diminution maximum de la PaO2 dans le groupe épidurale à la morphine se situe à la dixième heure postopératoire, et atteint une valeur de 72,8 ± 10,3 mm Hg. Elle n’est associée à aucune augmentation de PaCO2 ni à une diminution de fréquence respiratoire, suggérant que l’hypoxémie plutôt que l’hypercapnie vu la diminution de fréquence respiratoire peut être un indice précoce de la dépression respiratoire chez des patients respirant l’air ambiant sans supplément d’oxygène. L’absence de dépression respiratoire cliniquement significative après une épidurale au tramadol par rapport à une épidurale à la morphine peut être attribuée à un mécanisme d’action analgésique différent. Ces résultats suggèrent qu’une épidurale au tramadol peut être utilisée pour procurer une analgésie post-opératoire prolongée sans effets secondaires sérieux.

Laparoscopic treatment of hydatid cysts of the liver and spleen

AbstractBackground: The short-term results from laparoscopic treatment of hydatid cysts of the liver and spleen were reported previously. The procedure was shown to be feasible and safe, offering the advantages of laparoscopic surgery. This is the first report on the long-term follow-up of this operation in a large group of patients. Methods: In this study, 108 hydatid cysts of the liver and spleen in 83 consecutive patients (43 males [52%] and 40 females [48%]) were approached laparoscopically. The mean age of the patients was 40 years (range, 13–85 years). There were 104 liver cysts and 4 spleen cysts. The liver cysts were located in the right lobe in 42 patients (53%), in the left lobe in 21 patients (26%) and in both lobes in 16 patients (21%). Of the 104 cysts, 44 (42%) were uniloculated and 60 (58%) were multiloculated. Results: All cysts were approached laparoscopically. The mean operative time was 80 min (range, 40–180 min). The conversion rate was 3%. The mean hospital stay was 3 days (range, 2–7 days). There were no mortalities, and complications occurred in nine patients (11%). All were managed conservatively except one patient in whom a laparotomy was needed. All patients were followed up for a mean period of 30 months (range, 4–54 months) with serological testing and ultrasonography if needed. In three patients (3.6%) recurrence of the disease developed. Conclusion: The laparoscopic approach to uncomplicated hydatid cysts of the liver and spleen is a safe and effective option with favorable long-term results.

Anaphylactic shock complicating laparoscopic treatment of hydatid cysts of the liver

Abstract. Hydatid cysts of the liver have been treated surgically for many years by several surgical techniques including evacuation, marsupialization, and filling the cyst with saline after evacuation of the endocyst. We have previously reported laparoscopic treatment of hydatid cysts using the same hydatid asepsis and surgical techniques as in open surgery, with comparable results. Spillage of hydatid fluid during open surgery has been shown to result in serious anaphylactic reaction. The present report describes the first case report of such a reaction during laparoscopic treatment of hydatid cyst of the liver.

Results of laparoscopic treatment of hydatid cysts of the liver

BackgroundWe have previously reported on the laparoscopic treatment of hydatid cysts of the liver. We now report the successful treatment of 18 cysts in 12 patients with a median follow-up of 12 months.MethodsThe standard treatment in the open technique was performed laparoscopically. The main concern was to prevent spillage of the hydatid fluid, for which the puncture and evacuation of the cyst is carried under scolicidal agents cover using 1% cetrimide, thus decreasing the chances of recurrence.ResultsIn this group of patients we had one biliary leak that ceased spontaneously and one recurrence of hydatid cyst but not in the same lobe.ConclusionsWe conclude that laparoscopic evacuation of hydatid cysts is a successful operation comparable to the open technique, with the added advantages of the laparoscopic approach.

End-tidal carbon dioxide tension during laparoscopic cholecystectomy.: Correlation with the baseline value prior to carbon dioxide insufflation

An investigation of end‐tidal carbon dioxide tension changes was carried out in 19 healthy adult patients undergoing laparoscopic cholecystectomy. Following induction of anaesthesia, and throughout surgery, the end‐tidal carbon dioxide tension was continuously monitored by capnography. The value following carbon dioxide insufflation increased with time to reach a maximum value after 40 min. Correlation of the individual maximum end‐tidal carbon dioxide tension during laparoscopy with the corresponding baseline value prior to carbon dioxide insufflation showed a positive linear relationship (correlation coefficient 0.86). The correlation showed that an end‐tidal carbon dioxide tension of 5.32 kPa (40 mmHg) can be achieved during laparoscopy when the baseline value is adjusted to around 4.0 kPa (30 mmHg).

Trauma management in a war zone: the Lebanese war experience.

Lessons learned from the Vietnam and Korean conflicts have emphasized the necessity of an organized preparedness for optimal management of casualties. The present report summarizes the experience of a tertiary care center in the present Lebanese war. Between 1975 and 1986, approximately 30,000 war casualties were treated at the American University of Beirut Medical Center (AUBMC). A disaster plan was implemented whenever more than 25 major trauma victims were received within 1 hour. In-field stabilization and emergency room (ER) thoracotomy were not employed. The results are illustrated by an analysis of 1,500 cases of abdominal trauma, (1,314 high-velocity gunshot wounds, 29 stab wounds, 157 blunt injuries). A total of 1,420 patients were operated on within 6 hours of admission and 711 within the first hour. Overall mortality was 130, 8.7%; 9.5% for gunshot wounds, 3.4% for stab wounds, and 2.5% for blunt trauma. One hundred forty-five patients or 9.7% had negative findings at laparotomy. The factors affecting mortality were hypotension on admission (26.5% for a BP less than 90 mm Hg and 2.8% for a BP higher than 90 mm Hg) and the presence of extra-abdominal injuries (14.4% with and 4.4% without). The chief causes of death were hemorrhage (3.7%), sepsis (2.1%), and ARDS (1.2%).

Traumatic arteriovenous fistulae: “The Lebanese War Experience”

Over a 16-year period from January 1975 to December 1990, 823 patients with 840 vascular injuries were treated at the American University of Beirut Medical Center. Of these, 661 injuries involved peripheral vessels; 26 of which had 31 arteriovenous fistulae (AVF). Most of the AVF (80%) were diagnosed within 1 year from the injury. The most common presenting symptom was a thrill (74%) followed by a pulsating mass (32%). The most commonly affected vessels were the femoral and popliteal arteries. Angiograms were used preoperatively to delineate the extent and location of the fistulae. All patients except three, underwent surgical repair with excellent results with no limb loss. None of the patients developed late complications such as claudication or a vascular deficit in the involved limb. Arteriovenous fistula is a rare but challenging condition following vascular trauma. Its recognition and treatment give excellent results.

Laparoscopic treatment of hydatid cysts of the liver.

We report for the first time treatment of hydatid cyst of the liver laparoscopically. The patient is a 27-year-old man who presented to our hospital with a 6-week history of recurrent right-upper-quadrant pain with abdominal ultrasound findings compatible with hydatid cyst of the liver. The cyst was approached laparoscopically using the same hydatid asepsis as in open surgery. The cyst was evacuated laparoscopically and marsupialized, and its remaining cavity was packed with omentum. The patient did well postoperatively and was discharged home on the third postoperative day. He had minimal biliary leak that ceased spontaneously on the fifth postoperative day.

Penetrating trauma to the abdominal vessels

Between January 1975 and December 1989, 1860 patients were admitted to the American University of Beirut Medical Centre with abdominal injuries. Their mean age was 23 years. Of these patients 107 had vascular injuries (an incidence of 6%). Bullets were the most common injurious agents (72%), followed by shrapnel (22%). There were 28 arterial and 113 venous injuries. All patients presented to the emergency unit within 5 h of injury (mean 45 min) and were surgically explored. The overall mortality rate was 36.5%. Patients who were haemodynamically stable had a better outcome than those who presented in shock (P < 0.005). The major cause of death was haemorrhage from uncontrolled bleeding. Two subgroups with a higher mortality were identified: patients with inferior vena caval injury associated with a liver injury had a mortality rate of 78.5%, and those with vascular injury associated with pelvic fracture had a mortality rate of 57% (P < 0.05). Abdominal vascular injuries have a high mortality rate, especially if the inferior vena cava is involved or associated pelvic fractures are present. Prompt resuscitation and control of bleeding are the key to an improved salvage rate.

Injury to the femoral vessels--the Lebanese War experience.

Over a 10-year-period extending from January 1976 to September 1986, 800 peripheral vascular injuries were surgically treated at the American University of Beirut Medical Centre. Of these, 150 were operated on because of injury to the femoral vessels. Bullets were the commonest wounding agents (60% of cases). Thirty-seven patients had a femoral artery injury, 27 a femoral vein injury and 86 combined femoral artery and vein damage. Twenty-three per cent of the patients had an associated fracture of the femur. Patients with fractures had an 11% amputation rate compared with 1% for those without fractures. Our data reveals the importance of venous reconstruction in the presence of an arterial injury instead of its ligation (P less than 0.05), particularly when there is an associated fracture of the femur. Thirty-seven per cent of patients were in shock on admission (systolic BP 90 mmHg). The amputation rate in these patients was 6.8% in contrast to 1% in the haemodynamically stable group (P less than 0.05). The overall amputation rate was 3.3%. Complications occurred in 36.6% of patients and the mortality was 4.0%.