Roman M. Herman

A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy

Aim: This study aimed to investigate the advantages and disadvantages of LP (7 mmHg) in comparison to SP (12 mm Hg) pneumoperitoneum in a prospective randomized clinical trial. Materials and Methods: 148 consecutive patients qualified for laparoscopic cholecystectomy (LC) due to uncomplicated symptomatic gallstones were randomized to either SPLC or LPLC. All the procedures were performed by the same experienced team of surgeons. The statistical analysis included sex, mean age, body mass index, ASA grade, operative time, complication rate, conversion rate, postoperative pain assessed by the Visual Analogue Scale of Pain (VAS) including the incidence of shoulder-tip pain, postoperative hospital stay, recovery time, and the quality of life (QOL) within 7 days following the operation. p <0.05 was considered as indicative of significance. Results: Neither conversion to an open procedure nor major complications occurred in either group. The operative time was similar in both groups (LP 55.7 ± 8.6 min vs SP 51.9 ± 8.3 min). The mean postoperative pain score was 6.18 ± 3.48 lower after LP than SPLC and the difference amounted to 22.2% (p <0.005). The incidence of shoulder-tip pain was 2.1 times lower after LP than SPLC (p <0.05). QOL within 7 days following the operation was remarkably better after LPLC than after SPLC (p <0.01). Conclusions: LP pneumoperitoneum is superior to SP pneumoperitoneum in terms of lower postoperative pain, a lower incidence of shoulder-tip pain, and a better QOL within 5 days following the operation. LP should be used for LC in cases of uncomplicated symptomatic gallstones as a recommended procedure as long as an adequate exposure is obtained with this technique.

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy : a randomized, double-blind, placebo-controlled study

BackgroundThis study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial.MethodsIn this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption.ResultsSignificantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 ±57.2 min in group A, as compared with 307 ± 39.8 min in group B, 109.3 ± 51 min in group C, and 109 ± 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05).ConclusionsPreemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Doppler guided haemorrhoidal arterial ligation with recto‐anal‐repair (RAR) for the treatment of advanced haemorrhoidal disease

Objective  A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto‐anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given.

Doppler-Guided Hemorrhoid Artery Ligation with Recto-Anal-Repair Modification: Functional Evaluation and Safety Assessment of a New Minimally Invasive Method of Treatment of Advanced Hemorrhoidal Disease

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Możliwości leczenia popromiennych przetok odbytniczo-pochwowych

A pathological communication between the rectum and the vagina, referred to as rectovaginal fistula, can develop as a result of...

Use of high-dose oxycodone hydrochloride in patients with visceral and neuropathic pain

1Department of Clinical Oncology, University Hospital in Krakow, Krakow, Poland 2Department of Experimental and Clinical Surgery, Jagiellonian University Medical College, Krakow, Poland 3Department of Palliative Medicine, Department of Internal Medicine and Geriatrics, University Hospital in Krakow, Krakow, Poland 4Department of Pain Treatment and Palliative Care, Jagiellonian University Medical College, Krakow, Poland 5Department of Oncology, Jagiellonian University Medical College, Krakow, Poland

Influence of the rectal resection on the sphincters function: electromyographic and manometric assessment

Colonic ischaemia, commonly referred to as ischaemic colitis, is the most common type of intestinal ischaemia. The term ischaemic colitis was used by Marston (1966) with three typical patterns of injury described: transient reversible ischaemia, ischaemic ulcers with stricturing, and gangrenous ischaemic colitis. Dominant presenting symptoms were colicky abdominal pain, vomiting, bloody diarrhea, and hematochezia. Patients often have minimal signs on clinical examination. Most patients were diagnosed at colonoscopy. Two regions that are believed to be anatomically vulnerable to ischemic disease are Griffith’s point , at the splenic flexure and Sudeck’s critical point, of the Durmond marginal artery. Clinically, IC is classified as non-gangrenous or gangrenous. Nongangrenous IC involves the mucosa and submucosa and accounts for 80–85% of all cases of IC. Nongangrenous IC is further subclassified into transient, reversible IC with a less severe form of injury and chronic, non-reversible IC, which includes chronic colitis and stricture and has a more severe form of injury. Gangrenous IC accounts for the remaining 15–20% of cases and manifests as the most severe form of injury. It includes acute fulminant ischaemia with transmural infarction that may progress to necrosis and death. Specific indications for operation include peritonitis, perforation, recurrent fever or sepsis, clinical deterioration in patients refractory to medical management. Other indications include fulminant colitis, massive hemorrhage, chronic protein losing colopathy, and symptomatic ischemic stricture.