Evaluation of post-operative analgesia following laparoscopic application of Filshie clips

OBJECTIVE: To evaluate the efficacy of injecting 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes to control post-operative pain after laparoscopic Filshie clip application. DESIGN: A double blind, randomised controlled trial. SETTING: The day surgery unit of the Dunedin Public Hospital, Otago, New Zealand. PARTICIPANTS: Fifty-nine women attending the public hospital requesting sterilisation. INTERVENTIONS: The experimental group received an infiltration of 1% lignocaine into the subserosal aspect of the cornual end of the fallopian tubes. The control group received an infiltration of normal saline in the same site. MAIN OUTCOME MEASURES: The use of post-operative pethidine and the scores obtained on a modification of the McGill present pain intensity score, a visual analogue scale of present pain, a pain relief score and comparisons of time to first analgesia use. RESULTS: The use of pethidine in the experimental group was significantly reduced [P = 0.001] Pain relief scores indicated significant benefit from the intervention. The time to first analgesic use was significantly greater in the experimental group. CONCLUSION: Lignocaine infiltration at the cornual end of the fallopian tubes during laparoscopic Filshie clip application is highly effective in producing post-operative pain relief.     

Shaving of the scalp may increase the rate of infection in CSF shunt surgery

Most surgeons use metal clips in laparoscopic cholecystectomy. The aim of this prospective randomized controlled study was to evaluate the efficacy of absorbable clips in elective laparoscopic cholecystectomy. One hundred consecutive patients with symptomatic gallstones without complications were randomized into groups; group T had two metal clips (titan clip ETHICONR), group R (laproclipR Davis and Geck) had one absorbable clip applied on the cystic duct and cystic artery. The patients were followed for one year. There was no difference between the two groups concerning operative time, hospital stay and postoperative complications. The absorbable clips seem to be as effective as metal clips in providing hemostasis in cystic artery and in cystic duct ligation.     

Bilateral ruptured tubo-ovarian abscesses following bilateral tubal ligation several years earlier

The occurrence of pelvic inflammatory disease and tubo-ovarian abscesses previously has been regarded as essentially nonexistent in the patient who has undergone tubal sterilization, although there have been isolated reports in the literature. This case describes a patient who underwent tubal ligation approximately 6 years prior to presenting with bilateral ruptured tubo-ovarian abscesses. The patient underwent emergency surgery and had an uneventful recovery. Theoretically, although bilateral tubal ligation should preclude the development of pelvic inflammatory disease, it is a diagnosis that should be considered in the patient presenting with lower pelvic and abdominal pain.     

Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis

We used a new laparoscopic technique to treat infiltrative symptomatic intestinal endometriosis. Eight women, ages 29-38, with extensive symptomatic pelvic endometriosis were included in this series. All were diagnosed as having severe pelvic endometriosis and had not responded to previous conservative surgical and hormonal therapy. In a 5-18-month postoperative followup, six women have reported complete relief of the symptoms. Two have right lower quadrant pain and menstrual cramping. Second-look laparoscopy was offered to all patients and so far, two have accepted. These procedures were performed 6 weeks postoperatively. At that surgery, we found that the anastomotic site had healed completely with filmy adhesions between the posterior aspect of the uterus and the rectosigmoid colon in one patient. The second woman had undergone extensive adhesiolysis at the first surgery, and these adhesions recurred; however, the anastomotic site had healed completely. One of the two infertility patients has achieved pregnancy. The only complications was one patient with ecchymosis of the anterior abdominal wall. Sigmoidoscopy was performed 6 weeks postoperatively, and has been or will be performed at 6 months postoperatively. To date, all anastomotic sites have healed well with no sign of stricture. Our results with this technique in a small series were positive, and it appears that, in the hands of experienced laparoscopists, it may prove useful in treating symptomatic infiltrative endometriosis.     

The laparoscopic sterilization of women

The optimal time for sterilization is 24-36 hours after childbirth or during the 8th week in the postpartum period. The surgical methods of sterilization of the ovarian ducts are simple, harmless, effective, reversible, economical, and voluntary. These considerations also apply to endoscopic methods. For the occlusion of ovarian ducts, electrical current (monopolar and bipolar) and mechanical means (Yoon ring, Hulka and Filshie clips) are used. Unipolar coagulation of the ovarian ducts is another method of surgical sterilization done by laparoscopy. The area of coagulation occupies about 1.5 cm. The length of bipolar coagulation is 10 times larger than the unipolar coagulation site. Patients can be released 4 hours or the next day after the operation. The frequency of complications with bipolar coagulation is low: burning occurs in 0.04-0.1% of cases and bleeding from the mesosalpinx in 0.16-0.5%. The incidence of pregnancy after the operation amounts to 0.1-0.4%. Mechanical methods of sterilization are also reliable, although they are not suitable for all women. For young women who may still want children it is uniquely expedient to employ the Hulka or Filshie clips. In the rest of the cases the Yoon ring can be used, which was first used in the US in 1972 and became popular subsequently. The rate of complications is rare with its use (0.12-3.75%), and pregnancy occurs in 0.08-0.4% of cases. The incidence of complications with the use of clips amounts to 0-0.71%, the pregnancy rate is 0-0.59%, and the possibility of reversal is 80-100%. This method is ideal for young women who do not want to use other contraceptives and who want to have more children.     

Experience with transcutaneous electrical nerve stimulation for relief of intractable pain in cancer patients

Sixty patients with intractable cancer pain were subjected to transcutaneous electrical stimulation for pain control. Evaluation, after two weeks of treatment, revealed: 17 (28.3%) excellent response, 22 (36.2%) fair and 21 (35.0%) no relief. Re-assessment after 3 months revealed 9 (15%) excellent responses, 11 (18.3%) fair and 40 (67%) failures. Extremity and trunk pains appeared to be most rewarding to patient pain, so far as pain relief is concerned. Perineal and pelvic pains were most difficult to control, only 5 of 12 (41%) cases obtained some short term relief. Pain location and sources correlated with treatment results.     

Laparoscopy for chronic abdominal pain

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.     

Pre- and peroperative misdiagnosed sellar tumour

BACKGROUND: The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome occurs in 1 of every 4,000-5,000 female births. It is characterized by normal external genitalia, an absent vagina, absent or rudimentary uterus, and normal fallopian tubes and ovaries. When associated with a rudimentary uterine horn, cyclic catamenial pelvic pain may result. The standard procedure for pain relief has been removal of the uterine horn by laparotomy. CASE: A rudimentary uterine horn was diagnosed in a woman with MRKH syndrome who developed monthly severe pelvic pain. Removal of the structure was performed via laparoscopy. The patient had complete resolution of her pain. CONCLUSION: As an alternative to laparotomy, laparoscopic resection of a rudimentary horn in patients with MRKH syndrome is both feasible and beneficial in the treatment of pelvic pain.     

Novel technique and instrumentation for laparoscopic application of hemostatic clips

A novel device for applying hemostatic clips in laparoscopic surgery incorporates a distal hook into a multiple-firing titanium clip applier. The hook may be used for blunt dissection of tissue, and to displace and control ducts and vessels during clip application. A single instrument may be used to achieve hemostasis in areas that are difficult to reach, and past pointing problems encountered with straight on clip appliers are alleviated. Comparative testing of the holding force of the curved clips used with this device versus the straight clips used in conventional multiple-clip appliers demonstrated a higher mean pull-off force of 0.473 lbs versus 0.33 lbs. Clinical application of the device in laparoscopic procedures including cholecystectomy, vaginal hysterectomy, Nissen fundoplication, vagotomy, varicocelectomy, and lymphadenectomy show the utility of the hook clip applier.     

Bile leakage resulting from clip displacement of the cystic duct stump: a potential pitfall of laparoscopic cholecystectomy

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.     

Idiopathic bronchiolitis obliterans with organizing pneumonia presenting with adult respiratory distress syndrome

We report a multiple trauma case with complex pelvic fractures and perineal wounds. The patient had a laparoscopic abdominal exploration with a simultaneous laparoscopic colostomy using the same wounds. Only two trocars were needed to perform both procedures. The technique is detailed here. The procedures were performed in less than an hour, with excellent postoperative recovery, achieving complete diversion of the rectal fecal contents.     

Sonographic features of ovarian remnants

Ovarian remnants occur after a portion of ovarian tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients, extrinsic compression of the distal ureter. Ovarian remnants frequently are associated with adhesions from previous pelvic surgery for endometriosis or pelvic inflammatory disease. Ovarian remnants also may be included within pelvic peritoneal inclusion cysts. In this retrospective study, the sonographic features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described. Most ovarian remnants were simple cysts (seven of 10), three had multiple septations, and six had a rim of presumably ovarian tissue with arterial and venous flow. Three patients with ovarian remnant masses that were aspirated had symptomatic relief without recurrence. In one patient, guided aspiration was unsuccessful, probably owing to the presence of organized hemorrhage within the mass. Extrinsic compression of the distal ureter was observed in one patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic findings of a completely cystic or multiseptated pelvic mass with a rim of vascularized solid tissue in a postoophorectomy patient, although such cases are rare, suggest the diagnosis of an ovarian remnant. If the diagnosis can be established with a high degree of certainty, sonographically guided aspiration may be attempted in an effort to provide symptomatic relief. Otherwise, sonography is useful in serial assessment of these masses in patients receiving medical treatment.     

Specific amino acid substitutions in the proline-rich motif of the Rhizobium meliloti ExoP protein result in enhanced production of low-molecular-weight succinoglycan at the expense of high-molecular-weight succinoglycan

A case of a 35-year-old woman with abdominal migraine is presented. For four years she had been suffering from abdominal pains occurring only at night, always between 1 and 3 a.m. The patient always woke with abdominal pains and nausea. Each time she had diarrhoea and vomited and found that this gave her relief from the pain. Sometimes she lost consciousness for 1-2 minutes. After the attack she felt very weak, her legs and feet became numb and she found it difficult to get to sleep. The attacks and the fainting fits increased in frequency until she had several a month. Numerous gastrological examinations did not reveal any deviations from the normal. At the anti- epileptic consulting unit, abdominal epilepsy was excluded (no abnormalities were found in the eeg and CT examinations of the cranium). As a child she had paroxysmal abdominal pains. When the patient was 10 years old, she had an attack lasting one week and though the pain was severe on the left side, appendectomy was performed. Her mother suffers from migraine with very severe head pains. The patient was referred to our consulting unit where she was treated with Pizotifen in doses of 0.5 mg morning and noon and 1 mg in the evening for three months during which time she had no attacks. A few weeks after discontinuing this treatment, the nocturnal attacks again occurred though the pains were not so severe. She was then prescribed Nitrendipine, 5 mg nightly, and the attacks ceased. However, the patient said that she had felt better when taking Pizotifen.     

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. Pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.     

Isolation and absolute structures of enantiomeric 1,2-bis(4-hydroxy-3-methoxyphenyl)-1,3-propanediol 1-O-glucosides from the bark of Hovenia trichocarpa

The common diagnoses in low back pain are lumbar strain, lumbosacral radiculopathy, osteoarthritis, degenerative disc disease, spinal stenosis, and sacroiliac joint dysfunction. Unusual causes of low back pain that have been previously identified include abdominal aortic aneurysms, pelvic neoplasms, and retroperitoneal hemorrhages. This report describes a case of back pain that was apparently caused by a duodenal ulcer. A 54-year-old man with no significant medical history presented with a complaint of mid to low back pain (T10-L2), which was diagnosed as joint dysfunction. A comprehensive treatment program was prescribed and the patient was instructed to return to clinic in 4 weeks. Three weeks later, he experienced a syncopal episode followed by coffee ground emesis. He immediately sought medical attention at an emergency room, where he was admitted to the hospital with a diagnosis of upper gastrointestinal bleed. Esophagogastroduodenoscopy showed a large duodenal ulcer, and the patient underwent vagotomy and pyloroplasty. He returned to his physiatrist's office 3 weeks after hospital discharge with minimal back pain. The cause of the back pain proved to be referred visceral pain from his duodenal ulcer. This case is presented to reemphasize the need to include the uncommon phenomena in the differential diagnosis of low back pain.     

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs

BACKGROUND: While pelvic arterial insufficiency, either acute or chronic, results in stereotypic clinical findings which may readily be reversed by indirect techniques of revascularization, few reports document the indications for, techniques of, and results following direct pelvic revascularization by reconstruction of the hypogastric artery. METHODS: Retrospective review of 8 patients with symptomatic pelvic arterial insufficiency undergoing direct hypogastric artery reconstruction during the period from 1984 to 1995. RESULTS: Eight patients underwent unilateral hypogastric artery reconstruction by bypass graft (3 patients) or endarterectomy and patch angioplasty (5 patients). One patient had immediate symptomatic relief of his symptoms, but was lost to follow-up after 1 month. One patient manifested no symptomatic improvement despite a technically successful operation. The remaining 6 patients experienced significant symptomatic relief that has persisted during follow-up from 3 months to 11 years postoperatively. Among 4 men in whom erectile impotence comprised one of the indications for intervention, 3 reported sustained restoration of sexual function. CONCLUSION: In properly selected patients, direct pelvic revascularization by hypogastric artery reconstruction may predictably and durably relieve symptoms of pelvic arterial insufficiency.     

Pelvic radiation therapy as a risk factor for ischemic colitis complicating abdominal aortic reconstruction

Ischemic colitis is an infrequent but potentially devastating complication of abdominal aortic reconstruction. Identification of patients with predisposing risk factors for the development of ischemic colitis can guide intraoperative measures to preserve or restore colonic blood flow during aortic surgery. Previous radiation therapy for pelvic malignancy may be one such predisposing risk factor. Two cases are presented in which ischemic colitis complicated abdominal aortic reconstruction in the setting of previous pelvic irradiation. In the months after radiation therapy for prostate cancer, one patient underwent infrarenal abdominal aortic aneurysm repair. Ischemic infarction of the sigmoid colon developed acutely after surgery and required emergent sigmoid colectomy. The second patient underwent reconstruction of an infrarenal abdominal aortic aneurysm after having had radiation therapy for a bladder tumor. Despite an initial satisfactory result, the patient's abdominal pain and diarrhea progressively worsened and he eventually required sigmoid colectomy for severe ischemic colitis. In both of these patients, the inferior mesenteric arteries were patent and had not been reimplanted. The association of pelvic radiation therapy with ischemic colitis after aortic reconstruction should focus attention to the operative details for maintaining the colonic circulation in these patients. Reimplantation of the inferior mesenteric artery in particular may prevent both the acute and the insidious variants of this complication in patients who undergo aortic surgery and decrease the incidence of this complication in patients with a history of radiation therapy to the pelvis.     

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.     

Inhibitors of tyrosine kinase

BACKGROUND AND OBJECTIVES: Neurolytic superior hypogastric plexus block has been shown to be safe and effective in selected cancer patients. A large cohort of patients was studied to evaluate the continued efficacy and safety of this block in cancer patients with advanced disease. METHODS: A total of 227 pelvic pain patients with gynecological, colorectal, or genitourinary cancer who experienced poor pain control due to either progression of disease or to untoward side effects were enrolled in this study during a 3-year period. All pain patients receiving oral opioids were eligible to participate. A bilateral percutaneous neurolytic superior hypogastric plexus block with 10% phenol was performed 1 day after a successful diagnostic block with 0.25% bupivacaine. RESULTS: All patients reported a visual analog scale (VAS) pain score of 7-10/10 before the block. A positive response to a diagnostic block was obtained in 159 patients (79%). Overall, 115 patients of the 159 patients who responded to a diagnostic block (72%, 95% confidence interval of 65-79%) had satisfactory pain relief (VAS < 4/10), 99 (62%) after one block, and 16 (10%) after a second block. The remaining 44 patients (28%) had moderate pain control (VAS 4-7/10) after two blocks and received oral pharmacological therapy and epidural analgesic therapy with good results. Both groups experienced significant reductions in oral opioid therapy after the neurolytic blocks. No additional blocks were required by patients who had a good response during a follow-up period of 3 months. No complications related to the block were detected. CONCLUSIONS: Neurolytic superior hypogastric plexus block provided both effective pain relief and a significant reduction in opioid usage (43%) in 72% of the patients who received a neurolytic block. Overall, this represents 51% of the patients enrolled in the study. Poor results should be expected in patients with extensive retroperitoneal disease overlying the plexus because of inadequate spread of the neurolytic agent.     

The clinical characteristics of intraoral herpes simplex virus infection in 52 immunocompetent patients

OBJECTIVES: To determine if nonsteroidal anti-inflammatory drugs provide adequate pain control for patients having laparoscopic hernia repair and to compare the effectiveness of ketorolac tromethamine with ibuprofen in reducing postoperative laparoscopic hernia pain. DESIGN AND SETTING: Prospective double-blind randomized study at a 100-bed community hospital. PATIENTS: Seventy patients ranging in age from 16 to 83 years scheduled for elective laparoscopic inguinal hernia repair. INTERVENTIONS: Patients undergoing laparoscopic hernia repair were enrolled in a double-blind randomized study to compare the 2 treatments. Group 1 received a placebo capsule 1 hour before surgery and ketorolac tromethamine, 60 mg intravenously, at the time of trocar insertion. Group 2 received ibuprofen, 800 mg an hour before surgery, and isotonic sodium chloride solution, 2 mL intravenously, at the time of trocar insertion. In addition, all patients received local infiltration of 30 mL of bupivacaine hydrochloride into their trocar sites. All patients were discharged within 5 hours of the operation and were instructed to take 400 mg of ibuprofen orally every 4 hours for 24 hours whether or not they were experiencing pain. A 24-hour supply of ibuprofen was provided to all study patients. Pain was assessed using the Visual Analog Pain Scale with a maximum pain rating of 100. Assessments were done at the time of and 18 hours after discharge. MAIN OUTCOME MEASURE: Postoperative pain 18 and 24 hours after discharge was assessed using a standardized questionnaire in a telephone interview by a registered nurse from the Outpatient Surgical Unit. RESULTS: There was no significant difference in the level of pain experienced by 35 patients who received ketorolac intravenously and 35 who received ibuprofen orally. There was no significant difference between the 2 treatment groups in the amount of pain experienced at discharge and 18 hours after discharge. CONCLUSIONS: Pain relief from ibuprofen, 800 mg, administered orally an hour before laparoscopic hernia repair was not statistically different from that obtained with intravenous ketorolac, 60 mg, administered intraoperatively when comparing the hospital discharge pain score and the mean and highest pain scores 18 hours after discharge. Ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair. No patient required narcotic supplementation, and pain control was judged satisfactory by all the patients.