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Background and purpose: Evaluation of suspected biliary obstruction is performed by common old methods such as Ultrasound, CT, and invasive cholangiography. These techniques have limitations due to the poor visualization of intraductal stones (US, CT) and the need for an invasive procedure (ERCP, PTC). Magnetic resonance cholangiography (MRC) is noninvasive imaging modality that provides good visualization of the hepatobiliary system. The aim of the present study was to determine the utility of Magnetic resonance cholangiography, Ultrasonography and Liver function test in preoperative assessment of patients with symptomatic cholecystolithiasis and suspected biliary obstruction.
Materials and Methods: Patients selected for elective open cholecystectomy with risk factors of common bile duct stones as suspected biliary obstruction underwent MRC, US, and Liver function test preoperatively. All patients underwent open cholecystectomy and intraoperative cholangiography in Imam Khomeini Hospital, Academic Medical Center of Medicine School, Mazandaran University of Medical Sciences, Sari, Iran from January 2003 to February 2006.
Results: 30 patients (11 male, 19 female) with the mean age 53.93±13.32 years in a range of 38-75 years underwent all preoperative and operative assessments. 81.81% Sensitivity, 87.5% specificity and 83.33% efficacy in MRC 18.18% Sensitivity, 87.5% specificity and 36.66% efficacy in US, and 54.54% Sensitivity, 37.50% specificity and 50% efficacy in Liver function test were the results obtained for biliary stones.
Conclusion: MRC has excellent diagnostic accuracy in the detection of biliary disease. Due to its non-invasive nature, MRI may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

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Background and purpose: Gallstone is one of the most common problems of hepatobiliary system. Laparoscopic cholecystectomy is a gold standard treatment for this problem. Carbon dioxide (CO2) insufflated in the abdomen for better exposure in laparoscopic cholecystectomy could increase the liver enzyme levels. The goal of this study was to assess the effect of different CO2 pressure (12-16 mm Hg) on liver enzymes in laparoscopic cholecystectomy compared with open cholecystectomy. Materials and methods: In this clinical trial 60 patients were randomly assigned into three groups. The first group had low pressure (12mm Hg) laparoscopic cholecystectomy. The second group had laparoscopic cholecystectomy with high pressure (16mm Hg) and the third group had an open cholecystectomy. To assess the liver enzyme levels we checked the AST, ALT, ALP, LDH, and Bil, before, 24h, and 72h after surgery. Data analysis was done in SPSS ver.15 using repeated measures ANOVA. Results: The changes in liver function tests were significantly different before and 24h after the surgery in first and second group, however, these changes reduced to primary level after 72h. In the group with open cholecystectomy significant changes were seen in AST and ALT levels before and 24h after the surgery which decreased to primary level after 72h. The level of LDH was significantly different before and 24h after the surgery in group one and two. Conclusion: Gas insufflation in to abdomen transiently changed the liver enzyme levels that reduced to primary level after 72h.

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Background and purpose: Postoperative pain is the most common problem after elective laparoscopic cholecystectomy. This study assessed the effect of gabapentin on postoperative pain after laparoscopic cholecystectomy. Materials and methods: In this study 80 patients aged 20-60 (ASA class I, II) who were candidates for laparoscopic cholecystectomy were randomized into two groups to receive gabapentin 600 mg (n=40) and placebo (n=40). The pain was evaluated by a visual analogue scale (VAS) at 2, 4, 6, 8, 12, 18, and 24 hour post operation. Intravenous morphine was administrated to treat postoperative pain on VAS>3. Morphine consumption and pain scores were recorded. Results: The means of intravenous morphine consumption were 2.5 ± 2.6 mg and 2.7 ± 2.7 mg in the gabapentin group and the placebo group, respectively which showed no significant difference between the two groups (P>0.05). We also found no significant difference in the average pain score of the two groups in the first 24 hours after surgery (P>0.05). Conclusion: According to this study, the analgesic effect of gabapentin at a single dose of 600 mg before laparoscopic cholecystectomy is not obvious, so we recommend it at repeated and higher doses.

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Background and purpose: Postoperative nausea and vomiting (PONV) is a side effect of anesthesia. Without prophylactic intervention, it occurs in about one-third of patients (10 to 60%) under general anesthesia. PONV could be more uncomfortable than postoperative pain. The aim of this study was to compare the efficacy of ondansetron and dexamethasone in reducing nausea and vomiting after laparoscopic cholecystectomy.

Materials and methods: A randomized double blind clinical trial was performed and 90 patients (in Imam Khomeini Hospital in 2011) undergoing laparoscopic cholecystectomy were randomly allocated into three groups (n=30 per group) and received continuous intravenous anesthesia. Before induction of anesthesia the patients in first group (D) had 8mg dexamethasone injection, the second group (O) had 4 mg intravenous ondansetron and the control group (P) received 2 cc injection of normal saline. Anesthesia complications and PONV were recorded in recovery room at 6 and 24 hours following the surgery. Data was analyzed in SPSS applying Chi-square test and analysis of variance (ANOVA).  

Results: The incidence of nausea in groups P, D, and O was 66.7%, 33.3% and 33.3%, respectively. A significant difference was seen between the control group and intervention groups (P=0.01) but the difference was not significant between groups D and O. The incidence of vomiting in control group was 56.7%, and in groups D and O were 23.3% and 26.7%, respectively indicating a significant difference between the controls and intervention groups. But, no significant difference was observed between the intervention groups (group O: P=0.01 and group D: P=1).

Conclusion: In preventing nausea and vomiting after laparoscopic cholecystectomy, dexamethasone and ondansetron were found to be similarly effective.

(Clinical Trials Registry Number: IRCT201111094093N2)

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 Background and purpose: Transversus abdominal plane block is used in management of pain in patients undergoing abdominal surgery. This study aimed at investigating the effect of ultrasound-guided transversus abdominis plane block on postoperative pain control in patients undergoing laparoscopic cholecystectomy.
Materials and methods: This double-blind randomized clinical trial was performed in 60 patients undergoing laparoscopic cholecystectomy. General anesthesia was induced in all patients. At the end of the operation, a subcostal transverse abdominis plane (SCTAP) block was performed in the intervention group, while the control group received no intervention. In all samples, pain intensity based on Visual Analogue Scale (VAS) and the dose of opioid and anti-emetics drugs were assessed at recovery, 2, 4, 8, 12, and 24 hours after the surgery. Data analysis was performed in SPSS 24 applying independent t-test and chi-square.
Results: The number of patients with VAS<4 was significantly higher in intervention group compared with the control group at recovery (96.4%), 2 (96.4%), 4 (89.2%), and 8 (57.1%) hours after the surgery (P<0.05), but, data showed no significant difference between the intervention group and control group at 12 and 24 hours after surgery (P>0.05). Findings showed significant differences in mean opioid administration during 8 (4.4 ± 11.9) and 24 hours (38.3 ± 21) after surgery between the intervention group and the control group (P<0.001). The mean use of metoclopramide was not found to be significantly different between the two groups at 8 and 24 hours after surgery (P> 0.05).
Conclusion: Current study showed that ultrasound-guided SCTAP block could reduce postoperative pain and opioid administration after laparoscopic cholecystectomy.
 
(Clinical Trials Registry Number: IRCT20180325039148N1)

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 Background and purpose: Obesity as a risk factor puts patients at risk for postoperative complications. Shoulder pain is one of the early post-laparoscopic cholecystectomy symptoms related to CO2, which remains in the abdomen. Motivational spirometry is a novel technique used in management of shoulder pain after LC. This research aimed to evaluate the effect of motivational spirometry on severity of shoulder pain after LC considering body mass index (BMI).
Materials and methods: A randomized clinical trial was performed in 84 patients who were candidate for LC. They were randomly divided into a control group and an intervention group. Demographic characteristics and body mass index were recorded. Patients in intervention group used motivational spirometry (10 deep breaths in sitting or semi-sitting positions) in full consciousness every 2 hr after surgery. In both groups, intensity of shoulder pain was measured at 4, 8, 12, 24, and 48 hours after surgery using Numerical Rating Scale (NRS).
Results: Among the intervention group, 28.9% had a BMI higher than 25. Kruskal-Wallis test showed significant differences in pain intensity between patient in the intervention group with different BMI at 4, 8, 12, and 24 hours after surgery (P<0.05).
Conclusion: In this study, motivational spirometry reduced intensity of shoulder pain in patients following LC, however, some patients with high BMI had more sever and long-lasting pain, because obesity impede proper deep and effective inhalation and exhalation in these patients.
 
(Clinical Trials Registry Number: IRCT20181106041569N1)