Background and Objectives: Multimodal analgesia has been shown to be effective in facilitating early postoperative gastrointestinal function and rehabilitation in patients undergoing open gastrectomy. We conducted a clinical trial to investigate the effectiveness of bilateral rectus sheath block (RSB) with continuous bupivacaine infusion in comparison with placebo following elective open gastrectomy. Materials and Methods: Patients indicated for elective open gastrectomy were screened, enrolled, and randomised between October 2021 and September 2023. The patients were randomised to either Group A (intervention—continuous bupivacaine) or Group B (control—NaCl saline). The primary outcome measures were the quantity of an opioid analgesic administered during the initial 72 h post-surgery and the level of postoperative pain as indicated by the visual analogue scale (VAS). Mann–Whitney U test was used for quantitative analysis while Pearson Chi-square was used for categorical variables. Results: A total of 60 patients completed the trial, with 30 patients in each of the two groups. Patients in Group A reported lower median VAS pain scores at all observed time points following surgery (p < 0.001). No patient in Group A required rescue opioid analgesia, although non-steroidal anti-inflammatory drugs were necessary during the initial 12 h postoperatively. Clinically, Group A patients had a significantly shorter time to first gas (p = 0.001), a shorter time to first bowel movement (p < 0.001), a shorter time to first out-of-bed activity (p < 0.001), and a shorter overall hospitalisation duration (p < 0.001) compared to Group B patients. Conclusions: Bilateral RSB with continuous bupivacaine infusion is effective in managing pain and can reduce the use of opioid analgesics in the postoperative period. Furthermore, it promotes early recovery, and a shorter hospital stay.

Background: Laparoscopic cholecystectomy for acute cholecystitis carries an increased risk of biliovascular injuries. Fluorescence cholangiography (FC) is a valuable diagnostic tool for identifying extrahepatic bile ducts (EHBD). The objective of this study was to evaluate the efficacy of FC in delineating EHBD anatomy, both before and after dissection, based on the critical view of safety (CVS) principles. Methods: Urgently admitted patients were prospectively stratified into two groups, depending on whether they had mild or moderate acute cholecystitis, in accordance with the 2018 Tokyo guidelines. All patients were scheduled for an early laparoscopic cholecystectomy using FC and were administered a fixed dose of indocyanine green (ICG) intravenously 12 h prior to the surgical procedure. Results: A total of 108 patients—75 patients with mild acute cholecystitis and 33 patients with moderate acute cholecystitis—were included. More than four CVS steps were performed in 101 patients (93.5%). Less than four CVS steps were performed only in seven patients—three (2.5%) patients with mild acute cholecystitis and four (4%) patients with moderate acute cholecystitis. The achievement of the CVS principles and the visualization rate using FC significantly increased in both patient groups, ranging from 3% before CVS to 100% after CVS (p < 0.001). In both groups, the cystic duct was visualized in most patients after CVS and FC, followed by the common bile duct and the common hepatic duct. Conversely, even after using CVS and FC, the visualization of the confluence of the cystic and common hepatic ducts remained less likely and challenging in both groups (57.3% in mild patients vs. 33.3% in moderate patients; p = 0.022). Background liver fluorescence disturbance was observed equally in both patient groups (6–11%), but it did not reach statistical significance. The median operative time was 60 ± 25 min in patients with mild acute cholecystitis compared to 85 ± 37 min in patients suffering from moderate acute cholecystitis (p < 0.001). No postoperative complications or biliovascular injuries were observed. Conclusions: FC is a convenient, safe, and efficacious procedure for attaining CVS principles and identifying the EHBD anatomy in most patients. The procedure showed superior results in mild acute cholecystitis patients in comparison to moderate acute cholecystitis patients.

Background and Objectives: Thoracic epidural analgesia (TEA) is considered the gold standard for postoperative pain control following major abdominal surgery. Bilateral rectus sheath block (RSB) is a promising alternative regional technique. This study aimed to compare the efficacy of RSB and TEA in managing early postoperative pain and enhancing recovery after open gastrectomy. Materials and Methods: Between October 2021 and December 2024, 70 patients scheduled for elective open gastrectomy were randomized into two groups: Group A (RSB with continuous bupivacaine infusion) and Group B (TEA with 10 mg bupivacaine plus 1 µg/mL fentanyl). Primary outcomes included opioid consumption within 72 h postoperatively and pain intensity measured using the visual analog scale (VAS). Statistical analysis was conducted using the Mann–Whitney U test, Friedman’s ANOVA with Bonferroni correction, and Chi-square or Fisher’s exact test for categorical variables. Results: A total of 64 patients were finally included (30 in RSB, 34 in TEA). VAS scores in the RSB group were significantly lower at 24 and 48 h postoperatively compared to baseline (p < 0.001). Between-group comparisons showed consistently lower pain scores in the RSB group at all measured time points. At 48 h, 94% of patients in the TEA group required rescue analgesia, compared to only 17% in the RSB group. Additionally, the RSB group had a significantly shorter postoperative hospital stay (mean 6 vs. 9 days) and demonstrated earlier return of bowel function. Conclusions: RSB is a safe and effective alternative to TEA for analgesia after open gastrectomy. It significantly lowers pain scores, reduces opioid and rescue medication use, shortens hospital stay, and enhances early recovery. Bilateral rectus sheath block with continuous bupivacaine infusion significantly lowers pain scores, reduces opioid and rescue medication use, shortens hospital stay, and facilitates early recovery.

Chylous ascites is an uncommon complication following invasive procedures, occurring in fewer than 5% of cases. Most patients with low output lymphorrhea respond favourably to conservative management. However, in cases of persistent lymphatic leakage, surgical intervention may be warranted. Case presentation. A 42‑year‑old male developed lymphorrhea following ultrasound‑guided percutaneous drainage of a large perisplenic hematoma and hemoperitoneum. Despite repeated drainage of ascitic fluid (performed three times) and conservative therapy, including dietary modifications, the patient exhibited persistent chylous ascites that necessitated surgical intervention. A total of five abdominal computed tomography (CT) scans and two magnetic resonance imaging (MRI) studies failed to identify the site of lymphatic leakage. The patient was admitted to Riga East Clinical University Hospital, where additional CT and MRI imaging of the abdomen was performed. Surgical treatment was scheduled. During laparotomy, intraoperative fluorescence lymphography was employed using near‑infrared imaging with indocyanine green (ICG) injection. Lymphatic leakage was identified in the vicinity of the left diaphragmatic crus. Approximately three minutes after paraaortic administration of ICG, intact lymphatic vessels became visible, and within five minutes, the precise site of leakage was localized via fluorescence‑guided extravasation. The leaking lymphatic vessel was coagulated and sealed using a TachoSil® hemostatic patch. A surgical drain was placed adjacent to the repair site for postoperative monitoring. No recurrence of chylous ascites was observed during a four‑month follow‑up period. Intraoperative identification of lymphatic leakage remains challenging due to the small calibre of lymphatic vessels and the low‑pressure flow of lymph, which is often imperceptible to the unaided eye. Fluorescence‑guided lymphography using ICG significantly enhances intraoperative visualization of compromised lymphatic structures. In cases of refractory chylous ascites, surgical management incorporating this technique appears to be both safe and effective. Conclusions. This case highlights the successful surgical management of refractory chylous ascites utilizing intraoperative indocyanine green fluorescence lymphography, which enabled precise identification and closure of the lymphatic leakage site.

Laparoskopiska holecistektomija (LH) ir standarta ārstēšanas metode pacientiem ar akūtu holecistītu. LH asociējas ar īsāku pēcoperācijas hospitalizācijas ilgumu, salīdzinot ar vaļēju holecistektomiju (VH). Mūsdienās žultsakmeņu slimība ir biežākais akūta vēdera etioloģiskais faktors pieaugušajiem, kā arī biežākā indikācija operācijai gados veciem cilvēkiem (Terho et al., 2016). Laparoskopiska holecistektomija ir viena no biežākajām ķirurģiskajām operācijām Eiropā (Lehrskov et al., 2020). Latvijā vidēji gadā tiek veiktas 3800 laparoskopiskas holecistektomijas (Latvijas Ķirurgu asociācijas statistikas dati). Salīdzinoši Vācijā katru gadu tiek veiktas vidēji 158 000 (Nimptsch et al., 2015), savukārt Amerikas Savienotajās Valstīs vairāk nekā 1 200 000 laparoskopisku holecistektomiju (Strosberg et al., 2017; Sharrak et al., 2024). LH kā žultsakmeņu slimības ārstēšanas metode tiek lietota vairāk nekā 30 gadus. Tomēr LH uzdevums ir ne tikai veikt žultspūšļa izņemšanu slimniekiem ar simptomātisku holecistītu, bet arī izvairīties no jatrogēniem žultsvadu bojājumiem. Šobrīd LH ir standartizēta un vadlīnijas rekomendē ievērot tā saukto Critical View of Safety (CVS) principu, lai izvairītos no žultsceļu bojājumiem (Lehrskov et al., 2020). Šo tehniku pirmais aprakstījis un ieviesis Stīvens Stasbergs (Steven Strasberg) (Renz et al., 2017). Tā ietver sistēmisku etapa veida audu disekciju jeb izdalīšanu pēc CVS principiem, vadoties pēc anatomisku struktūru savienojumu intraoperatīvas vizualizācijas (Lehrskov et al., 2020). Šo principu ievērošana ir svarīga, jo ekstrahepatisko žultsceļu anatomija ir variabla. Neizmainīta, tā sauktā tipiskā žultsceļu anatomija ir sastopama tikai 58 % pacientu (Sureka et al., 2016), jeb 42 % gadījumu ķirurgam nākas sastapties ar žultsvadu anatomiskām variācijām, kuru vizualizācija ir īpaši apgrūtināta akūtās situācijās. Izvērtējot publikācijas, konstatējams, ka žultsceļu bojājumus visbiežāk izraisa nepareiza anatomijas interpretācija (Lehrskov et al., 2020). Grūtības pareizi izvērtēt žultsceļu anatomiju saistāmas ar: 1) anatomiskām žultsceļu variācijām, 2) ķirurga pieredzes trūkumu (netiek ievērots CVS princips), 3) izteiktu perivezikālu iekaisumu un/vai infiltrātu hepatoduodenālajā saitē, 4) pavadošu pankreatītu, 5) tehniskiem sarežģījumiem operācijas laikā, piemēram, asiņošanu, palielinātu intraabdominālo taukaudu daudzumu (Roy et al., 2020). Lai gan žultsceļu jatrogēni bojājumi ir reti (VH 0,1–0,2 %; LH laikā 0,4–0,6 %), tie var izraisīt ļoti nopietnus ilgtermiņa veselības traucējumus. Latvijā žultsceļu bojājumi vidēji gadā sasniedz 24 gadījumus, Vācijā – 948, bet ASV – aptuveni 300̴̴0, sasniedzot 0,4–0,6 % no visām veiktajām LH. Žultsvadu bojājumi asociējas ar nozīmīgu neatgriezenisku dzīves kvalitātes pasliktināšanos, palielinātu hospitalizācijas ilgumu, paaugstinātām hospitalizācijas izmaksām un letalitāti (Vinay et al.2020). Iespējamās komplikācijas ir žultsceļu oklūzija ar obstruktīvu dzelti, holangītu un sekojošu aknu bojājumu, kas sliktākajā gadījumā var novest pie aknu transplantācijas. Agrīni žultsvadu lēzijas var izraisīt žults peritonītu, komplicētu intraabdominālu infekciju, smagu sepsi un nāvi (Boni et al., 2015). Lai uzlabotu drošību un vizualizētu žults izvades sistēmu, veicot LH papildus CVS principiem, iespējams veikt gan intraoperatīvu holangiogrāfiju (IOH), gan intraoperatīvu sonogrāfiju (IOS). IOH samazina jatrogēnus žultsceļu bojājumus (JŽCB), tomēr šīs metodes lietojums ir pretrunīgs, jo: 1) ievērojami palielinās operācijas ilgums, 2) ir jāizveido žultsvada stoma, 3) pastāv jonizējošā starojuma risks, 4) tā prasa papildu medicīnas personālu, aprīkojumu un izmaksas. Savukārt IOS ir ātrāka papildu izmeklēšanas metode, bez radiācijas riska, minimāli invazīva un, pēc literatūras datiem, ar līdzīgu vai pat labāku vizualizācijas efektu, ja salīdzina ar IOH (Verbeek et al., 2014; Hakamada et al., 2008). Tomēr šīs metodes lietojumu limitē speciāli apmācīta personāla un aparatūras nepieciešamība. Pēdējā dekādē ir parādījusies jauna intraoperatīva žultsvadu vizualizācijas metode Image-guided surgery (Agnus et al., 2019). Starptautiski ir pieņemts termins Fluorescence image-guided surgery (FIGS), kas nozīmē intraoperatīvas optiskas navigācijas sistēmas lietošanu, nodrošinot labāku anatomisko struktūru vizualizāciju (Baiocchi et al., 2018). Metode tiek realizēta, izmantojot...