Morbidity related to concomitant adhesions in abdominal surgery

Background

We sought to assess the independent effect of concomitant adhesions (CAs) on patient outcome in abdominal surgery.

Materials and methods

Using the American College of Surgeons National Surgical Quality Improvement Program data, we created a uniform data set of all gastrectomies, enterectomies, hepatectomies, and pancreatectomies performed between 2007 and 2012 at our tertiary academic center. American College of Surgeons National Surgical Quality Improvement Program data were supplemented with additional variables (e.g., procedure complexity–relative value unit). The presence of CAs was detected using the Current Procedural Terminology codes for adhesiolysis (44005, 44180, 50715, 58660, and 58740). Cases where adhesiolysis was the primary procedure (e.g., bowel obstruction) were excluded. Multivariable logistic regression analyses were performed to assess the independent effect of CAs on 30-d morbidity and mortality, while controlling for age, comorbidities and the type/complexity/approach/emergency nature of surgery.

Results

Adhesiolysis was performed in 875 of 5940 operations (14.7%). Operations with CAs were longer (median duration 3.2 versus 2.7 h, P < 0.001), more complex (median relative value unit 37.5 versus 33.4, P < 0.001), performed in sicker patients (American Society for Anesthesiologists class ≥3 in 49.9% versus 41.2%, P < 0.001), and harbored higher risk for inadvertent enterotomies (3.0% versus 0.9%, P < 0.001). In multivariable analyses, CAs independently predicted higher morbidity (adjusted odds ratio [OR], 1.35; 95% confidence interval, 1.13–1.61, P = 0.001). Specifically, CAs independently correlated with superficial and deep or organ-space surgical site infections (OR = 1.42 (1.02–1.86), P = 0.036; OR = 1.47 (1.09–1.99), P = 0.013, respectively), and prolonged postoperative hospital stay (≥7 d, OR = 1.34 [1.11–1.61], P = 0.002). No difference in 30-d mortality was detected.

Conclusions

CAs significantly increase morbidity in abdominal surgery. Risk adjusting for the presence of adhesions is crucial in any efforts aimed at quality assessment and/or benchmarking of abdominal surgery.     

Evaluation of anastomotic strength and drug safety after short-term sunitinib administration in rabbits

Background

Sunitinib (Sutent) is a Food and Drug Administration–approved receptor tyrosine kinase inhibitor found to reduce postoperative adhesion formation in animal models. The objective of the present study was to evaluate anastomotic healing and potential drug-related toxicities after short-term sunitinib administration in New Zealand White rabbits.

Materials and methods

Under an approved study protocol, 40 rabbits underwent a laparotomy followed by colonic transection and anastomosis. Animals were randomly assigned to treatment with oral sunitinib (10 mg/kg/d) or placebo, received one preoperative dose followed by 10 postoperative doses, and were divided into two groups following the procedure: group I animals were euthanized on completion of drug treatment and group II animals were euthanized 30 d after completion of treatment. Prior to study completion, animals underwent an echocardiogram and laboratory test results were obtained. At necropsy, intestinal bursting strength (in mmHg) was evaluated.

Results

All animals survived until designated euthanasia. There was no evidence of intra-abdominal sepsis or intestinal obstruction. Sunitinib-treated animals were found to have lower intestinal anastomotic strength compared with placebo-treated animals, as measured by bursting pressure at euthanasia, and a greater percentage of bursting at the anastomosis. On echocardiography, all ejection and shortening fractions were within established normal reference values. There were no significant differences in liver enzymes between animals. There were no wound infections, dehiscence, or delayed wound healing in any animal.

Conclusions

These results caution against the administration of sunitinib in cases involving intestinal anastomoses because of the elevated risk of anastomotic leak. No evidence of cardiotoxicity, hepatotoxicity, or detrimental effect on wound healing was found in any animal.     

Quality of life,functional status and adhesiolysis during elective abdominal surgery

Background

Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery.

Feasibility of 3.0T pelvic MR imaging in the evaluation of endometriosis

Introduction

Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3 T magnetom system MRI in the evaluation of endometriosis.

Materials and methods

Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0 T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard.

Results

MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%).

Conclusion

Pelvic MRI performed with 3 T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments.     

Ultrasonic detection of viscera slide as an indicator of abdominal wall adhesions.

Real-time ultrasonography can detect the movement of viscera immediately deep to the abdominal wall. This motion of abdominal contents is called viscera slide, and is produced by the force of respiratory motion (spontaneous viscera slide) or by manual ballottement of the abdomen (induced viscera slide). Viscera slide was observed in 18 "normal" subjects (no history of previous abdominal surgery or peritonitis) and in 24 subjects at "risk" for abdominal wall adhesions because of previous abdominal operations or past history of peritonitis. In 14 of the 24 "risk" group subjects, spontaneous and induced viscera slide was restricted to excursions of less than 1 cm (58.3%). Operations were performed on 18 patients, which confirmed the fact that restriction of ultrasonically detected viscera slide identified abdominal wall adhesions in all cases, but no adhesions were found in patients with normal viscera slide. This ultrasonic finding of restricted viscera slide may be useful in the preoperative discovery and localization of abdominal wall adhesions prior to laparoscopy or laparotomy.     

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm®) have possible short-term beneficial impact?

PURPOSE: The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm®) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity. METHODS: All patients who had Seprafilm® placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm®. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatoryvs. noninflammatory), and urgency of surgery (electivevs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student'st-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test. RESULTS: Two hundred fifty-nine patients in whom Seprafilm® was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm® group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm® group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm® group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm® group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm® group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm®. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm® (3.4 percent) and control (1.1 percent) groups. CONCLUSION: During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm® did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.Supported by an educational grant from Genzyme Surgical Products, Inc.Presented at the Association of Coloproctology of Great Britain and Ireland, Southport, UK, July 10 to 12, 1999.     

Peritonitis esclerosante encapsulante: hallazgos en imágenes de una entidad poco frecuente

ObjectivesTo describe the most characteristic imaging findings for sclerosing encapsulating peritonitis, with an emphasis on the computed tomography findings.ConclusionThe incidence of sclerosing encapsulating peritonitis is low. The pathophysiology of this condition is unclear. Two types are recognized: idiopathic and secondary; the secondary type is generally a complication of peritoneal dialysis. Its nonspecific clinical presentation and the absence of blood markers mean that sclerosing encapsulating peritonitis is usually diagnosed late. Thus, it is important to know the imaging signs; these include thickening and calcification of the peritoneum and dilation of bowel loops with thickening and calcification of bowel walls, whether in isolation or in association with loculated ascites. Although ultrasonography allows the complexity of the collections to be evaluated, computed tomography is the most useful technique for the general assessment of the signs mentioned above.     

Analysis of adipose tissue immune gene expression after vaccination of rainbow trout with adjuvanted bacterins reveals an association with side effects

Most existing fish vaccines are presented in the form of oil-based emulsions delivered by intraperitoneal injection. Whilst very effective they are frequently associated with inflammatory responses that can result in clinically significant side-effects often involving the adipose tissue that is in direct contact with the vaccine. To explore the potential of immune gene expression changes in the adipose tissue of fish to be markers of vaccination efficacy or development of side-effects we have studied the response to a bacterial (Aeromonas salmonicida) vaccine administered with two different adjuvants. The first adjuvant was Montanide™ ISA 763A VG, thought to induce a mostly humoral response, and the second was Montanide™ ISA 761 VG that gives a more balanced humoral and cell mediated response. Following vaccination tissue samples were collected at days 3, 14 and 28 for RTqPCR analysis. Fifty immune genes were studied with a focus on a) pro-inflammatory associated molecules and b) adaptive immune response related molecules linked with possible Th1, Th2, Th17 and T-regulatory pathways, with the expression data analysed for associations with Speilberg post-vaccination side effect scores. The results showed that the adipose tissue is a particularly sensitive and discriminatory tissue for studying adjuvant effects. A clear upregulation of many immune genes occurred in response to both vaccine groups, which persisted over time and overlapped with the appearance of visible adhesions. Our analysis revealed a relationship between adipose tissue immune function and the development of vaccine-induced adhesions giving the potential to use immune gene expression profiling in this tissue to predict the side-effects seen.     

分米波防治屈肌腱粘连机制的实验研究

目的　研究分米波对肌腱粘连和愈合的影响。方法　选用 2 8只白色Leghorn鸡 ,随机平均分为A组 (术后分米波治疗组 )和B组 (手术对照组 ) ,将趾深屈肌腱切断、修复 ,术后 1d～ 3周A组足爪局部用分米波治疗 ,B组不行分米波治疗。每组动物分别于术后 3、6周随机处死 7只 ,进行大体和光镜、电镜观察及生物力学检测。结果　大体和组织学观察见A组粘连明显减少 ,电镜检查A组成纤维细胞蛋白合成代谢较B组更旺盛。生物力学检测显示A组肌腱滑动距离、康复顺应性 抗张力强度均大于B组 (P <0 .0 1)。结论　分米波可有效地促进肌腱愈合 ,减少肌腱粘连 ,为肌腱损伤修复术后的早期康复训练提供了必要的条件 ,是防治肌腱粘连理想的辅助措施