A standardised and reproducible model of intraabdominal infection and abscess formation in rats.

OBJECTIVE: To develop a standardised and reproducible model of intra-abdominal infection and abscess formation in rats. DESIGN: Experimental study. SETTING: University hospital, The Netherlands. SUBJECTS: 36 adult male Wistar rats. INTERVENTIONS: In 32 rats, peritonitis was produced using two different concentrations of Escherichia coli (E. coli) and Bacteroides fragilis (B. fragilis) incorporated in fibrin clots (E. coii 1 x 10(5) colony forming units (CFU)/ml or 1 x 10(8) CFU/ml, B. fragilis: 1 x 10(8) CFU/ml). Four rats with fibrin clots without bacteria served as uninfected controls. MAIN OUTCOME MEASUREMENTS: Macroscopy and bacterial counts in peritoneal fluid, blood, and fibrin clots after 24 hours, 4 days, 7 days, and 4 weeks. RESULTS: Macroscopically, there were signs of intra-abdominal infection and abscesses. With the higher starting concentration of E. coli, macroscopic signs were more pronounced and in nearly all rats bacterial counts in peritoneal fluid and fibrin clots showed persistently high numbers of E. coli and B. fragilis for at least 7 days (E. coli = 2 x 10(3) to 1 x 10(6) CFU/ml and 5 x 10(7) to 9 x 10(8) CFU/clot; B. fragilis = 1 x 10(3) to 1 x 10(6) CFU/ml and 5 x 10(7) to 6 x 10(8) CFU/clot). CONCLUSION: This standardised and reproducible model of intra-abdominal infection and abscess formation seems well suited for further use and development in experiments on the pathophysiology of intra-abdominal infection and abscesses.     

Effects of laparoscopic models on anaerobic bacterial growth with bacteroides fragilis in experimentally induced peritonitis

BACKGROUND: Previous reports of recurrent intra-abdominal abcess formation after the laparoscopic treatment of perforated acute appendicitis led us to investigate the possible effects of gas insufflation on the spread of infection. We previously showed that Escherichia coli counts were significantly higher in a laparoscopy group that underwent carbon dioxide (CO2) insufflation than in control and laparotomy groups. The aim of this study is to investigate the effects of intra-abdominal CO2 and nitrous oxide (N2O) insufflation on anaerobic bacterial growth in a rat model. METHODS: A standard strain of Bacteroides fragilis (ATCC 25285) was injected intraperitoneally (1 x 10(6) cfu/mL per kilogram) in 40 Wistar rats under sterile conditions. Forty rats with induced peritonitis were randomly divided into five groups: control, laparotomy, CO2 insufflation, N2O insufflation, and one group without pneumoperitoneum. Eight hours after the intraperitoneal injection of B. fragilis, peritoneal aspirates were obtained and inoculated onto Brucella agar. At the sixteenth hour of induced peritoneal infection (corresponding to hour 8 in the laparoscopy groups) all animals underwent laparotomy; peritoneal aspirates were obtained and inoculated into Brucella agar for bacterial counts. The colonies of B. fragilis were counted manually, and the results were expressed as the mean number of colony-forming units per milliliter. RESULTS: No significant differences in microorganism counts were noted between the study groups before the procedure (p>.05 for all comparisons). We observed a significant increase in the number of bacteria (mean +/- SD) in the CO2 insufflation group between hour 8 and hour 16 of peritoneal contamination. CONCLUSION: The results suggest that CO2 insufflation may promote the growth of intra-abdominal anaerobic bacteria. Such bacterial growth may lead to intra-abdominal abcess formation or cause localized peritonitis to develop into generalized peritonitis. We suggest that laparoscopy without pneumoperitoneum may be preferred in patients with peritonitis.     

Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study

BACKGROUND: The optimal strategy for identifying patients with abdominal stab wounds requiring surgical repair has not been defined. The potential benefits of diagnostic laparoscopy by incorporating it into the routine diagnostic workup of patients with anterior abdominal stab wounds was evaluated in a two-layer, randomized study. METHODS: From May 1997 through January 2002, stable patients without peritonitis but with demonstrated peritoneal violation were randomized (A) to exploratory laparotomy (AEL) (n = 23) or diagnostic laparoscopy (ADL) (n = 20). Simultaneously, patients with equivocal peritoneal violation on local wound exploration were randomized (B) to diagnostic laparoscopy (BDL) (n = 28) or expectant nonoperative management (BNOM) (n = 31). Hospital morbidity, length of stay, and costs were primary endpoints, with postdischarge disability being a secondary endpoint. RESULTS: In patients with peritoneal penetration (AEL vs. ADL), there were minimal differences in the therapeutic operation rate (8 of 23 [AEL] vs. 8 of 20 [ADL], p = 0.761), mortality (none), morbidity (3 of 23 vs. 2 of 20, p = 0.999), hospital stay (mean +/- SD) (5.7 +/- 2.5 vs. 5.1 +/- 4.0 days, p = 0.049), hospital costs (4.6 +/- 1.3 vs. 4.8 +/- 1.9 x 1,000 EUR, p = 0.576), and length of sick leave (34 +/- 12 vs. 29 +/- 11 days, p = 0.305). In patients with equivocal peritoneal penetration (BDL vs. BNOM), laparoscopy found more mostly minor organ injuries (7 of 28 [BDL] vs. 1 of 31 [BNOM], p = 0.022) with no significant difference in therapeutic operations (3 of 28 vs. 1 of 31, p = 0.337) or morbidity (3 of 28 vs. 0 of 31, p = 0.101), but was associated with increased length of stay (2.6 +/- 2.1 vs. 1.9 +/- 1.8 days, p = 0.022), hospital costs (4.2 +/- 1.3 vs. 1.5 +/- 1.1 x 1,000 EUR, p = 0.000), and sick leave requirements (18 of 23 vs. 8 of 28 of eligible patients, p = 0.001). CONCLUSION: In patients with demonstrated peritoneal violation, laparoscopy offers little benefit over exploratory laparotomy. In patients with equivocal peritoneal penetration on local wound exploration, laparoscopy detects more mostly minor organ injuries than expectant nonoperative management but is associated with increased hospital stay, costs, and sick leave requirements. Overall, diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds.     

Peritonitis models in the rat with special reference to laparoscopic therapy options]

With ongoing development of minimally invasive surgery the laparoscopic techniques are increasingly used also in patients with intra-abdominal inflammatory diseases. The systemic sequelae of laparoscopy are not yet clear. In this study, we investigated three experimental models of peritonitis in rats (cecal ligation and puncture n = 14, cecal stent peritonitis n = 14, implantation of a standardized fecal inoculum n = 18) concerning the therapeutic potential of laparoscopy, reproducibility of the results and clinical relevance (elimination of the inflammatory focus, intraperitoneal modulation of inflammation). The peritonitis model of implantation of a standardized fecal inoculum was shown to be the experimental model with the closest clinical relevance. In this technically simple, reproducible model, the primary inflammatory focus can be eliminated by laparoscopic lavage. A significant difference (p < 0.002) of survival between the groups with and without laparoscopic lavage was found. In addition, the intraperitoneal application of drugs is possible in order to modulate peritoneal and systemic inflammation.     

Prevention of intra-abdominal abscesses with fibrinolytic agents

Fibrin deposition during secondary peritonitis predisposes to abscess formation by protecting bacteria from host-defence mechanisms. To test the hypothesis that local fibrinolytic therapy can prevent the formation of intra-abdominal abscess, daily injections of the fibrinolytic enzymes trypsin and tissue plasminogen activator (t-PA) were administered intraperitoneally to Wistar rats inoculated intraperitoneally with infected fibrin clots. After 5 days, trypsin (1 mg/ml) had significantly (p less than 0.001) reduced abscess formation in animals inoculated with monomicrobial Bacteroides fragilis clots (20% versus 87%) or mixed Escherichia coli-B. fragilis clots (11% versus 91%). Bacteroides fragilis abscesses were also completely prevented with t-PA (0.25 mg/ml). The number of B. fragilis organisms present in residual abscesses in the trypsin-treated group was significantly (p less than 0.05) lower than in the control group (8.2 +/- 0.2, n = 7 versus 5.7 +/- 1.4, n = 4, log CFU/g abscess). In-vitro studies demonstrated that trypsin had no bactericidal effect on B. fragilis, suggesting enhanced clearance of bacteria. From these studies it appears that controlled fibrinolysis at operation may be a useful adjunct to surgery and systemic antibiotics in preventing abscess formation postoperatively.     

Peritoneal response to a septic challenge

Background: Laparoscopic surgery has a lower incidence of surgical infection than open surgery. Differential factors that may modify the bacterial biology and explain this finding to some extent include CO₂ atmosphere, less desiccation of intraabdominal structures, fewer temperature changes, and a better preserved peritoneal and systemic immune response. Previous data suggest that the immune response and acute phase response are better preserved after laparoscopy. Therefore, we designed a study to evaluate the early peritoneal response to sepsis in an experimental peritonitis model comparing open surgery with CO₂ and abdominal wall lift laparoscopy. Methods: The study subjects comprised 360 mice distributed into the following four groups: group 1, n= 72 (controls); group 2, n= 96 (open surgery), 2–3 cm laparotomy, with abdominal cavity exposed to the air for 30 min; group 3, n= 96, CO₂ laparoscopy (5 mmHg pneumoperitoneum) for 30 min; group 4, n= 96, wall lift laparoscopy for 30 min. Intraabdominal contamination in the four groups was induced with 1 ml of E. coli suspension (1 × 10⁴ CFU/ml) 10 min before abdomen closure. Peritoneal fluid and blood samples were obtained 1.5, 3, 24, and 72 h after surgery, and TNF, IL-1, and IL-6 were measured (via ELISA), as well as quantitative culture. Results: The number of CFU (colony-forming units) obtained in peritoneal fluid and positive blood culture rates were significantly lower in the laparoscopic groups than in the open group. IL-1 peritoneal levels were significantly lower after 24 h and 72 h in the laparoscopy groups. IL-6 levels decreased sharply in the laparoscopy groups at 24 h and 72 h. There were no differences between the two types of laparoscopy models (CO₂ and wall lift). Conclusions: Peritoneal response to sepsis is better preserved after laparoscopy than after open surgery. CO₂ does not seem to influence bacterial growth. According to these findings, laparoscopy entails less local trauma and better preserved intraabdominal conditions. Received: 29 June 1998/Accepted: 25 August 1998     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Peritoneal response to pneumoperitoneum and laparoscopic surgery

BACKGROUND: It is generally believed that laparoscopic surgery inflicts less trauma to the peritoneum than open surgery. Local peritoneal fibrinolysis is a critical factor in adhesion development. The objective was to investigate fibrinolytic changes in the peritoneum during laparoscopic and open surgery. METHODS: At laparotomy (n = 10) peritoneal biopsies were taken at opening of the abdomen and just before closure. At laparoscopy (n = 12) opening peritoneal biopsies were taken after carbon dioxide insufflation, and closure biopsies just before exsufflation. Tissue concentrations of tissue-type plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1) and the resulting tPA activity were assayed. RESULTS: Concentrations of tPA in peritoneal tissue declined during operation in both groups, but significantly so only in the laparotomy group (- 53 per cent; P = 0.01). PAI-1 levels were higher in opening biopsies from the laparoscopy group (P = 0.004). There was an increase in PAI-1 concentration during laparotomy, but not during laparoscopy. At the end of the operation, there was no difference between the groups. The resulting tPA activity did not differ between groups at opening or closure. In both groups there was a significant decline during operation (laparotomy: - 59 per cent, P = 0.02; laparoscopy: - 63 per cent, P = 0.01). CONCLUSION: These findings indicate that the peritoneal response to open and laparoscopic surgery is similar. The initial rise in peritoneal PAI-1 concentration during laparoscopy suggests an adverse effect of carbon dioxide insufflation, which might affect peritoneal repair.     

腹腔镜技术在结核性腹膜炎诊断中的应用

目的:探讨腹腔镜技术用于诊断结核性腹膜炎的价值,总结结核性腹膜炎的镜下特点及诊断要点。方法:回顾分析2002年7月至2010年7月27例结核性腹膜炎患者的临床资料。患者均行腹腔镜检查,术中取腹水及病灶标本行生化、病理学等检查。结果:27例患者均获确诊,手术时间30～140 min,平均40.2 min,术中出血量10～110 ml,平均12.3 ml。术中及术后均未出现肝、肠管等器官损伤。结论:腹腔镜检查诊断结核性腹膜炎具有患者创伤小、阳性率高、痛苦小等优点,可作为诊断结核性腹膜炎的优选术式。     

Impact of gas(less) laparoscopy and laparotomy on peritoneal tumor growth and abdominal wall metastases.

OBJECTIVE: A tumor model in the rat was used to study peritoneal tumor growth and abdominal wall metastases after carbon dioxide (CO2) pneumoperitoneum, gasless laparoscopy, and laparotomy. SUMMARY BACKGROUND DATA: The role of laparoscopic resection of cancer is under debate. Insufflation of the peritoneal cavity with CO2 is believed to be a causative factor in the development of abdominal wall metastases after laparoscopic resection of malignant tumors. METHODS: In the solid tumor model, a lump of 350-mg CC-531 tumor cells was placed intraperitoneally in rats having CO2 pneumoperitoneum (n = 8), gasless laparoscopy (n = 8), or conventional laparotomy (n = 8). After 20 minutes, the solid tumor was removed through a laparoscopic port or through the laparotomy. In the cell seeding model, 5 x 10(5) CC-531 cells were injected intraperitoneally before CO2 pneumoperitoneum (n = 12), gasless laparoscopy (n = 12), or laparotomy (n = 12). All operative procedures lasted 20 minutes. After 6 weeks, in the solid tumor model and after 4 weeks in the cell seeding model, tumor growth was scored semiquantitatively. All results were analyzed using the analysis of variance. RESULTS: In the solid tumor model, peritoneal tumor growth in the laparotomy group was greater than in the CO2 pneumoperitoneum group (p < 0.01). Peritoneal tumor growth in the CO2 group was greater than in the gasless group (p < 0.01). The size of abdominal wall metastases was greater at the port site of extraction of the tumor than at the other port sites (p < 0.001). In the cell seeding model, peritoneal tumor growth was greater after laparotomy in comparison to CO2 pneumoperitoneum (p < 0.02). Peritoneal tumor growth in the CO2 group was greater than in the gasless group (p < 0.01). The port site metastases in the CO2 group were greater than in the gasless group (p < 0.01). CONCLUSIONS: The following conclusions can be made: 1) that direct contact between solid tumor and the port site enhances local tumor growth, 2) that laparoscopy is associated with less intraperitoneal tumor growth than laparotomy, and 3) that insufflation of CO2 promotes tumor growth at the peritoneum and is associated with greater abdominal wall metastases than gasless laparoscopy.     

Correlation between peritoneal mesothelial cell cytology and peritoneal histopathology with respect to prognosis in patients on continuous ambulatory peritoneal dialysis

BACKGROUND: Sclerosing encapsulating peritonitis (SEP) is a serious complication seen in patients on long-term continuous ambulatory peritoneal dialysis (CAPD). We have previously reported that mesothelial cells in effluent dialysate significantly increased in size as the duration of CAPD progressed. In this study, we investigated the relationship between mesothelial cytology, histopathology of the peritoneum, and clinical outcomes of 34 CAPD patients. METHODS: When peritoneal dialysis catheters were inserted (n = 7) or removed (n = 27), a peritoneal biopsy was performed and results compared with mesothelial cytology in effluent dialysate. RESULTS: A significant positive correlation was noted between the duration of CAPD and the surface area of peritoneal mesothelial cells (r = 0.721, p < 0.0001). The surface area of mesothelial cells in peritoneal sclerosis (n = 9; 584 +/- 97 microm(2)) was significantly greater than in peritoneal fibrosis (n = 14; 389 +/- 26 microm(2), p < 0.05), pathologic acute peritonitis (n = 3; 223 +/- 10 microm(2), p < 0.005), and normal peritoneum (n = 7; 247 +/- 12 microm(2), p < 0.001). The surface area in sclerosing peritonitis (n = 1; 1,200 microm(2)) was greater than that of all the others. Giant cells were found in the 1 case with sclerosing peritonitis and in 3 of 9 cases with peritoneal sclerosis, although they were found in only 1 of 14 patients with peritoneal fibrosis and in none of those with pathologic acute peritonitis or normal peritoneum. As the surface area of mesothelial cells increased to more than 400 microm(2) and giant cells appeared in the effluent, the frequency of peritoneal sclerosis and/or clinical SEP increased. CONCLUSION: An increase in the mesothelial cell surface area and the emergence of giant cells in the effluent indicate advanced peritoneal histopathology, and may be useful indicators to determine appropriate timing of discontinuation of CAPD to prevent the development of SEP.     

Laparoscopic diagnosis and management of primary bacterial peritonitis

Primary bacterial peritonitis is a rare condition occurring, by definition, in patients without an underlying cause as is otherwise observed in patients with perforated viscus, pre-existing ascites, or nephrosis. The diagnosis is usually made at laparotomy. Laparotomy, however, is often associated with significant morbidity and wound complications. We report a case of primary bacterial peritonitis diagnosed at laparoscopy that was managed successfully by laparoscopic peritoneal lavage and appropriate antibiotic therapy with expeditious recovery. This is yet another argument for the application of laparoscopy in the management of generalized peritonitis.     

Prognostic significance of intraperitoneal free cancer cells obtained by laparoscopic peritoneal lavage in patients with gastric cancer

Laparoscopy is a safe and useful method for examining the local extent and regional spread of disease in patients with gastric cancer. Peritoneal dissemination remains a frequent type of recurrence after surgical treatment. The aim of this study was to determine the prognostic value of intraperitoneal free cancer cells (IFCCs) detected by laparoscopic peritoneal lavage. Forty-nine patients with advanced gastric cancer underwent laparoscopy with cytologic examination for staging. Peritoneal lavage was performed when ascites was not present. Aspirated fluid from the peritoneal cavity was centrifuged and subjected to cytologic examination using Giemsa and Papanicolaou staining methods. Patients were surgically treated and followed for a minimum of 5 years. IFCCs were detected in 41% of the patients. In eight cases (16.3 %) laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Patterns of recurrence after curative resection included the following: peritoneal (n = 3), local (n = 4), liver (n = 1), and other (n = 1). All patients who tested positive for IFCCs had peritoneal recurrence. The absence of IFCCs was associated with improved overall survival (2 1 months for a 95% confidence interval of 7.4 to 34.6 vs 4 months for a 95% confidence interval of 2.4 to 5.6). Overall survival adjusted for type of resection also demonstrated a favorable outcome for patients who were negative for IFCCs. The following conclusions were drawn: (1) laparoscopic peritoneal lavage cytology may be useful in identifying patients at high risk for peritoneal relapses and may alter treatment, and (2) IFCCs provide additional prognostic information in patients with gastric cancer. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease

STUDY AIM: The aim of this retrospective study was to report a continuous series of 44 perforated duodenal peptic ulcers operated on through laparoscopic approach with curative treatment of the peptic ulcer disease for socioeconomic purpose. PATIENTS AND METHOD: From February 1995 to May 1996, 44 patients were operated on laparoscopically. There were 42 men and two women (mean age: 36 years). All patients had peritonitis with pneumoperitoneum in 68%. Duodenal peptic ulcer was known in 12 patients and antecedent of episodic epigastric pain were present in 27. Four trocads were used. The diagnosis was confirmed by abdominal exploration and peritoneal lavage was performed with physiological serum. RESULTS: The procedures were: suture of perforated ulcer associated with posterior vagotomy and anterior seromyotomy (n = 6), with troncular vagotomy and pyloroplasty (n = 24) and single suture (n = 1). A conversion into laparotomy was necessary in 13 patients (29.5%). There was no mediastinitis, no postoperative death. Peritonitis by leakage occurred in two patients who were reoperated by laparotomy; mean duration of hospital stay was 5.5 days. With a one-year follow-up, all patients were in good condition, free of pain. CONCLUSION: With laparoscopic surgery, diagnosis of peptic ulcer perforation was confirmed, peritoneal lavage was perfectly done, duodenal perforation was sutured and surgical treatment of the peptic ulcer disease was performed, which is important in poor countries.     

Cytology of peritoneal lavage performed during staging laparoscopy for gastrointestinal malignancies: is it useful?

OBJECTIVE: To evaluate the potential benefit of cytology of the peritoneal lavage obtained during diagnostic laparoscopy for staging gastrointestinal (GI) malignancies. SUMMARY BACKGROUND DATA: Peritoneal lavage is a simple procedure that can be performed during laparotomy for GI tumors. Tumor cells in the lavage fluid are thought to indicate intraperitoneal tumor seeding and to have a negative effect on survival. For this reason, peritoneal lavage is frequently added to diagnostic laparoscopy for staging GI malignancies. METHODS: Patients who underwent peritoneal lavage during laparoscopic staging for GI malignancies between June 1992 and September 1997 were included. Lavage fluids were stained using Giemsa and Papanicolaou methods. Cytology results were correlated with the presence of metastases and tumor ingrowth found during laparoscopy and with survival. RESULTS: Cytology of peritoneal lavage was performed in 449 patients. Tumor cells were found in 28 patients (6%): 8/87 with an esophageal tumor, 2/32 with liver metastases, 11/72 with a proximal bile duct tumor, 7/236 with a periampullary tumor, and none in 7 and 15 patients with a primary liver tumor or pancreatic body or tail tumor, respectively. In 19 of the 28 patients (68%) in whom tumor cells were found, metastatic disease was detected during laparoscopy, and 3 of the 28 patients had a false-positive (n = 1) or a misleading positive (n = 2) lavage result. Therefore, lavage was beneficial in only 6/449 patients (1.3%); in these patients, the lavage result changed the assessment of tumor stage and adequately predicted irresectable disease. Univariate analysis showed a significant survival difference between patients in whom lavage detected tumor cells and those in whom it did not, but multivariate analysis revealed that these survival differences were caused by metastatic or ingrowing disease. CONCLUSION: Cytology of peritoneal lavage with conventional staining should no longer be performed during laparoscopic staging of GI malignancies because it provides an additional benefit in only 1.3% of patients and has limited prognostic value for survival in this group of patients.     

Reduced Neutrophil Sequestration in Lung Tissue after Laparoscopic Lavage in a Rat Peritonitis Model

Laparoscopy to treat abdominal infections is becoming more and more popular. The effects of the CO(2) pneumoperitoneum have not yet been completely clarified. In a rat peritonitis model, therefore, we investigated the influence of laparoscopic lavage in comparison with the conventional technique. A defined multibacterial fecal specimen was installed in the abdominal cavities of 80 rats. These animals were randomized to three groups: group 1 (n = 32), no intervention; group 2 (n = 24), conventional; group 3 (n = 24), laparoscopic lavage. At 1, 2, and 8 hours after the surgical intervention, animals were killed and autopsied. The main outcome measures were bacteremia, interleukin-6 (IL-6) in plasma and ascites, changes in the blood count, and myeloperoxidase (MPO) activity in lung, liver, kidney, and pancreas. Differences of bacteremia were not found. In the ascites a marked increase in IL-6 was observed after 8 hours, which was lower in the treatment groups than in the controls (p <0.025). MPO activity as a measure of the granulocytes present in the tissue showed significant changes only in lung tissue. Two hours after the surgical intervention, the MPO in the lung in the laparoscopy group was significantly lower than that in the controls and the laparotomy group. In conclusion, conventional and laparoscopic lavage reduce inflammation. In this model, laparoscopic lavage with a CO(2) pneumoperitoneum appeared to have no negative influence on the inflammatory reaction during the early postoperative phase. Reduced neutrophil sequestration in lung tissue following laparoscopic lavage reflects the lower level of trauma caused by laparoscopy.     

Cholecystectomy in sickle cell disease patients: is there more acute chest syndrome after laparoscopy? A case controlled study

Laparoscopy is increasingly being recommended in order to reduce postoperative complications among sickle cell disease patients undergoing cholecystectomy. Acute chest syndrome is the most deadly of these complications. The purpose of this study was to assess if laparoscopic approach reduces postoperative complications related to sickle cell disease after cholecystectomy. A retrospective study of records of sickle cell patients who underwent cholecystectomy for cholelithiasis, from January 1990 to December 2005 was conducted. 136 sickle cell patients underwent surgery: 47 (34.5%) by laparoscopy and 89 (63.5%) by laparotomy. The mean operative time was 71.4+/-18.9 min in the laparoscopy group and 61.2+/-15.3 min in the laparotomy group (non-significant difference). The mortality was not significantly different between the two groups: one patient died in the open cholecystectomy group but no death occurred in the laparoscopic one. The morbidity related to the sickle cell disease was significantly higher in the laparoscopy group [n=5 (10.5%)] than in the laparotomy group [n=4 (4.5%)] (p=0.04). This difference was associated with a higher rate of acute chest syndrome in the laparoscopy group [n=4 (8, 5%)] compared to that in the laparotomy group [n=1 (1.1%)] (p=0.01). There were more complications related to sickle cell disease in the laparoscopy group due to acute chest syndrome. Thus, these data should be confirmed in further randomized studies which must be undertaken.     

Management of Candida peritonitis by prolonged peritoneal lavage containing 5-fluorocytosine.

A 55 year old woman on chronic maintenance peritoneal dialysis developed Candida albicans peritonitis. This was successfully treated by continous five day peritoneal lavage containing 5-fluorocytosine. By this technique stable serum levels of the drug (58 mug/ml +/- 3.2 SEM) could be maintained. The peritoneal clearance of 5-fluorocytosine was found to be 7.5 ml/min (for peritoneal dialysis flow rate 1.2 1/hr) and the serum half-life 34 hours. The use of this drug in renal failure and its kinetics are reviewed.     

Inflammatory response and bacterial dissemination afterlaparotomy and abdominal CO2 insufflation in a murine model of peritonitis

Background The immunologic repercussions due to cavity insufflation are the focus of great discussion. The aim of this study was to compare the inflammatory response and bacterial dissemination after laparotomy and abdominal CO₂ insufflation in a murine model of peritonitis. Methods Swiss mice were inoculated intraperitoneally with 0.5 ml of a solution containing 1 × 10⁸ colony-forming units (CFU)/ml of Escherichia coli and were divided into three groups as follow: control (anesthesia for 30 min), laparotomy (2.5-cm midline incision for 30 min), and CO₂ pneumoperitoneum (CO₂ cavity insufflation for 30 min). The number of leukocytes, CFU/ml counting, and the levels of interleukin (IL)-6, tumor necrosis factor-α (TNF-α), and IL-10 were evaluated in blood, peritoneal, and pleural fluid samples obtained at 90 min and 18 h after the procedures. Results The laparotomy group showed a greater bacterial dissemination to the blood, peritoneum, and pleural cavity and also greater neutrophil migration to the peritoneal cavity compared to the CO₂ insufflated and control groups. The 24-h mortality was also significantly higher in the laparotomy group. The IL-6 levels showed a precocious rise in all groups submitted to bacterial inoculation at the 90-min time point. At the 18-h time point, IL-6 levels in the peritoneum were significantly higher in the laparotomy group than in the control or CO₂ insufflated groups. At the same time, TNF-α levels were higher in the laparotomy and CO₂ insufflated groups than in controls; IL-10 levels showed no differences among the groups. Conclusions Our results suggest that cavity insufflation with CO₂ is a more effective method of access, inducing less bacterial dissemination and also a less intense inflammatory response. Cavity insufflation with CO₂ may present a good option for the surgical treatment of patients with bacterial peritonitis.