Time to reconsider saline as the ideal rinsing solution during abdominal surgery

BACKGROUND: Peritoneal mesothelial cells lining the peritoneal cavity play a primary role in prevention of formation of peritoneal adhesions, which depends mainly on their fibrinolytic activity. During surgical procedures, the abdominal cavity is in most cases rinsed with normal saline solution, which may modify the fibrinolytic activity of the peritoneal mesothelium and predispose to formation of adhesions. The goal of our experiments was to evaluate how normal saline and other solutions affect the fibrinolytic properties of the peritoneal mesothelial cells. MATERIAL AND METHODS: Experiments were performed on in vitro cultures of human peritoneal mesothelial cells. Mesothelial monolayers were exposed during 6 hours to the following solutions: culture medium (control), .9% NaCl, Hanks solution, Earles solution, new peritoneal dialysis fluid with low glucose degradation products (GDP) concentration (PDF), and peritoneal dialysis fluid with high concentration of GDP (PDF-GDP). Afterwards, morphology of the cells as well as leakage of lactate dehydrogenase (LDH) from their cytosol were evaluated. During the next 24 hours when the cells were cultured in standard medium synthesis of interleukin-6 (IL-6), tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) were studied. RESULTS: Mesothelial monolayers exposed to .9% NaCl or to PDF-GDP showed destruction of their morphology after 6 hours incubation and in case of PDF-GDP release of LDH from the cytosol was increased by 275% versus the control (P<.05). During subsequent culture of all cells in standard medium, the release of IL-6 was decreased in cases of cells pretreated with .9% NaCl (-58%, P<.05) or PDF-GDP (-93%, P<.001). The release of t-PA was also reduced from cells pretreated with .9% NaCl (-71%, P<.01) or with PDF-GDP (-74%, P<.01) but increased after exposure of these cells to PDF (+35%, P<.05). Statistically significant decrease of PAI-1 synthesis was observed in cells preexposed to .9% NaCl (-69%, P<.01) or to PDF-GDP (-82%, P<.05). When changes in the PAI-1/t-PA ratio were calculated, a strong tendency for increase of that value was seen in cells pretreated with .9% NaCl or Earles salts solution but not with PDF. However, in cases of Hanks solution, a significant increase in the PAI-1/t-PA ratio was observed (+104%, P<.01). CONCLUSION: Exposure of the peritoneal mesothelial cells to .9% NaCl, Hanks, Earles salts solution, or PDF-GDP results either in reduction of their viability or in loss of their fibrinolytic activity. Peritoneal dialysis fluid with a low content of glucose degradation products appears to be the optimal solution causing the least damage to mesothelial cells and therefore may be the ideal solution for rinsing the abdominal cavity with low risk of inducing deterioration of the mesothelial cells fibrinolytic activity and formation of adhesions. We postulate therefore that such hypertonic peritoneal dialysis fluids should be used not only during peritoneal dialysis but also for rinsing the abdominal cavity during any surgical procedures.     

The neurokinin 1 receptor regulates peritoneal fibrinolytic activity and postoperative adhesion formation

Background

Intra-abdominal adhesions are a common source of postoperative morbidity. Previous studies in our laboratory have shown that a neurokinin 1 receptor antagonist (NK-1RA) reduces abdominal adhesion formation and increases peritoneal fibrinolytic activity. However, the cellular pathway by which the antagonist exerts its effects is unclear, as cultured peritoneal mesothelial cells exposed to the NK-1RA show increases in fibrinolytic activity despite having very low expression of neurokinin 1 receptor (NK-1R) messenger RNA and protein. Our aim was to determine whether the NK-1R plays an essential role in the adhesion-reducing effects of the NK-1RA, or if the NK-1RA is acting independently of the receptor.

Methods

Homozygous NK-1R knockout mice and age matched wild-type mice underwent laparotomy with cecal cautery to induce adhesions. At the time of surgery, mice received a single intraperitoneal dose of either NK-1RA (25 mg/kg) or saline alone. Adhesion severity at the site of cecal cautery was assessed on postoperative day 7. In a separate experiment, peritoneal fluid was collected from wild type and NK-1R knockout mice 24 h after laparotomy with cecal cautery and administration of either NK-1RA or saline. Tissue plasminogen activator levels, representative of total fibrinolytic activity, were then measured in peritoneal fluid.

Results

In wild-type mice, NK-1RA administration significantly decreased adhesion formation compared with saline controls. Among the NK-1R knockout mice, there was no significant reduction in adhesion formation by the NK-1RA. Fibrinolytic activity increased 244% in wild-type mice administered NK-1RA compared with saline controls; however, the NK-1RA did not raise fibrinolytic activity above saline controls in NK-1R knockout mice.

Conclusions

These data indicate that the NK-1R mediates the adhesion-reducing effects of the NK-1RA, in part, by the upregulation of peritoneal fibrinolysis, and suggest that the NK-1R is a promising therapeutic target for adhesion prevention.     

Effects of omentectomy on the peritoneal fibrinolytic system

PURPOSE: Decreased fibrinolytic activity in the serosal surfaces of peritoneal tissue appears to be a major factor in the development of peritoneal fibrous adhesions. The omentum reduces peritoneal adhesion by creating a mechanical barrier and producing fibrinolytic factors. This experimental study was designed to investigate the effects of omentectomy on the peritoneal fibrinolytic system. METHODS: Thirty animals were assigned randomly to a control group or an omentectomy group. On postoperative day 10, peritoneal and blood samples were collected and adhesions were graded qualitatively. We measured the concentrations of serum and peritoneal tissue plasminogen activator, peritoneal plasminogen activator inhibitor-1, tissue plasminogen activator/plasminogen activator inhibitor complex, and hydroxyproline. RESULTS: Adhesions were significantly increased after omentectomy. Omentectomy also resulted in a reduction of both serum and tissue "tissue plasminogen activator" levels. On the other hand, an increment in "plasminogen activator inhibitor-1" levels was observed after omentectomy. There were no differences in "tissue plasminogen activator/plasminogen activator inhibitor" complex or "hydroxyproline" levels. CONCLUSION: Omentectomy reduced peritoneal fibrinolytic activity significantly and the peritoneal plasminogen activator system showed corruption that did not resolve with the rest of the peritoneal system after omentectomy.     

Role of Pulsatile Perfusion With Tissue Plasminogen Activator in Deceased Donor Kidneys With Extensive Glomerular Thrombosis

Background

Pulsatile perfusion (PP) improves delayed graft function, whereas tissue plasminogen activator (tPA) lyses thrombi. We studied the role of PP with tPA containing perfusate in deceased donor kidneys (DDK) with 50% thrombosed glomeruli.

Methods

Fourteen DDK with extensive glomerular thrombi on biopsies were preserved using PP with histidine-tryptophan-ketoglutarate solution containing tPA. Wedge biopsies were repeated after PP.

Results

Causes of donor death included closed head trauma in 8, anoxia in 2, and stroke in 4. Donors who averaged 33.3 years old displayed a final 24-hour urine volume of 1933 mL, a terminal serum creatinine level of 1.8 mg/dL, a blood urea nitrogen of 20 mg/dL, and a platelet count of 128,000/μL. The initial flow of 47 mL improved to 111 mL/min after 16.17 hours of perfusion. Resistive indices (RI) decreased from 0.69 to 0.26 at 4.2°C. Biopsy specimens after PP showed a reduction in glomerular thrombi from 50% to 23%. Recipients averaged 54.9 years old. Cold ischemia time averaged 35.5 hours. One patient displayed primary allograft nonfunction, 3 required transient dialysis, and 10 showed prompt allograft function. Recipient follow-up averaged 12 months, with serum creatinine levels of 4.3 mg/dL at 1 week, 2.0 mg/dL at 1 month, and 1.6 mg/dL at last follow-up.

Conclusions

Renal allografts with extensive glomerular thrombosis improved their biopsy appearance following PP with tPA. Improvement in PP parameters allowed successful transplantation of such kidneys that otherwise would have been discarded. PP with tPA appears to be beneficial for kidneys with extensive glomerular thrombosis.     

Laparoscopic placement of peritoneal dialysis catheters in children

Background

Peritoneal dialysis (PD) is preferred over hemodialysis. The aim of this study was to evaluate our experience with laparoscopic PD catheter placement and omentectomy in children.

Methods

We reviewed all children (N = 21) who underwent laparoscopic placement of PD catheters and omentectomy. Ages ranged from 3 months to 16 years. Five children had previous major abdominal surgery and required extensive lysis of adhesions. During the same intervention, other surgical procedures were performed using laparoscopy or open technique, including umbilical hernia repair in 3, bilateral inguinal hernia repair in 3, ventral hernia repair in 2, gastrostomy in 4, kidney biopsy in 2, and cholecystectomy in 1.

Results

Thirteen children received successful kidney transplantation and no longer needed dialysis. Two children still have functioning PD catheters. One patient developed membrane failure and was converted to hemodialysis. Four patients recovered enough renal function and no longer need dialysis. There were no complications related to the laparoscopic procedure.

Conclusion

Laparoscopy is ideal for PD catheter placement. It facilitates omentectomy, and it allows for the catheter to be placed in the proper position under direct vision and for lysis of adhesions to increase peritoneal surface. Other abdominal procedures can be performed laparoscopically at the same time.     

Locally increased concentrations of inflammatory cytokines in an experimental intraabdominal adhesion model

Background

Peritoneal adhesions may cause bowel obstruction, infertility, and pain. This study investigated cytokines, proteins and growth factors thought to promote formation of adhesions in an experimental intraabdominal adhesion model.

Methods

Male Sprague-Dawley rats were subjected to laparotomy, cecal abrasion, and construction of a small bowel anastomosis and examined at various time points after surgery. Concentrations of cytokines and growth factors in plasma and peritoneal fluid were analyzed using electrochemoluminescence and quantitative sandwich enzyme immunoassay technique.

Results

Concentrations of interleukin-6 (IL-6), interleukin-1beta (IL-1β), and tumor necrosis factor alpha (TNF-α) increased in peritoneal fluid from 6 h after incision. Plasma concentrations of IL-6 increased at 6 h, but plasma concentrations of IL-1β and TNF-α remained low. Peritoneal fluid concentrations of platelet-derived growth factor-BB (PDGF-BB), transforming growth factor beta1 (TGF-β1), vascular endothelial growth factor (VEGF), tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) were below detection levels at all time points.

Conclusion

Early elevations of IL-6, IL-1β, and TNF-α concentrations in peritoneal fluid correlated to adhesion formation in this rodent model. Our model is relevant and reproducible, suitable for intervention, and indicates that antiadhesion strategies should be early, local and not systemic.     

Laparoscopic-type environment enhances mesothelial cell fibrinolytic activity in vitro via a down-regulation of plasminogen activator inhibitor-1 activity

BACKGROUND: Fewer intraperitoneal adhesions have been observed after laparoscopic surgery compared with conventional techniques. The aim of this study is to assess the effect of the pneumoperitoneum on mesothelial cell fibrinolytic activity by use of an in vitro model. METHODS: Human peritoneal mesothelial cells were seeded onto 24-well plates and incubated in carbon dioxide or helium at 5 mm Hg for 4 hours or standard culture conditions. Supernatant was removed for analysis at 0, 24, 48, and 72 hours after gas incubation and analyzed for plasminogen activator activity, total tissue plasminogen activator (tPA), and total plasminogen activator inhibitor-1 (PAI-1) concentrations by use of an enzyme-linked immunosorbent assay. The effect of different insufflation pressures (0, 7, and 14 mm Hg) was also examined. RESULTS: Enhanced plasminogen activator activity was observed at 48 hours and 72 hours from cells exposed to CO(2) (P<.04 each) and helium (P<.05 each) compared with control. This was associated with a decrease in PAI-1 concentrations at 48 and 72 hours in both the CO(2) and helium groups compared with control (P<.03 each, CO(2) vs control; and P<.04 each, helium vs control). No changes in tPA levels were observed. Changes in insufflation pressures did not affect plasminogen activator activity. CONCLUSIONS: These results suggest that incubation of human mesothelial cells with both CO(2) and helium in the absence of oxygen enhances mesothelial cell fibrinolytic activity because of a reduction in PAI-1 concentrations. These changes may participate in the observed reduction in adhesions after laparoscopic surgery relative to open surgery.     

Adhesions after abdominal surgery in children

Purpose

The objective of this study is to quantify the overall burden (operative and nonoperative) of small bowel obstruction caused by adhesions after laparotomy in children.

Methods

Data from the Scottish National Health Service Medical Record Linkage database were used to assess risk of an adhesion-related readmission in the 5 years after open abdominal surgery in children and adolescents younger than 16 years from April 1996 to March 1997.

Results

A total of 1581 children underwent abdominal surgery (ie, from duodenum downward). Patients undergoing surgery on the ileum had the highest risk of readmission because of adhesions in the subsequent 5 years after surgery (9.2%)—formation/closure of ileostomy had the greatest risk (25%); 6.5% of children were readmitted after general laparotomy, 4.7% after duodenal surgery, and 2.1% after colonic surgery. The incidence of readmissions was 0.3% after appendicectomy. The overall readmission rate was 5.3% (if appendicectomy was excluded) and 1.1% (if appendicectomy was included).

Conclusion

This population-based study has demonstrated that children have a high incidence of readmissions owing to adhesions after lower abdominal surgery. The risks are related to the site and the type of the original surgery. The risk of further readmissions was highest in the first year but continued with time. The data enable surgeons to target antiadhesion strategies at procedures that lead to a high risk of adhesions.     

Is the outcome of the left colon antegrade continence enema better than that of the right colon antegrade continence enema?

Background/Purpose

The purpose of this report was to review the results of the antegrade continence enema (ACE) procedure and to compare the outcomes of right and left colon ACEs in children.

Methods

Thirty patients who underwent an ACE between 1998 and 2005 were analyzed. Data were obtained based on the following parameters: postoperative soiling, catheter insertion time, colonic washout time, quality of life, and abdominal pain during and after the ACE. Twenty-nine patients were followed for an average of 3.8 years (range, 4 months-7.3 years).

Results

Right colon ACEs were performed in 23 patients, and left colon ACEs were performed in 7 patients. The common complications of the ACE included abdominal pain during and after the ACE (51.7%) and stoma strictures (41.4%). The overall ACE success rate was 24/29 (82.8%; right colon ACE, 18/29; left colon ACE, 6/29). Twenty-three patients (95.8%) believed their quality of life was improved. There were no significant differences in complications or outcomes between the right and left ACEs.

Conclusions

An ACE is an effective treatment for children with fecal incontinence. A left colon ACE has similar efficacy as a right colon ACE in managing fecal incontinence in children.     

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

Background

To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW).

Methods

Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes).

Results

Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%).

Conclusions

We find no role for DL in the evaluation of ASW patients solely to determine PV.     

Trehalose solution protects mesothelium and reduces bowel adhesions

Background

Preventing interbowel adhesions still remains a challenge. Peritoneal mesothelial damage can induce postoperative adhesions. Our study evaluated the effects of 3% trehalose solution on mesothelial protection and adhesion prevention. Also, we compared this novel solution with Seprafilm regarding efficacy.

Methods

Mesothelial damage was induced on the cultured human mesothelial cell (Met-5A) and rabbit cecum-serosal surface by air-drying for 60 min, and trehalose solution was applied. Cell integrity was tested by measuring lactate dehydrogenase, and serosal-morphologic changes were analyzed using scanning electron microscopy. Intra-abdominal adhesions were induced in rabbits by the combination of abrasion and air-drying procedures. Animals were divided into four groups: control, 3% trehalose solution, Seprafilm, and 3% trehalose solution with Seprafilm. Adhesions were evaluated blindly 7 d later.

Results

Lactate dehydrogenase release from the Met-5A cells was reduced dose-dependently by trehalose (P < 0.05). Morphologic studies clearly showed that mesothelial cells on the serosal surface were kept intact by 3% trehalose solution. In a rabbit adhesion model, 3% trehalose solution reduced adhesions between bowel and bowel or bowel and surrounding structures (P < 0.01 versus control and Seprafilm). Seprafilm reduced adhesions between abdominal wall and underlying viscera (P < 0.01 versus control and 3% trehalose solution). Three-percent trehalose solution with Seprafilm showed additive effects of adhesion prevention, reducing adhesion formation at the previously mentioned sites.

Conclusions

Three-percent trehalose solution protects mesothelial cells and leads to reduced adhesions between bowel and bowel or bowel and surrounding structures. This effect seems to be resulted from the characteristics of the solution covering most areas that potentially develop adhesions.     

Coagulation, fibrinolysis and cytokine responses to intramedullary nailing of the femur: An experimental study in pigs comparing traditional reaming and reaming with a one-step reamer-irrigator-aspirator system

Introduction

Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR).

Materials and methods

Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR (n = 8) and the RIA (n = 7) reaming systems were compared to a control group (n = 7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn.

Results

Significantly procedure-related increased levels were found for thrombin-antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group.

Conclusion

A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group.     

Reduction of adhesion formation by an angiotensin type 1 receptor antagonist

Purpose  

Adhesion formations are important causes of intestinal obstruction and can lead to infertility in women. The formation of adhesion appears to be determined by the fibrinolytic activity. Fibrinolysis itself is controlled by the plasminogen activator system, and several studies have shown that angiotensin type 1 (AT₁) receptor antagonists can reduce plasminogen activator inhibitor-1 (PAI-1) expression, but the effect of AT₁ receptor antagonists on PAI-1 expression involved in the adhesion formation remains unclear. The aim of this study was to investigate whether an AT₁ antagonist, candesartan, can reduce PAI-1 mRNA expression using experimental model of peritoneal adhesions, which seems to reflect post-operative adhesions.     

Hyperthermic intraperitoneal chemoperfusion is an option for treatment of peritoneal carcinomatosis in children

Background

Gastrointestinal carcinomas in childhood are rare and frequently present at an advanced stage. Besides lymphatic and distant organ metastasis, peritoneal carcinomatosis may be detected and has a poor prognosis. In addition to surgery and intravenous chemotherapy, hyperthermic intraperitoneal chemoperfusion (HIPEC) may be an option for selected patients. Our aim was to demonstrate the feasibility of the method and to discuss possible indications.

Methods

After treating a series of adult patients, HIPEC for peritoneal carcinomatosis from a signet cell carcinoma of the colon was performed intraoperatively in a 12-year-old boy. We gave mitomycin C at a dose of 30 mg/m² over 90 minutes at maximum temperature of 41.2°C. We performed intraoperative drug level monitoring and daily postoperative liver and kidney function tests and differential blood counts.

Results

Hyperthermic intraperitoneal chemoperfusion was performed according to protocol without complications. Perfusate and venous drug levels were similar to those in an adult case. The patient had an uneventful recovery, and serum chemistry and blood count returned to normal after a week. The boy lived for 36 months after initial presentation. Sixteen months after HIPEC, still with excellent quality of life, an elevated carcinoembryonic antigen (CEA) indicated recurrence. Thirty months after HIPEC, he died of progressive recurrent disease.

Conclusions

Hyperthermic intraperitoneal chemoperfusion as performed in adults may be beneficial to children with peritoneal carcinomatosis and merits further study.     

Surgical experimental jejunoileal atresia in rat embryo

Purpose

Jejunoileal atresia represents about 40% of intestinal atresia. After surgical repair, intestinal motility disorders are burdened with the postoperative outcome, and the origin of these troubles remains unclear. To specify the physiopathologic feature of jejunoileal atresia, we developed an experimental surgical model in fetal rat.

Methods

Time-dated pregnant rats were operated on at 18 days of gestational age. Hysterotomy was performed, followed by fetal wall incision. The exteriorization of the bowel loop was obtained by saline injection; the intestine was ligated and returned to the abdominal cavity before incisions were closed. Fetal intestine was excised at day 21, after cesarean delivery.

Results

Twenty-one pregnant rats underwent operation with 90% maternal survival rate. Among the 56 fetuses successfully operated on, 49 survived (87%). In fetuses with atresia, the mean birth weight (4.5 ± 0.6 g) and the mean intestinal length (12.8 ± 1.3 cm) were significantly lower compared to sham fetuses and controls.

Conclusion

The rat model offers the advantage of a low-expense mammal model with a wide panel of probes and reagents available for the study of the gut. This model of jejunoileal atresia could be used to study the consequences of prenatal intestinal obstruction on fetal gut.     

Chronic abdominal wall pain—A diagnostic challenge for the surgeon

Background

Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.

Methods

The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.

Results

CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.

Conclusion

The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.     

Abdominal pathology requiring laparotomy in very preterm infants is associated with need for surgical closure of patent ductus arteriosus

Background

Extensive intestinal surgery in very preterm infants and its influence on somatic growth is of major concern. There is little consensus as to which is the most appropriate surgical approach in extremely low-birth-weight infants with abdominal pathology. Laparotomy is currently advocated, but peritoneal drainage is also discussed.

Objective

To study laparotomy as surgical intervention in newborn infants with less than 28 gestational weeks and to investigate associated mortality and morbidity and its impact on short-term growth.

Study Design/Methods

The study was a retrospective case-control study of newborn infants requiring laparotomy. All infants with gestational age less than 28 weeks who were subject to acute laparotomy in the neonatal period at Sahlgrenska University Hospital during a 5-year period (2003-2007) were included in the study (n = 20). The control group consisted of infants admitted to the unit with the same gestational age but not requiring laparotomy. Infants with severe malformations were excluded.

Summary and Conclusion

Extensive abdominal surgery was feasible in very preterm infants. Necrotizing enterocolitis dominated the abdominal pathology requiring surgery. Patent ductus arteriosus requiring surgical closure occurred more often in the lapatotomy group and in those diagnosed as necrotizing enterocolitis. There was no impact on first year somatic growth.     

Preincisional local infiltration of tramadol at the trocar site versus intravenous tramadol for pain control after laparoscopic cholecystectomy

Study Objective

To compare the effects of preoperative intravenous (IV) tramadol and preoperative tramadol infiltration of trocar sites on postoperative pain and postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.

Design

Prospective, randomized study.

Setting

Operating room, recovery room, and surgical ward.

Patients

70 ASA physical status 1 and 2 patients, aged 20-70 years, scheduled for elective laparoscopic cholecystectomy.

Interventions

In Group I, patients received IV 2.0 mg/kg of tramadol; in Group II, trocar insertion points were infiltrated with 2.0 mg/kg of tramadol in 20 mL of 0.9% NaCl.

Measurements

Pain scores, sedation scores, postoperative analgesic requirement, and PONV were recorded at 0 and 30 minutes and one, three, 6, 12, and 24 hours. At 30 minutes and one hour, pain localization (incisional or diffuse abdominal) was also recorded.

Main Results

Visual analog scale scores at 30 minutes were significantly lower in Group II [3 (0-7)] than Group I [6 (3-8)] (P < 0.001). In Group I, 91.4% of patients received sodium diclofenac, while 68.6% of Group II patients received sodium diclofenac (P = 0.002). The time to first analgesic requirement was significantly lower in Group II (P = 0.004). At the 30-minute measurement time, a significant difference was recorded between the groups in incisional pain (P < 0.001). There was also a significant difference between groups in the frequency of PONV.

Conclusions

Trocar site infiltration of tramadol improves early postoperative pain and decreases PONV.     

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children

Purpose

Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication.

Methods

The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed.

Results

Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 ± 1.0 and 2.6 ± 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth.

Conclusion

Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.     

Primary closure of persistent tracheocutaneous fistula in pediatric patients

Objective

The aim of the study is to review the safety and efficacy of partial fistulectomy with 3-layered primary closure without postoperative intubation for persistent tracheocutaneous fistula (TCF).

Design

This is a retrospective study.

Setting

The study was conducted in a tertiary care pediatric hospital.

Patients

Records of 49 children treated for persistent TCF between 1996 and 2005 were reviewed. Patients were studied if the TCF was closed using a 3-layered primary closure, and they had at least 1 year of follow-up. Thirty-nine patients met inclusion criteria.

Results

All patients were extubated immediately after surgery. Drains were removed, and all patients were discharged on the first postoperative day. The most common indications for tracheostomy were prolonged intubation and subglottic stenosis. There were 2 major and 3 minor complications. One major complication involved subcutaneous emphysema that developed on the seventh postoperative day because of cough. The other involved a poorly controlled diabetic patient who developed a postoperative infection with dehiscence. All fistulas remained closed at follow-up.

Conclusion

Partial excision and primary closure of persistent TCF is safe and effective. Drain placement and overnight observation are imperative. Careful patient selection is important. Routine postoperative intubation is not necessary.