Ultrapure alginate gel reduces adhesion reformation after adhesiolysis

Purpose

Adhesiolysis at repeat surgery induces adhesion reformation which seems more virulent than development of de novo adhesions. We studied the effect of a new ultrapure alginate gel on adhesion reformation.

Methods

In 46 male Wistar rats, adhesion formation was induced using the cecal abrasion and peritoneal sidewall excision procedure. Two weeks later, a second laparotomy was performed, adhesions were graded, and surgical adhesiolysis was performed. The animals were then allocated to one of two equal groups, a control group without further intervention and a group receiving 1-ml ultrapure alginate gel to the two opposing and damaged surfaces. Two weeks after the second surgery, rats were sacrificed. Primary endpoint was the incidence of adhesion reformation at areas of injury. Secondary endpoints were adhesion scores, extent of adhesions, and tissue histology.

Results

Ultrapure alginate gel significantly (p?=?0.046) reduced the incidence of adhesion reformation from 100 % in controls to 78 % in experimental rats. Both the adhesion score (p?=?0.009) and the extent of adhesions (p?=?0.001) were significantly lower in the alginate group. Tissue healing histology was similar in both groups.

Conclusion

Ultrapure alginate gel reduces adhesion reformation following adhesiolysis.     

Liquid antiadhesive product (Adcon-p) prevents post-operative adhesions within the intra-abdominal organs in a rat model

Background and aims Postoperative adhesions mostly cleave to small bowel and lead to troublesome problems. This study evaluated the effectiveness of a novel liquid antiadhesive product (Adcon-P) in rats.Subjects and methods Thirty-eight Sprague Dawley rats underwent laparotomy during which the surgeon created abrasions on five different small bowel locations and the cecum in order to generate adhesions. Rats were randomly assigned to receive Adcon-P (n=19) or to a control group (n=19). The animals were killed on postoperative day 21. An observer blinded to the randomization assessed the difficulty of adhesiolysis with a six-point scoring system, recorded locations of adhesions and, noted the presence of serosal and full-thickness injuries. The total number of adhesions was also chronicled.Results The severity of adhesion and adhesion scores were significantly lower in animals receiving Adcon-P. More animals suffered full-thickness and serosal injuries in the control group. The adhesions between small bowel segments and the number of adhesions attached to the small bowel were significantly lower in animals that received Adcon-P.Conclusion Adcon-P leads to an easier adhesiolysis and lessens the risk of bowel injury during relaparotomy. In particular, Adcon-P reduces the probability that adhesions specifically attach to the small bowel.     

Preventing Intra-Abdominal Adhesions With Polylactic Acid Film: An Animal Study

PURPOSE The aim of this study was to evaluate the efficacy of an absorbable polylactic acid film (SurgiWrap^TM) in preventing postoperative intra-abdominal adhesions in an animal model.METHODS Forty-four female Sprague-Dawley rats underwent laparotomy with subsequent cecal wall abrasion and abdominal wall injury. Rats were divided equally between untreated and treated groups. Treated rats had a polylactic acid film (SurgiWrap^TM) placed between the cecal and abdominal wall defects. Rats in the untreated group received no barrier material. The animals were killed on postoperative day 21. Two blinded observers, using predetermined criteria, graded the cecum-to-abdominal wall adhesions and estimated the percent of cecal surface area involved in the adhesion. The adhesions were classified as absent, moderate, or severe.RESULTS Four rats died postoperatively. Of surviving rats, all of the rats in the untreated group had cecum-to-abdominal wall adhesions, whereas 42.1 percent of rats in the treated group had no adhesions between the cecum and the abdominal wall (two-tailed, P = 0.001). Altogether, 28.6 percent and 71.4 percent of untreated rats experienced moderate and severe adhesions, respectively, compared to 47.4 percent and 10.5 percent of treated rats (two-tailed, P < 0.001).CONCLUSIONS Strategic placement of polylactic acid film during abdominal surgery is associated with a significantly reduced rate and severity of postoperative intra-abdominal adhesions in this model. A technique for film placement is suggested.Macropore Biosurgery, Inc. supported this work.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 9 to 13, 2004.     

Comparison of a Novel Liquid (Adcon-P®) and a Sodium Hyaluronate and Carboxymethylcellulose Membrane (Seprafilm™) in Postsurgical Adhesion Formation in a Murine Model

PURPOSE: Intra-abdominal administration of antiadhesive barriers may reduce the extent and severity of postoperative adhesions. This study aimed to compare the effectiveness of a novel liquid antiadhesive barrier with a conventional sheet (Seprafilm) antiadhesive barrier in a murine cecal abrasion model. METHODS: One hundred fifty Swiss-Wister mice underwent laparotomy and cecal abrasion and were randomly assigned to receive Adcon-P (n = 30) or Seprafilm (n = 30) or to a control group (n = 90). At postoperative Day 21, the mice underwent relaparotomy and complete adhesiolysis. An investigator who was blinded to the group assignment scored the extent of adhesion formation and the difficulty of adhesiolysis using a 6-point scale that ranged from 0 (no adhesions) to 5 (full-thickness intestinal injury with adhesiolysis). Results are reported as median (range). RESULTS: Median adhesion scores in mice receiving Adcon-P (0 (range, 0-1)) and Seprafilm (1 (range, 0-3)) were lower than in mice in the control group (2 (range, 0-5); P < 0.0001 for both comparisons). In addition, the median adhesion score for the Adcon-P group was significantly lower than that of the Seprafilm group (P = 0.02). CONCLUSION: This study suggests that both Adcon-P and Seprafilm trade mark decrease the incidence of postoperative adhesions and the difficulty of adhesiolysis in the murine cecal abrasion model. However, Adcon-P appeared to be superior to Seprafilm. This agent is an attractive device that requires additional studies.     

Intra-Abdominal Use of Taurolidine or Heparin as Alternative Products to an Antiadhesive Barrier (Seprafilm®) in Adhesion Prevention: An Experimental Study on Mice

Purpose

Seprafilm® (Genzyme Biosurgery, Cambridge, MA) remains a widely used product in postoperative adhesion prevention. This study was designed to compare the antiadhesive effects of taurolidine, heparin, and Seprafilm® in a murine cecal abrasion model.

Methods

Sixty male Balb/c mice underwent a cecal abrasion procedure and were randomized into four groups (n?=?15 in each). Groups T, H, and S animals intraperitoneally received taurolidine, heparin, and Seprafilm®, respectively, and Group C animals were reserved as control. Animals were killed on Day 21, and the severity of adhesions was evaluated with a scoring system ranging between 0 to 5. In addition, the localizations of the adhesions were questioned.

Results

Five (1 in Group S and 4 in Group H) animals died before they were killed. The deaths were related to intra-abdominal bleeding, and mortality rate was significantly higher in Group H than those in other groups (P?P?P?

Conclusions

All products are effective in adhesion prevention. Heparin use provides the best results but may be associated with a higher mortality rate related to intra-abdominal bleeding. Taurolidine may be an alternative product to Seprafilm®, but further studies are required.

     

Experimental Study Evaluating the Effect of a Barrier Method on Postoperative Intraabdominal Adhesions

The purpose of this animal study was to determine if tissue glue-coated collagen sponge is an effective barrier method to prevent localized adhesions in a modified rabbit sidewall model. Rabbits were divided into two groups and underwent laparotomy with subsequent creation of a cecal wound according to the rabbit sidewall model. Rabbits of group I (treatment group; n = 10) were treated with a TachoComb H patch placed on the defect, whereas group II animals (control group; n = 6) did not receive further treatment. All animals were sacrificed 2 weeks postoperatively and adhesions were evaluated using special adhesion score. A further six rabbits underwent TachoComb H application at the cecum to investigate the histological changes during a course of 12 weeks. The average adhesion scores were significantly (P < 0.05) reduced in the treatment group compared to the controls. Histologically the TachoComb H patch was surrounded by granulation tissue without signs of infection. Tissue glue-coated collagen sponge (TachoComb H) is effective to prevent localized intraabdominal adhesions in the modified rabbit sidewall model.     

Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

Objectives: Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

Methods: Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

Results: Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4–18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p?=?.001) and age <5years (p?=?.007) were inversely related to successful ileal intubation.

Conclusions: High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.     

Novel treatment in peritoneal adhesion prevention: Protection by polypeptides

Objective. To evaluate a novel antiadhesive polypeptide complex containing a combination of poly-L-glutamate and poly-L-lysine in order to study its effectiveness and mechanisms in the prevention of postoperative abdominal adhesions in mice. Material and methods. The length of peritoneal adhesions was measured and expressed in percentage of the wound length in a standardized peritoneal injury model and evaluated 7 days and 4 weeks after adhesion induction. The test compound was administered intraperitoneally following surgery. Peritoneal swabs, including the wound area, were stained in order to determine the peritoneal location and clearance of the polypeptides. Electron microscopy was performed to analyze the wound surface and the ultra-structural changes of the phagocytes in cell culture. Moreover, flow cytometry was used to evaluate the effect on macrophage phagocytic function. Results. The poly-L-lysine and poly-L-glutamate combination significantly decreased peritoneal adhesions both at 7 days’ (p<0.001) and 4 weeks’ (p≤0.001) follow-up. From the first day, the compound was found in the wound, after which this was gradually rebuilt, and covered with mesothelial cells. The macrophages phagocytosed the test compound particles, resulting in significant cell growth, and large phagocytic vacuoles. Conclusions. The intraperitoneal administration of poly-L-lysine and poly-L-glutamate resulted in a significant decrease in experimental postoperative peritoneal adhesions.     

Early effects of fibrin sealant on colonic anastomosis in rats: an experimental and case-control study

Background Leakage from colonic anastomoses leads to mortality and morbidity. Fibrin adhesives can be used to increase the strength of the anastomosis. In this study, we evaluated the early effects of fibrin sealant and hyaluronic acid-carboxymethylcellulose on colonic anastomosis in rats. Methods Anastomoses were made in the descending colon of 38 female Wistar-Albino rats, in three groups: control group (n=12), group 1 treated with hyaluronic acid-carboxymethylcellulose (n=16), and group 2 treated with fibrin sealant (n=10). After 72 hours, adhesion scores, bursting pressure, rupture strength and histopathologic healing scores were evaluated. Results Due to postoperative mortality, we evaluated 10, 10 and 9 rats in the control group and in groups 1 and 2, respectively. Of these, we excluded 4, 5 and 4 rats that had macroperforations at autopsy. In the remaining rats, bursting pressure (123.2±14.8 mmHg) and rupture strength (400±16 mg) in the fibrin sealant group were significantly greater than in the two other groups (Control: 68.0±10.6 p=0.006 and 325±52 p=0.009; Group 1: 74.0±9.8 p=0.03, 330±27 p=0.016). However, we did not observe any significant difference between adhesion scores (2.5±0.6, 2.0±0.7, 2.0±0.7, p=0.343). Conclusions In this experimental study, fibrin sealant increased bursting pressure and rupture strength of colonic anastomoses while hyaluronic acid-carboxymethylcellulose had no effetcs in rats, but both of them showed no effect on adhesion scores. In order to use fibrin sealant to decrease the rate of early leakages from colonic anastomoses, further studies have to be performed.     

Evaluation of postoperative adhesions in rats submitted to peritoneostomy with polypropylene mesh associated to nitrofurazone

BACKGROUND: Peritoneal injuries, common in per and postoperative, lead to the formation of adhesions. The use of polypropylene mesh increases the postoperative adhesions incidence. Based on the fact of nitrofurazone accelerates the healing process, a possible action on peritoneal adhesions was cogitated. AIM: To evaluate postoperative adhesions in rats submitted to peritoneostomy with polypropylene mesh fixation associated to nitrofurazone. METHODS: Thirty-three Wistar rats were separated into three groups of eleven animals each one. In group I was performed the laparotomy with exposition of the abdominal cavity followed by the laparotomy suture; in group II was performed the resection of a abdominal wall fragment followed by polypropylene mesh fixation on the gap and in group III was performed the same done in group II, but the mesh was previously impregnated with nitrofurazone. After 45 days the animals were sacrificed and necropsied. RESULTS: Seven animals of group I had no adhesions (degree 0), two had degree 1 adhesions and two had degree 2. In group II, one animal was classificated as degree 3 and ten as degree 4. In group III, one had degree 0, eight had degree 3 and one had degree 4 (one animal died before 45 days). All adhesions found involved the abdominal wall; ten animals had adhesions involving only omentum (group I = 4; group II = 1 and group III = 5); eleven animals had adhesions involving omentum, small bowel and other abdominal organs (group II = 10; group III = 1); three animals had adhesions involving only small bowel, all belonged to group III. Fourteen animals had adhesions involving small bowel, of these ten belonged to group II (nine with more than one fixation point) and four belonged to group III (three with just one fixation point). CONCLUSION: The association of nitrofurazone with polypropylene mesh did not reduce significantly the postoperative adhesions incidence in rats, but reduced the intensity and severity of these adhesions.     

Fecal calprotectin is equally sensitive in Crohn's disease affecting the small bowel and colon

Abstract

Objective. The utility of fecal calprotectin (fCal) in small bowel Crohn's disease (CD) remains to be clarified. The primary aim of this study was to determine levels of fCal in CD restricted to the small bowel compared with CD affecting the colon, in patients undergoing their first diagnostic work-up. In addition, the study assessed the sensitivity and specificity of fCal in suspected CD. Material and methods. A total of 83 patients referred to gastroenterology out-patient clinic with suspected CD were included in this prospective, blinded study, and fCal was measured during diagnostic work-up. Ileo-colonoscopy + capsule endoscopy/surgery (n = 81), ileo-colonoscopy + upper endoscopy (n = 1), and ileo-colonoscopy (n = 1) served as gold standard for the presence and location of CD. Results. A total of 40 patients were diagnosed with CD: small bowel 13, colonic 16, and ileo-colonic 11. Levels of fCal were equal in patients with small bowel or colonic CD: median 890 mg/kg and 830 mg/kg, respectively (p = 1.0). With a 50 mg/kg cut-off, CD in the small intestine and colon was diagnosed with 92% and 94% sensitivities, respectively, and the overall sensitivity and specificity of fCal was 95% and 56%. In this cohort, CD was ruled out with a negative predictive value of 92%. Conclusions. This is the first study to show that fCal is equally sensitive in colonic and small bowel CD. In patients suspected of CD, fCal is an effective marker to rule out this diagnosis and select patients for endoscopy.     

Effects of an intra-abdominal latex (drain-like) tube on anastomotic resistance and adhesion formation in a rat model

PURPOSE: Aim of the present study was to determine effect of a latex drain on colonic resistance and its relation to adhesion phenomena. METHODS: Forty Sprague-Dawley rats were divided into two groups (n=20): Group 1, simple colonic anastomosis; and Group 2, colonic anastomosis with drain ad latum. Rats were sacrificed four days after surgery, and adhesions were evaluated. Segment containing anastomosis was removed, and bursting pressure was determined. RESULTS: General adhesion scores in Group 2 were higher than in Group 1 (P =0.002). Score for adhesions to anastomotic line in Group 1 was higher than in Group 2 (P =0.016). Bursting pressure was significantly lower in Group 2 (Group 1, 67.90±31.39 mmHg; Group 2, 46.95±29.69 mmHg;P =0.034). In all cases, leakage of dye was observed at the anastomotic line. A multiple regression test was applied to both groups (40 cases), taking bursting pressure as the dependent variable and other parameters as independent variables. A strong relationship appeared to exist between anastomotic resistance and fraction of anastomotic line that was covered by the neighboring organ (P <0.001). CONCLUSIONS: Placing a latex drain near a colonic anastomosis is associated with local inhibition of spontaneous adhesions to anastomotic line and, therefore, to significantly decreased resistance.Supported in part by the Asociación Médica para la Investigación y Docencia en Albacete (A.M.I.D.A), Spain.     

Intermediate-length colonoscope needs more training duration than long-length colonoscope

Abstract

Objective. Few data are available on the influence of a colonoscope length for trainees, which could affect both the duration of training and colonoscopy quality. We conducted this study to validate which scope needs more duration for training to reach technical competence and to shows better quality indicators during diagnostic colonoscopy. Materials and methods. We conducted a prospective randomly assigned study from April 2010 to February 2011 at Asan Medical Center. Among the 1329 patients enrolled, 1200 colonoscopies were analyzed. We compared cecal intubation rate, adenoma detection rate, cecal intubation time (<20 min), and withdrawal time between the trainees using the intermediate-length colonoscope and those using long-length colonoscope. Results. Trainees who used the long-length colonoscope showed a higher overall cecal intubation rate (88.2% vs. 81.0%, p = 0.001) and adenoma detection rate (49.7% vs. 34.2%, p < 0.001) than those using the intermediate-length colonoscope. The successful cecal intubation rate improved significantly and reached the requisite standard of competence (>90%) after 90 procedures in the long-length colonoscope group. However, the trainees using the intermediate-length colonoscope reached the requisite standard of competence after 150 procedures. Logistic regression analysis revealed that prolonged cecal intubation was associated with the use of the intermediate-length colonoscope, poor colon preparation, a small number of esophagastroduodenoscopy or sigmoidoscopy procedures conducted, and pain during procedures. Conclusions. During the same training period, use of the long-length colonoscope in trainee was better in terms of reaching competency and quality indicators, and was less painful for the patients during colonoscopic procedures.     

Risk factors for surgery in patients with retention of endoscopic capsule

Objectives: Surgery is still the main means for removing retained endoscopic capsules. This study intended to evaluate risk factors for surgery in patients with capsule retention.

Materials and methods: The data of 5348 consecutive capsule endoscopy examinations were retrospectively analyzed. Cox regression analysis was used to evaluate risk factors.

Results: Seventy-seven patients (1.4%) had capsule retention. Spontaneous passage occurred in 16 patients, of which 14 were asymptomatic. Successful retrieval by double-balloon enteroscopy (DBE) was achieved in 14 patients, of which 11 did not need surgery during clinical follow-up. A total of 50 patients underwent surgery. The cumulative rates of surgery were 44.2%, 53.2%, 55.8%, 62.3% and 64.9% at 1, 3, 6, 12 and 60 months after capsule retention, respectively. Intestinal obstruction [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.12–3.76; p?=?.020] and overt small bowel bleeding (HR 2.01, 95%CI 1.08–3.71; p?=?.027) during capsule retention were independently associated with an increased risk for surgery. Specific treatment for primary disease (HR 0.22, 95%CI 0.07–0.74, p?=?.014) and successful endoscopic retrieval (HR 0.20, 95%CI 0.06–0.66; p?=?.008) were independently associated with a decreased risk for surgery.

Conclusions: For asymptomatic patients, specific medical treatment for primary disease can be maintained until the capsule spontaneously passes or symptoms appear. For patients with slight abdominal pain, DBE can be performed. For patients with intestinal obstruction or overt small bowel bleeding, early surgical consultation should be considered.     

Effects of Hyaluronic Acid–Carboxymethylcellulose Antiadhesion Barrier on Ischemic Colonic Anastomosis

PURPOSE: Intraperitoneal adhesions may help the healing of marginally viable bowel ends. If adhesion formation is prevented by various methods, the integrity of ischemic bowel anastomosis may be compromised. Thus, we decided to study the effects of hyaluronic acid–carboxymethylcellulose, an antiadhesion barrier, on ischemic bowel anastomosis. METHODS: Thirty Wistar-Albino rats were divided into three groups. In Group A (control), a well-perfused distal colonic segment was transected, and free ends were anastomosed. In Group B, an ischemic colonic segment was prepared, then divided and anastomosed. In Group C, after completion of ischemic colonic anastomosis, hyaluronic acid–carboxymethylcellulose film was wrapped around the anastomosis. In all groups, rats were killed on the seventh day. Intraperitoneal adhesions were graded by adhesion score, and healing of the anastomosis was assessed by measurement of bursting pressure and hydroxyproline levels in the anastomotic tissue. RESULTS: A statistically significant difference was found between hydroxyproline levels of the control group and the ischemic group (P = 0.02). HP level was also significantly higher in the hyaluronic acid–carboxymethylcellulose group than in the ischemic group (P = 0.01). There was no difference in hydroxyproline levels between the control and hyaluronic acid–carboxymethylcellulose groups. Compared with the control group, bursting pressure was lower in the ischemic group (P = 0.02). Hyaluronic acid–carboxymethylcellulose wrapping increased the bursting pressure significantly (P < 0.001). However, there was no difference in bursting pressure between the control group and the hyaluronic acid–carboxymethylcellulose group (P = 0.13). A marked increase in the adhesion score was observed in the ischemic group (P = 0.01). The difference between adhesion scores of the hyaluronic acid–carboxymethylcellulose and ischemic groups was not found to be significant, although the adhesion score in the hyaluronic acid–carboxymethylcellulose group was lower (P = 0.16). There was no difference in adhesion score between the control and hyaluronic acid–carboxymethylcellulose groups. CONCLUSIONS: Application of hyaluronic acid–carboxymethylcellulose in ischemic colonic anastomosis did not compromise anastomotic integrity. The adverse effect of ischemia on healing of colonic anastomosis was counteracted by hyaluronic acid–carboxymethylcellulose.     

Prevention of Postoperative Abdominal Adhesions by a Novel, Glycerol/Sodium Hyaluronate/Carboxymethylcellulose-Based Bioresorbable Membrane: A Prospective, Randomized, Evaluator-Blinded Multicenter Study

INTRODUCTION Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients.METHODS Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no antiadhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision.RESULTS Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose.CONCLUSIONS Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.Supported in full by grants from Genzyme Corporation, Cambridge, Massachusetts.Lena Holmdahl, M.D., Ph.D. is an employee of Genzyme Corporation.     

Outcome of parastomal hernia repair with and without midline laparotomy

Background Surgical options for parastomal hernia (PSH) repair are primary fascial, mesh repair, and relocation with or without midline laparotomy. Overall, recurrence rates are higher after fascial repairs than after relocation. However, stoma relocation may require a midline laparotomy with higher associated morbidity. The aim of this study was to assess the outcome of PSH repair with relocation with or without a midline laparotomy. Methods All patients who underwent PSH repair with relocation were identified from a clinical database. Data were collected by retrospective review of medical records including patient demographics, presenting symptoms, predisposing factors, type of surgery, postoperative complications, recurrence, and follow-up. Patients were divided into two subgroups, with or without a midline laparotomy. In patients without a laparotomy, the stoma was intraperitoneally mobilized, passed behind the abdominal wall, and delivered and matured through a premarked stoma site, across the midline. Results Between 1992 and 2001, a total of 27 patients underwent PSH repair with relocation of the stoma to the opposite side of the abdominal wall. Of these, the operation was performed without a midline laparotomy in 11 patients (41%). There were no significant differences in age, gender, body mass index, and the duration of hernia between the non-laparotomy and laparotomy groups. Prior abdominal surgery was recorded for 3 patients in the group without a laparotomy and for 9 patients in the group with a laparotomy (p=NS). Although not quantified, patients in the non-laparotomy group were less likely to have significant intraabdominal adhesions. Conversely, patients in the laparotomy group had more advanced adhesions. The operative time was longer in the group with a laparotomy than in the group without [96.8 (50–220) minutes vs. 123.9 (45–360) minutes; (p=NS)], and the mean hospital stay was significantly less in patients without vs. with a laparotomy [5.5 (SD=1.6) days vs. 9.5 (SD=3.8) days, respectively; (p<0.05)]. There was only one recurrence in the group without a laparotomy compared to 3 in the group with a laparotomy. The mean follow-up periods were 36.8 and 56.6 months in the groups without and with a laparotomy, respectively. The postoperative complications included wound infection that occurred in 3 patients in each group. Conclusions PSH repair with relocation without laparotomy was associated with a significantly shorter hospital stay, possibly due to the lack of a midline abdominal wound. It may not be feasible in patients with significant intraabdominal adhesions. Poster presentation at the annual meeting of the Association of Coloproctology of Great Britain and Ireland, July 7–10, 2003, Edinburgh, UK. Supported in part by a research grant from the Caporella Family. An erratum to this article is available at .     

Minilaparotomy cholecystectomy with ultrasonic dissection versus conventional laparoscopic cholecystectomy: a randomized multicenter study

Abstract

Objective. Cholecystectomy by minilaparotomy (MC) or by laparoscopy (LC) has been shown to have equal results of both early and late recovery. Although, the ultrasonic dissection (UsD) technique has seen used in LC, the technique is rarely used in MC. Material and methods. Initially, 88 patients with uncomplicated symptomatic gallstones were randomized into MC with UsD (n = 44) or conventional LC (n = 44) over a 2-year period (2010–2012). The two groups were similar in terms of age and American Society of Anesthesiologists (ASA) physical status score. Results. Both groups were similar in terms of the operative time and the time in the operation theatre, the success of day-surgery and satisfaction with the procedure. The MC group had significantly less postoperative pain than the LC group, p = 0.002, and the MC group used less analgesics doses during the first 24 h: 2.8 (1.2) doses vs. 3.8 (1.4) doses, p = 0.003. The convalescence needed was 3 days shorter in the MC group, 7 (3) days, than that in the LC-group, 10 (8) days, p = 0.024. In the MC group 4 patients and in the LC group 11 (p = 0.046) required more than 14 days of sick leave. In the MC group there was one and in the LC group two conversions to open surgery. Conclusion. The patients in the MC group had less early postoperative pain and had a shorter convalescence than the patients in the LC group.     

Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up

BACKGROUND: Recurrent small bowel obstruction caused by postoperative adhesions has traditionally been treated by conventional laparotomy, but laparoscopic management of acute small bowel obstruction has been reported. The aim of this study was to assess the long-term efficacy and clinical outcome of laparoscopic adhesiolysis for recurrent small bowel obstruction. METHODS: After conservative treatment, elective laparoscopic treatment was attempted in 17 patients hospitalized for recurrent small bowel obstruction after abdominal or pelvic surgery. RESULTS: Postoperative adhesions were identified laparoscopically in all patients. Laparoscopic treatment was possible in 14 patients (82.4%). Conversion to laparotomy was required for 3 patients (17.6%) because of intestinal perforation (n = 1) or a convoluted mass of adherent bowel (n = 2). Long-term follow-up was possible in 16 patients. Two recurrences of small bowel obstructions were noted over a mean follow-up period of 61.7 months. CONCLUSIONS: Laparoscopic adhesiolysis is a safe and effective treatment for recurrent small bowel obstruction. Conversion to laparotomy should be considered in patients with dense adhesions.     

Incidence of gastrointestinal bleeding in patients with cardiovascular disease: buffered aspirin versus enteric-coated aspirin

Abstract

Objective. Aspirin-induced enteropathy is increasing, but whether the type of aspirin affects the gastrointestinal (GI) bleeding, especially small intestine, is unclear. The incidence of GI bleeding for buffered aspirin and enteric-coated aspirin was evaluated in patients receiving long-term low-dose aspirin (LDA) for cardiovascular (CV) diseases. Methods. This retrospective cohort study assessed overt GI bleeding, decreased hemoglobin levels suspecting small bowel blood loss, and CV death in patients taking LDA for more than 1 year (LDA group) and in patients not taking LDA (control group). The LDA group was divided into two subgroups, patients taking either buffered aspirin (buffered subgroup) or enteric-coated aspirin (enteric subgroup), and their outcomes were compared. Results. A total of 1402 patients (LDA group 701, control group 701; median follow-up duration 1778 ± 747 days) were assessed. The incidences of overt GI bleeding and decreased hemoglobin were 3.9% and 1.4% in LDA group, respectively, significantly higher than the control group (p < 0.01; p < 0.01). In the LDA group, 3% died during the follow-up period. Ten (3.7%) in the buffered subgroup (n = 267) and 17 (3.9%) in the enteric subgroup (n = 434) developed GI bleeding (p = 0.92). One (0.3%) in the buffered subgroup and nine (2%) in the enteric subgroup developed decreased hemoglobin (p = 0.06, log-rank test). Conclusions. The type of aspirin does not affect the incidence of overt GI bleeding and decreased hemoglobin, but enteric-coated aspirin may be associated with an increased incidence of decreased hemoglobin.