血清t-PA和PAI-1水平在腹腔镜手术中的临床意义

目的:探讨腹腔镜与开腹手术中血浆纤维蛋白溶酶的变化。方法:在腹腔镜与开腹手术前、术后8h分别测量血浆中组织型纤溶酶原激活物(Tissue-type p lasm inogen activator,t-PA),纤溶酶原激活物抑制物-1(P lasm inogen activator inh ib itortype-1,PAI-1)浓度。结果:血浆t-PA浓度在腹腔镜手术和传统腹部手术两组病例术后均下降,但在传统腹部手术组下降更显著(P<0.05),而血浆PAI-1浓度在腹腔镜手术和传统腹部手术两组病例术后均升高,但在传统腹部手术组升高更显著(P<0.05)。结论:本次临床研究结果表明:腹腔镜手术组术前、术后血浆中t-PA、PAI-1浓度的变化小于传统腹部手术组,腹腔镜手术组引起腹腔粘连严重程度也低于传统腹部手术组。     

Response of visceral peritoneum to abdominal surgery

BACKGROUND: Postoperative adhesion formation has been associated with a reduced capacity to degrade fibrin within the peritoneal cavity. Peritoneal fibrinolytic capacity has been shown to decrease during the course of a surgical operation. The aim of this study was to investigate whether tissue-type plasminogen activator (tPA), a key fibrinolytic enzyme, is released into the peritoneal cavity during operation. METHODS: Fluid released from the serosal surface of the small bowel was collected in a plastic bag from 16 patients undergoing surgery. Intraoperative blood samples were also taken from seven patients. Concentrations of the fibrinolytic components tPA and urokinase plasminogen activator (uPA), tPA activity and plasminogen activator inhibitor type 1 (PAI-1) concentration were measured by enzyme-linked immunoabsorbent assay. RESULTS: Intraoperative tPA concentrations were significantly raised in the peritoneal fluid collected compared with peripheral blood levels (P = 0.008). This resulted in a significantly higher tPA activity in the fluid compared with blood (P = 0.001). However, neither uPA (P = 0.29) nor PAI-1 (P = 0.84) concentrations differed significantly in fluid compared with blood. CONCLUSION: These data suggest that tPA is rapidly released by the visceral peritoneum during abdominal surgery. The different concentrations in peripheral blood and peritoneum suggest that tPA is released from the peritoneum by an active process, and does not solely derive from leakage of plasma.     

Peritoneal fibrinolytic response to various aspects of laparoscopic surgery: a randomized trial

BACKGROUND: Peritoneal fibrinolysis is important in peritoneal wound healing processes and adhesion formation. The peritoneal fibrinolytic response to laparoscopy is merely unknown. In the present study we investigate the effect of short-term laparoscopy on the peritoneal fibrinolytic response and the influence of intra-abdominal pressure, light intensity and choice of dissection device on this response. METHODS: There were 50 patients scheduled for laparoscopic cholecystectomy randomized in five groups operated with various pressures, light intensities, and dissection devices. Peritoneal biopsies were taken at the beginning and the end of the procedure. Tissue concentrations of tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor type 1 (PAI-1), and the tPA-activity were measured using ELISA techniques. RESULTS: There were no differences in tPA antigen, tPA-activity, uPA antigen, or PAI-1 antigen concentrations in biopsies taken at the beginning compared to samples taken at the end of the operation. Different intra-abdominal pressures, light intensities and the choice dissection device did not affect any of the measured parameters. CONCLUSION: Short-term laparoscopy does not affect the peritoneal fibrinolytic activity. The used intra-abdominal pressure, light intensity and choice of dissection device do not affect peritoneal activity during short-term laparoscopy.     

Heating of carbon dioxide during insufflation alters the peritoneal fibrinolytic response to laparoscopic surgery

Background Laparoscopic surgery is evolving rapidly. It involves the creation of a pneumoperitoneum, mostly using carbon dioxide. Cooling of the peritoneum, due to insufflation, might traumatize the peritoneum and disturb peritoneal fibrinolysis, important in peritoneal healing processes. The current study was performed to elucidate the effects of the temperature of insufflation gas on the peritoneal fibrinolytic response to laparoscopic surgery. Methods Thirty patients scheduled for laparoscopic cholecystectomy were randomized in two groups: one group in which the pneumoperitoneum was created with carbon dioxide at room temperature, and one wherein carbon dioxide at body temperature was used. Peritoneal biopsies were taken at the start and at the end of surgery. Tissue concentrations of tPA antigen, tPA activity, uPA antigen, and PAI-1 antigen were measured using ELISA techniques. Results Peritoneal PAI-1 antigen levels were significantly higher at the end of the procedure in patients operated with carbon dioxide at room temperature (p < .05). A slight, but not significant, decrease in tPA antigen and activity was observed in both groups during the procedure. Peritoneal concentrations of uPa antigen did not change during the procedure. Conclusions The temperature of carbon dioxide used for insufflation of the abdominal cavity affects peritoneal biology. Cooling of the peritoneum by unheated carbon dioxide causes increased peritoneal PAI-1 levels, important in peritoneal healing processes.     

Fibrinolytic responses of human peritoneal fluid in laparoscopic cholecystectomy: a prospective clinical study

Background The reduction in peritoneal fibrinolysis is believed to be the pathogenetic mechanism of adhesion formation. The general conclusion based on previous clinical and experimental studies is that laparoscopic procedures produce less adhesion formation. The association between this beneficial effect of laparoscopic cholecystectomy and peritoneal fibrinolytic changes is not clear. Therefore, the authors aimed to compare the effects of open and laparoscopic cholecystectomy on peritoneal fibrinolysis. For this purpose, fibrinolytic parameters in peritoneal fluid were investigated 24 h after laparoscopic and open cholecystectomies. Methods In a prospective clinical study, peritoneal fluid was sampled via a drain 24 h after laparoscopic (n = 10) and open (n = 9) cholecystectomies. Activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), and tPA/PAI-1 complex were determined by enzyme-linked immunosorbent assay (ELISA) kits. Results In peritoneal fluids, tPA and tPA/PAI-1 complex concentrations were higher in the open cholecystectomy group (p = 0.009 and p < 0.001, respectively), but tPA activity and PAI-1 concentrations did not differ between the groups (p = 0.514 and p = 0.716, respectively). Conclusions Fibrinolytic changes in peritoneal fluid have several similarities in open and laparoscopic cholecystectomies with regard to tPA activity and PAI-1 levels. However, higher tPA levels after the open procedure probably are secondary to more intense tissue handling leading to mesothelial release of tPA.     

An evaluation of normal saline and taurolidine on intra-abdominal adhesion formation and peritoneal fibrinolysis

BACKGROUND: Intraoperative lavage with normal saline or taurolidine solutions is commonly used in abdominal surgery. For this purpose, normal saline and taurolidine, which may modify the intrinsic fibrinolytic activity of the peritoneum by breaking the peritoneal adhesions, are frequently used. We aimed to evaluate how normal saline and taurolidine affect peritoneal fibrinolysis and adhesion formation. METHODS: A rat model of peritoneal adhesion was used. Control animals received no medication, while normal saline or taurolidine solutions were administered intraperitoneally to the remaining two groups (n = 20 for each group). At postoperative day 10 adhesions were graded, and cardinal parameters of peritoneal fibrinolysis (activities and concentrations of tissue plasminogen activator [tPA], plasminogen activator inhibitor type 1 [PAI-1], and tPA/PAI-1 complex), and hydroxyproline contents were determined in peritoneal tissue samples. RESULTS: Total adhesion scores were decreased in both of the treated groups. Median tissue levels of tPA and tPA activity were higher in the treated groups versus controls. The PAI-1 levels were similar among the three groups. tPA/PAI-1 complex levels were higher in animals that received normal saline and in those treated with taurolidine solution compared with control animals. Peritoneal hydroxyproline levels were similar across the three groups. CONCLUSIONS: Our results suggest that normal saline and taurolidine solution administrations might reduce peritoneal adhesion formation, probably by altering peritoneal fibrinolytic activity.     

Peritoneal fibrinolytic activity in peritonitis

BACKGROUND: Peritonitis may cause a reduction in abdominal fibrinolytic activity. The reduced local fibrinolysis seems to be an important process in the subsequent development of adhesion formation. The aim of the study was to evaluate peritoneal fibrinolytic capacity in inflamed and normal peritoneum. METHODS: Peritoneal biopsy specimens were taken at the beginning of operation from 15 patients with peritonitis and 10 patients who underwent elective operation. Levels of tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor (PAI) type 1 (PAI-1) and type 2 (PAI-2), and tPA/PAI complex in tissue extracts were determinated by commercially available enzyme-linked immunosorbent assay kits. RESULTS: tPA was significantly reduced in peritonitis compared with normal peritoneum (P <0.001), whereas it was found that the levels of PAI-1, PAI-2, uPA, and tPA/PAI complex in peritonitis were significantly higher than those in normal controls. CONCLUSIONS: Plasminogen activator activity was significantly reduced in peritoneal biopsy samples from patients with peritonitis compared with those from patients without peritonitis.     

Statins (HMG-CoA reductase inhibitors) decrease postoperative adhesions by increasing peritoneal fibrinolytic activity

OBJECTIVES: The aims of this study were to determine if statins reduce adhesion formation in vivo and to identify the mechanism of action in vitro. BACKGROUND:: Intraperitoneal adhesions develop in up to 95% of patients following laparotomy. Adhesions are reduced by mechanisms that up-regulate fibrinolysis within the peritoneum. Statins promote fibrinolysis in the cardiovascular system and may play a role in the prevention of adhesions. METHODS: Adhesions were induced in rats (n = 102) using our previously described ischemic button model. Rats received vehicle (controls), lovastatin (30 mg/kg), or atorvastatin (30 mg/kg) as a single intraperitoneal dose at the time of laparotomy. Animals were killed and adhesions were quantified at day 7. Peritoneal fluid and tissue were collected at day 1 to measure tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) by real-time PCR and ELISA. To assess the effects of statins on wound healing, burst pressures were measured in anastomoses of the colon. The effects of lovastatin on tPA and PAI-1 production were measured in vitro in human mesothelial cells (HMC) in the presence or absence of mevalonate (MVA), geranylgeranyl-pyrophosphate (GGPP) and farnesyl-pyrophosphate (FPP), all intermediates in the cholesterol pathway downstream of HMG-CoA. The effect of a Rho protein inhibitor, exoenzyme C3 transferase, on tPA production was also determined. RESULTS: Lovastatin and atorvastatin reduced adhesion formation by 26% and 58%, respectively (P < 0.05), without affecting anastomotic burst pressure. At 24 hours, tPA mRNA levels in peritoneal tissue and tPA activity in peritoneal fluid from lovastatin-treated animals were increased by 57% and 379%, respectively (P < 0.05), while PAI-1 levels were unchanged. HMC incubated with either lovastatin or atorvastatin showed concentration-dependent increases in tPA production and decreases in PAI-1 production (P < 0.05). These lovastatin-induced changes in tPA and PAI-1 production were significantly reversed by the addition of MVA, GGPP, and FPP. The Rho protein inhibitor increased tPA production and rescued tPA production from the inhibitory effect of GGPP. CONCLUSION: These data suggest that statins administered within the peritoneum can up-regulate local fibrinolysis, while the in vitro studies show that this effect may be mediated, in part, by intermediates of the cholesterol biosynthetic pathway that regulate Rho protein signaling.     

Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection

BACKGROUND: Use of laparoscopy in patients with gastrointestinal cancer has been associated with port-site and peritoneal tumour metastases. The effect of laparoscopy on tumour recurrence and long-term survival in patients undergoing resection of ruptured hepatocellular carcinoma (HCC) remains unknown. METHODS: Between June 1994 and December 2001, 59 patients with ruptured HCC underwent surgical exploration with a view to hepatic resection. Laparoscopy with laparoscopic ultrasonography was performed in 33 patients; the other 26 patients underwent exploratory laparotomy without laparoscopy. Perioperative and long-term outcomes were compared between the two groups. RESULTS: Exploratory laparotomy was avoided in 12 of 13 patients with irresectable HCC who had a laparoscopy. The hospital stay of these 12 patients was significantly shorter than that of eight patients found to have irresectable HCC at exploratory laparotomy (median 11 versus 15 days; P = 0.043). Twenty patients had a laparoscopy followed by open resection of HCC, whereas 18 patients underwent laparotomy and resection without laparoscopy. There were no significant differences in disease-free (16 versus 19 per cent; P = 0.525) and overall (32 versus 48 per cent; P = 0.176) survival at 3 years between the two groups. The tumour recurrence pattern was similar between the two groups, and there were no port-site or wound metastases. CONCLUSION: Use of diagnostic laparoscopy in patients with ruptured HCC helps avoid unnecessary exploratory laparotomy. The present data suggest that laparoscopy does not have an adverse effect on tumour recurrence or survival in patients who undergo resection.     

Prospective randomized trial to determine the influence of laparoscopic and conventional colorectal resection on intravasal fibrinolytic capacity

Background: Although the pneumoperitoneum decreases venous reflux from the lower extremities, the rate of thromboembolic complcations seems to be lower after laparoscopic than after conventional procedures. Therefore, it has been assumed that laparoscopic surgery better preserves the intravasal fibrinolytic capacity. The aim of this study was to determine the influence of the operative technique on intravasal fibrinolytic capacity in colorectal resection. Methods: Randomized controlled trial conducted in parallel with the multicenter trial LAPKON II comparing the long-term effects of elective laparoscopic (group I) and conventional (group II) resections for colorectal cancer. Blood samples were taken from 30 patients preoperatively, at the beginning and end of surgery as well as 2, 8, and 24 hr postoperatively. Activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), tPA/PAI complex, fibrinogen, and D-dimers were determined in all specimen with ELISA tests. Area under the curve values (AUC) were calculated for all parameters. Results: Patient characteristics and indication for surgery were not different between both groups. Preoperative values of fibrinolytic parameters were similar in both groups. Postoperatively, tPA activity decreased significantly in both groups, but AUC values for tPA and PAI-1 activity (p = 0.23; p = 0.68); concentration of tPA, PAI-1, and tPA/PAI complex (p = 0.52; p = 0.78; p = 0.95); and concentration of fibrinogen and D-dimers (p = 0.67; p = 0.71) did not differ between the groups. Conclusions: An intravasal fibrinolytic "shutdown" occurs not only after conventional but also after laparoscopic colorectal resection. Both operative techniques had similar effects on postoperative intravasal fibrinolytic capacity. Therefore, the lower incidence of thromboembolic complications after laparoscopic colorectal resections does not seem to be caused by a lesser depression of the intravasal fibrinolytic capacity.     

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.     

Time course of peritoneal tissue plasminogen activator after experimental colonic surgery: effect of hyaluronan-based antiadhesive agents and bacterial peritonitis

BACKGROUND: This study assessed the peritoneal fibrinolytic response during the first week after colonic surgery in rats with and without bacterial peritonitis, and possible modulation of the response by two hyaluronan-based antiadhesive agents. METHODS: A colonic anastomosis was constructed in 90 male Wistar rats. Peritonitis was induced in another 108 rats and a colonic anastomosis was constructed after 24 h. Rats in both groups were randomized into an untreated group or one of two groups treated with hyaluronan-based agents. One-third of each group was killed at each of days 1, 3 and 7 after operation, and tissue plasminogen activator (tPA) antigen and activity were measured in peritoneal biopsies. RESULTS: One day after colonic surgery in normal rats, tPA antigen concentration was significantly (P < 0.005) increased, whereas tPA activity levels were normal. By day 3 after operation tPA antigen had returned to baseline values while tPA activity was significantly increased (P < 0.05). One day after inducing peritonitis tPA antigen was significantly increased (P < 0.001), while tPA activity was significantly reduced (P < 0.05). Three and seven days after colonic surgery in rats with peritonitis tPA activity was increased (P < 0.001) while tPA antigen had returned to baseline values. Neither of the hyaluronan-based agents affected peritoneal tPA antigen levels or activity after colonic surgery. CONCLUSION: Both abdominal surgery and infection caused an early increase in peritoneal tPA antigen levels, followed by an increase in tPA activity. Peritonitis severely depressed early tPA activity. Application of hyaluronan-based agents did not affect the peritoneal fibrinolytic response to surgery and/or infection.     

Laparoscopy or scanning in oesophageal and gastric carcinoma?

A prospective study was undertaken of the accuracy in diagnosing intra-abdominal metastatic disease of the liver by scintigraphy, ultrasound scanning and laparoscopy. The effect of laparoscopy on management was also studied. Fifty patients were studied: 23 oesophageal carcinoma, 14 gastric carcinoma and 13 with suspected intra-abdominal metastatic spread. Accuracy was determined by laparoscopic biopsy, laparotomy and autopsy. The accuracy was 72 per cent for scintigraphy, 75 per cent for ultrasound and 96 per cent for laparoscopy (with 10 per cent failed ultrasound due to intra-abdominal gas). There was no morbidity or mortality associated with laparoscopy, with one failure due to adhesions. Thirteen patients without hepatic metastases had nodal and/or peritoneal spread diagnosed only by laparoscopy. Laparotomy was avoided in 58 per cent, and 74 per cent died in the 18 month follow-up period. Laparoscopy can obviate the need for laparotomy in inoperable cases of oesophageal carcinoma and allow better planning for potentially curable surgery. In gastric carcinoma the value of laparoscopy is doubtful as a high percentage require at least palliative surgery.     

腹腔镜探查判断胆囊癌可切除性的临床意义

目的 初步评价腹腔镜探查在胆囊癌外科治疗中的应用价值.方法 自2007年1月至2010年3月在上海交大医学院附属新华医院普外科及第二军医大学东方肝胆外科医院腹腔镜科收治胆囊癌患者中,选择有手术切除可能的60例患者作为腹腔镜探查组,将同期符合相同条件行剖腹探查的192例胆囊癌患者作为对照组,比较两组手术切除率、腹腔广泛转移患者的手术时间及住院时间.计量资料采用t检验,计数资料采用x2检验.结果 腹腔镜探查组60例中27例患者的肝脏和(或)腹膜有肿瘤广泛转移,中止手术;33例转行剖腹探查,发现1例肝脏多处肿瘤转移、12例侵犯门静脉主干和(或)胰头、十二指肠,无手术切除可能,中止手术;其余20例中7例行胆囊癌姑息性切除,13例行胆囊癌根治性切除术.直接行剖腹探查组192例术中发现肝脏和(或)腹膜肿瘤广泛转移的82例及侵犯门脉主干和(或)胰头31例均中止手术,姑息性切除32例,根治性切除47例.两组手术切除率、腹腔广泛转移患者的手术时间及住院时间差异有统计学意义(x2=4.328,t=8.6501,t=5.8260;P＜0.05、P＜0.01、P＜0.01).结论 腹腔镜探查有助于手术决策的制定,减少不必要的非治疗性剖腹探查,能显著提高手术切除率,可以作为胆囊癌外科治疗中的常规操作.

Abstract：

Objective To evaluate the role of laparoscopic staging for the resectability of gallbladder cancer. Methods From Jan 2007 to Mar 2010,60 gallbladder cancer patients without of metastatic disease or main hepatic portal vessel invasion as assessed by preoperative imaging underwent staging laparoscopy for tumor resectability evaluation. Peritoneal and liver surface metastases were looked for and assessment of local spread was done if possible. Assessment was based on visual impression and biopsies were obtained routinely. T test and x2 test were used. Results At laparoscopy, 27 (45%) patients were found with disseminated disease on peritoneal cavity or the surface of liver, hence, senseless open surgery was avoided. The other 33 patients were converted to open laparotomy, among those 1 patient was found with disseminated metastasis in the liver and 12 patients with the invasion of main hepatic portal vessel,pancreatic head, duodenum did not undergo any further surgery. Finally 7 patients received surgical bypass procedure and 13 patients underwent radical resection. During the same period, 192 clinically diagnosed gallbladder cancer patients undergoing open laparotomy without laparoscopic pre-assessment served as control. Among those in control group 79 patients received radical or palliative resection. The resectability rate was significantly different between the two groups ( P ＜ 0. 05). Conclusion Staging laparoscopy in patients with gallbladder cancer is helpful in detecting liver and peritoneal metastases overlooked by preoperative imaging, avoiding unnecessary open explorations.     

腹腔镜结肠癌根治术中腹腔脱落肿瘤细胞的临床研究

目的:对比腹腔镜手术和传统开腹结肠癌根治术中腹腔內肿瘤细胞脱落的差异,探讨腹腔镜结肠癌根治术对腹腔脱落肿瘤细胞的影响.方法:将2010年4月至2011年2月60例结肠癌患者分为腹腔镜组和开腹组,每组30例.进腹后和关腹前分别注入500 ml生理盐水灌洗腹腔.对比分析两种术式腹腔灌洗液标本肿瘤细胞的阳性检出率及腹腔灌洗液...     

Experimental study of peritoneal blood flow and insufflation pressure during laparoscopy

BACKGROUND: Port-site metastases after laparoscopic surgery may occur with greater frequency than would be expected following open resection of intra-abdominal malignancies, but the causal mechanism for this is incompletely understood. The possibility that insufflation may increase peritoneal blood flow producing a wound environment conducive to the formation of metastases was investigated.METHODS: The effects of insufflation gas type and pressure were studied in 30-kg female pigs. Pigs were divided into five groups, which were subjected to insufflation at 12 mmHg pressure with helium, insufflation at 12, 8 or 4 mmHg pressure with carbon dioxide, or laparotomy. A microsphere technique utilizing two distinct radiotracers, 99mTc-labelled macroaggregated albumin (MAA) and 51Cr-labelled MAA, was used to study blood flow to the peritoneum, liver and kidneys.RESULTS: Insufflation with carbon dioxide or helium gases had no effect on renal (P < 0.09) or hepatic blood flow (P = 0.54). However, insufflation significantly increased peritoneal blood flow when carbon dioxide (P < 0.05), but not when helium (P = 0.99), was used as the insufflating gas.CONCLUSION: These data suggest that blood flow within the peritoneum is influenced by insufflation with carbon dioxide. It is conceivable that such hyperaemia could increase the propensity for implanted tumour cells to metastasize in these sites following laparoscopy.     

Long-term results of antireflux surgery indicate the need for a randomized clinical trial

BACKGROUND: Well conducted, comparative trials of laparoscopic versus open antireflux surgery with an adequate patient enrollment are few and they do not demonstrate obvious advantages for the laparoscopic approach except for a marginal gain in shorter hospital stay. The aim of this study was to compare the effectiveness of laparoscopic and open procedures. METHODS: Two unselected groups of 230 patients were identified through a register of all inpatient public care in Sweden. Outcomes of laparoscopic and open antireflux surgery were compared using a disease-specific questionnaire 4 years after operation. RESULTS: Failure and dissatisfaction were significantly more common in the laparoscopy group than among patients having conventional open surgery. Treatment failure rates were 29.0 and 14.6 per cent respectively (P = 0.004). Dissatisfaction rates were 15.0 and 7.0 per cent respectively (P = 0.005). There was no other questionnaire item for which the proportion of failures differed significantly between the two groups. CONCLUSION: This study does not support the presumption that laparoscopic antireflux surgery is to be preferred to the open procedure. It is strongly recommended that a randomized controlled trial be conducted.     

Laparoscopic surgery induced interleukin-6 levels in serum and gut mucosa: implications of peritoneum integrity and gas factors

Background  The peritoneum serves as an integral part of host immunity, and the homeostasis of intraperitoneal environment is held to be beneficial for patient recovery after abdominal surgery. How minimal invasive access to the abdomen by laparoscopy and incisions would alter the intraperitoneal immune response is not fully defined. This study examined the levels of IL-6 in serum and gut mucosa following laparoscopic surgery with reference to the peritoneum integrity and gas factors. Methods  BALB/c mice were divided into three groups (ten animals in each group) that underwent different abdominal surgical treatments: laparotomy (open group), laparoscopy with atmospheric air (air group) or carbon dioxide pneumoperitoneum (CO₂ group). A 3-cm incision of the skin and muscle was made in all animals except the peritoneum was left intact in the latter two animal groups in order to cancel out the incisional tissue injury present in laparotomy. Four hours after surgery, serum, and jejunal mucosa were extracted for IL-6 measurement by enzyme-linked immunosorbent assay (ELISA). Results  Open laparotomy resulted in significant elevation of serum IL-6 level when compared to the laparoscopic procedures in the descending order of open > air > CO₂ groups. For the mucosal IL-6 level, both the open and air groups were significantly higher than the CO₂ group. Data from multivariate analysis revealed that breaching or incision of the peritoneum was an important factor for the elevated levels of IL-6 in serum (p < 0.001) and jejunal mucosa (p = 0.032). Conclusion  The present study suggests that laparoscopic techniques to minimize the size of the peritoneal incision as well as exposure to atmospheric air can potentially reduce postoperative stress responses associated with abdominal surgery and prompt early recovery.     

Effects of seprafilm on peritoneal fibrinolytic system

BACKGROUND: There is a high incidence of adhesions after ventral hernia repair with polypropylene mesh. The purpose of the present study was to evaluate the efficacy of Seprafilm in the prevention of adhesion formation and effect on peritoneal fibrinolytic activity. METHODS: An incisional hernia model was created in rats. In the experimental group Seprafilm was placed between polypropylene mesh and abdominal organs. On the 14th day adhesions were evaluated and tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), plasminogen activator inhibitor (PAI) type 1 and 2 were measured in peritoneal biopsy specimens. Results: Adhesions were significantly reduced in the Seprafilm group (P = 0.002). Nevertheless, there were no difference between the two groups in levels of tPA, PAI-1 and PAI-2. However, the levels of uPA were significantly decreased in the Seprafilm group. CONCLUSIONS: The adhesion preventive effect of Seprafilm is not directly related in peritoneal fibrinolytic activity. Instead, the physical properties (barrier, hydroflotation and sliconizing effect) of the membrane are primarily responsible for adhesion prevention.