Abdominal drainage was unnecessary after hepatectomy using the conventional clamp crushing technique

A prophylactic abdominal drainage catheter is routinely inserted by many surgeons in patients after hepatic resection. Between January 2002 and September 2004, 462 consecutive patients who had undergone hepatic resection using a clamp crushing method by the same surgical team were retrospectively divided into the drainage group (n = 357) and the nondrainage group (n = 105). There was no difference in hospital mortality between the two groups of patients (drainage group, 0.6% vs. nondrainage group, 0%; P = 1.0). However, there was a greater incidence of surgical complications in the drainage group (31.4% vs. 8.6%, P < 0.001), and greater incidence of wound complications and subphrenic complications in the drainage group compared to the nondrainage group (24.4% vs. 4.8%, P < 0.001). In addition, the mean (+- SEM) postoperative hospital stay of the drainage group was 13 +- 6.5 days, which was significantly longer than that of the nondrainage group (9.7 +- 3.3 days, P = 0.001). On multivariate analysis, abdominal drainage and intraoperative bleeding were the independent risk factors that were significantly associated with the incidence of drainage-related complications. The results suggested that routine abdominal drainage is unnecessary after hepatic resection when the conventional clamp crushing method is used during parenchyma transection.     

Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery.

BACKGROUND: Although studies have shown that early oral feeding after abdominal surgery is feasible, many surgeons still advocate a careful, slow introduction of postoperative oral feeding. This study was conducted to investigate whether patient-controlled postoperative feeding is possible in patients undergoing colonic or aortic surgery. METHODS: A randomized clinical trial compared patient-controlled postoperative oral feeding (PC group) with a fixed regimen (FR group). Patients in the PC group (n = 56) received oral feeding when they requested it; patients in the FR group (n = 49) started a normal diet on day 5. Endpoints were time to tolerance of a diet similar to the preoperative diet, reinsertion of a nasogastric tube, complications and duration of hospitalization. RESULTS: Median time to resumption of a normal diet was 3 days in the PC group and 5 days in the FR group (P < 0.001). Reinsertion of a nasogastric tube was required in nine patients in each group (P not significant). The incidence of complications was similar in both groups: 12 of 56 in the PC group and 13 of 49 in the FR group. There was no significant difference in duration of hospital stay between the groups. CONCLUSION: Most patients tolerate a normal diet on the third day after operation. Patient-controlled postoperative feeding is safe and leads to earlier resumption of a normal diet.     

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery

BACKGROUND: Hypothermia is common in the operating theatre and may increase susceptibility to postoperative complications. Intraoperative systemic warming has been shown to improve outcomes of surgery. This study aimed to examine the effects of additional perioperative systemic warming on postoperative morbidity. METHODS: All patients admitted for elective major abdominal surgery and fulfilling the inclusion criteria were randomized into control or warming groups. Both groups were warmed during surgery, but patients in the warming group were additionally warmed 2 h before and after surgery using a conductive carbon polymer mattress. RESULTS: The trial recruited 103 patients (56 in the control group, 47 in the warming group). Both groups were well matched for age, sex and clinical state. Patients in the warming group had lower blood loss (median 200 (range 5-1000) ml versus median 400 (range 50-2300) ml in the control group; P = 0.011) and complication rates (15 (32 per cent) of 47 versus 30 (54 per cent) of 56 in the control group; P = 0.027). There were three deaths; two in the control group (P = 0.566). CONCLUSION: Extending systemic warming to the perioperative period had additional beneficial effects, with minimal additional cost and patient discomfort.     

Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection

BACKGROUND: The value of routine nasogastric tube (NGT) decompression after elective hepatic resection has not been investigated. METHODS: Of 200 patients who had elective hepatic resection, including 68 who had previously had colorectal surgery, 100 were randomized to NGT decompression, where the NGT was left in place after surgery until the passage of flatus or stool, and 100 to no decompression, where the NGT was removed at the end of the operation. RESULTS: There was no difference between patients who had NGT decompression and those who did not in terms of overall surgical complications (15.0 versus 19.0 per cent respectively; P = 0.451) medical morbidity (61.0 versus 55.0 per cent; P = 0.391), in-hospital mortality (3.0 versus 2.0 per cent; P = 0.640), duration of ileus (mean(s.d.) 4.3(1.5) versus 4.5(1.7) days; P = 0.400) or length of hospital stay (14.2(8.5) versus 15.8(10.8) days; P = 0.220). Twelve patients randomized to no NGT decompression required reinsertion of the tube 3.9(1.9) days after surgery. Previous abdominal surgery had no influence on the need for NGT reinsertion. Severe discomfort was recorded in 21 patients in the NGT group and premature removal of the tube was required in 19. Pneumonia (13.0 versus 5.0 per cent; P = 0.047) and atelectasis (81 versus 67 per cent; P = 0.043) were significantly more common in the NGT group. CONCLUSION: Routine NGT decompression after elective hepatectomy had no advantages. Its use was associated with an increased risk of pulmonary complications.     

TissueLink与钳夹法在肝癌切除术中的应用比较

目的:了解TissueLink在肝癌切除术中的应用是否较钳夹法对患者更有利.方法:回顾性分析68例应用TissueLink和81例应用钳夹法行肝癌切除术的肝细胞癌患者的资料,比较两组患者手术时间、术中出血量、术前后血清ALT、总胆红素(TBIL)的变化以及术后并发症发生情况.结果:TissueLink组(T组)和钳夹法(C组)的手术时间分别为(281.8±84.40)min和(247.9±91.63)min.术中失血量中位数分别为450 mL(100～3 900 mL)和630 mL(80～6 550 mE),P值均<0.05,差异均有统计学意义.两组术后各时相点ALT和TBIL水平及术后并发症发生率差异无统计学意义.结论:与钳夹法比较,Tis-sueLink行肝癌切除术虽手术时间长,但术中出血少,更具有优势.     

Randomized clinical trial of the anabolic effect of hypocaloric parenteral nutrition after abdominal surgery

BACKGROUND: The observed failure of hypocaloric nutrition to establish an anabolic state after surgery may reflect inadequate control for the type and quality of analgesia in the studies performed. This study was designed to test the hypothesis that hypocaloric nutrition induces anabolism in patients who receive effective segmental pain relief using perioperative epidural analgesia. METHODS: Sixteen patients who underwent colorectal surgery and received epidural analgesia were randomly assigned to receive intravenous glucose either without (glucose only) or with amino acids (nutrition). Feeding was administered over 48 h from surgical skin incision until the second day after operation. Glucose provided 50 per cent of the patient's resting energy expenditure (REE). Amino acids were infused at rates that provided 20 per cent of REE. Leucine rate of appearance (Ra), leucine oxidation and non-oxidative leucine disposal (NOLD) were assessed by measuring L-[1-13C]leucine kinetics. A positive leucine balance, that is the difference between NOLD and leucine Ra, indicated anabolism. RESULTS: After surgery, leucine Ra in the nutrition group was lower than that in the glucose only group (mean(s.d.) 88(25) versus 131(22) micromol per kg per h). The leucine balance remained negative in the glucose only group, whereas it became positive in the nutrition group (mean(s.d.) -24(3) versus 38(12) micromol per kg per h; P < 0.001). CONCLUSION: Patients who receive hypocaloric parenteral nutrition can be rendered anabolic after colorectal surgery in the presence of epidural analgesia.     

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection

BACKGROUND: Protocolized fluid administration using oesophageal Doppler monitoring may improve the postoperative outcome in patients undergoing surgery. METHODS: A total of 108 patients undergoing elective colorectal resection were recruited into a double-blind prospective randomized controlled trial. An oesophageal Doppler probe was placed in all patients. The control group received perioperative fluid at the discretion of the anaesthetist, whereas the intervention group received additional colloid boluses based on Doppler assessment. Primary outcome was length of postoperative hospital stay. Secondary outcomes were morbidity, return of gastrointestinal function and cytokine markers of the systemic inflammatory response. Standard preoperative and postoperative management was used in all patients. RESULTS: Demographic and surgical details were similar in the two groups. Aortic flow time, stroke volume, cardiac output and cardiac index during the intraoperative period were higher in the intervention group (P<0.050). The intervention group had a reduced postoperative hospital stay (7 versus 9 days in the control group; P=0.005), fewer intermediate or major postoperative complications (2 versus 15 percent; P=0.043) and tolerated diet earlier (2 versus 4 days; P=0.029). There was a reduced rise in perioperative level of the cytokine interleukin 6 in the intervention group (P=0.039). CONCLUSION: A protocol-based fluid optimization programme using intraoperative oesophageal Doppler monitoring leads to a shorter hospital stay and decreased morbidity in patients undergoing elective colorectal resection.     

Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery

BACKGROUND: Use of intravenous fluids is an important part of perioperative management. The aim of this study was to compare outcome following administration of restricted or standard postoperative intravenous fluids and sodium in patients undergoing elective colorectal surgery. METHODS: Eighty patients were randomized to restricted fluids (less than 2 litres water and 77 mmol sodium for 24 h after surgery) or a standard postoperative fluid regimen (3 litres water and 154 mmol sodium per day for as long as necessary). The primary endpoint was hospital stay. RESULTS: The median (i.q.r.) total intravenous fluid intake in the restricted group was 4.50 (4.00-5.62) litres compared with 8.75 (8.00-9.80) litres in the standard group (P < 0.001). Intravenous sodium intake was also significantly less in the restricted group (229 (131-332) versus 560 (477-667) mmol; P < 0.001). There was no difference in median time to first flatus (2.9 versus 2.9 days; hazard ratio (HR) 0.85 (95 per cent confidence interval (c.i.) 0.54 to 1.32); P = 0.466) or first bowel motion (4.7 versus 4.9 days; HR 1.06 (95 per cent c.i. 0.68 to 1.65); P = 0.802) between the restricted and standard groups, or in median hospital stay (7.2 versus 7.2 days; HR 1.03 (95 per cent c.i. 0.66 to 1.61); P = 0.902). CONCLUSION: Restriction of postoperative intravenous fluid and sodium does not reduce hospital stay following elective colorectal surgery.     

Randomized clinical trial of hepatectomy using intermittent pedicle occlusion with ischaemic intervals of 15 versus 30 minutes

BACKGROUND: The optimal ischaemic interval during hepatectomy with intermittent pedicle occlusion (IPO) remains to be established. The aim of the present randomized clinical trial was to compare the short-term outcome of hepatectomy using IPO with an ischaemic interval of 15 versus 30 min. METHODS: Between October 2002 and September 2004, 108 consecutive patients scheduled to undergo hepatectomy without bilioenterostomy were enrolled. During liver transection, IPO was performed with an ischaemic interval of either 15 min with 5 min of reperfusion (standard group, SG) or 30 min with 5 min of reperfusion (prolonged group, PG). After randomization and subsequent exclusion of certain patients, 44 patients in the SG and 48 in the PG were analysed. RESULTS: The mean(s.d.) bilirubin ratio (serum total bilirubin level on day 2 after operation divided by the preoperative level) was 1.6(0.8) in the SG and 1.7(0.8) in the PG (P = 0.874). The transection area per unit transection time was significantly greater in the latter group (median (range) 1.0 (0.4-2.1) versus 0.8 (0.0-1.5) cm(2)/min; P = 0.046). CONCLUSION: There was no difference in the bilirubin ratio when IPO was carried out for 30 or 15 min. By extension of IPO to 30 min, a greater resection area per unit time was possible with preservation of remnant liver function.     

Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy

BACKGROUND: Electrocautery is used increasingly for tissue dissection, although fears of excessive scarring and poor wound healing have curtailed its widespread use for skin incision. This study compared electrosurgical incision with traditional scalpel incision. METHODS: One hundred patients requiring elective midline laparotomy were randomized prospectively to either scalpel or diathermy incision. Parameters measured included incision time, wound size, wound blood loss, total intraoperative blood loss and postoperative wound pain. All wound complications were recorded. RESULTS: The two groups did not differ significantly in relation to patient or wound characteristics. Laparotomy incisions using diathermy were significantly quicker than scalpel incisions (mean(s. e.m.) 6.1(0.4) versus 7.5(0.5) s/cm2; P < 0.04). There was significantly less blood loss in the diathermy group compared with the scalpel group (0.8(0.1) versus 1.7(0.3) ml/cm2; P = 0.002). Postoperative pain scores were significantly lower in the diathermy group for the first 48 h after operation (P < 0.05). Morphine requirements were also significantly lower over the first 5 postoperative days in the diathermy incision group (P < 0.04). There was no difference between groups in wound complications before discharge and at the 1-month follow-up. CONCLUSION: Electrosurgical midline incision in elective surgery has significant advantages over scalpel use on the basis of incision time, blood loss, early postoperative pain and analgesia requirements.