Comparison of adhesion formation to intra-abdominal mesh after laparoscopic adhesiolysis in the New Zealand White rabbit

The purpose of this study was to investigate the effects of early adhesiolysis on long-term adhesion formation after the intraperitoneal implantation of polypropylene (PP) mesh and expanded polytetrafluoroethylene (ePTFE) mesh in a rabbit model. Through a small midline laparotomy a 2 x 2-cm piece of mesh (n = 80) was sewn to an intact peritoneum on each side of a midline incision in 40 New Zealand White rabbits. Two types of ePTFE mesh [Dual Mesh (Dual) and modified Dual Mesh (C-Type), W.L. Gore and Associates, Flagstaff, AZ] and PP mesh (Marlex, C.R. Bard, Murray Hill, NJ) were compared. In 10 rabbits (n = 20) a laparoscopic adhesiolysis (LapA) was performed at one week. Mesh adhesions were scored using a modified Diamond scale (0, 0%; 1, 1-25%; 2, 26-50%; and 3, > 50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopic (2 mm) examinations. After recording the final adhesion score at 16 weeks the prosthetic biomaterials were excised en bloc with the anterior abdominal wall for histologic evaluation of mesothelial layer growth (%) on the visceral surface of the mesh. Statistical differences (P value < 0.05) were measured by chi-square and Wilcoxon signed rank tests. There were no statistical differences in mean adhesion scores at adhesiolysis at 7 days. The mean adhesion scores in the groups undergoing laparoscopic adhesiolysis was statistically less (P < 0.05) for PP and both ePTFE meshes at 3-, 9-, and 16-week intervals compared with those not undergoing adhesiolysis. The percentage of mesothelialization on the visceral surface of the mesh was not statistically different between the adhesiolysis and control groups for any of the prosthetic biomaterials. Laparoscopic adhesiolysis at one week minimizes subsequent adhesion formation to PP and ePTFE mesh over a 4-month follow-up. Adhesion formation within the first 7 days after mesh implantation appears to determine the long-term adhesion score. Eliminating adhesions to mesh by mechanical or other means during this critical time may control adhesions to the mesh and subsequent mesh-related complications.     

Epidemiologic study of acute infantile gastroenteritis in New Caledonia

In a test area (suburbs of Nouméa), a survey on acute infantile gastro-enteritis showed an annual incidence of 2.2% and a hospitalization rate of 27.5%. The 0 to 23 months age group was the most exposed. The factors of severity were: a low age, a high frequency of liquid stool, vomits, fever and associated acute respiratory infection. The etiologic diagnosis was possible in 76% of cases: 49.5% enteropathogens (22% bacteria, 27.5% viruses), 26.5% non-intestinal infections. The asymptomatic carriers were 11.5% for bacteria and 27.4% for viruses. In regard to epidemiology, the housing hygiene, the potable water supply and the presence of suitable water closet were over 90%. On the contrary, the individual hygiene was neglected, especially the hand washing. The pathogens are transmitted by the dirty hands of asymptomatic carriers. Mass media campaigns and health education of parents and children are the recommended prophylactic measures.     

Multidisciplinary approach to abdominal wall reconstruction after decompressive laparotomy for abdominal compartment syndrome

INTRODUCTION: Decompressive laparotomy for abdominal compartment syndrome has been shown to reduce mortality in critically ill patients, but little is known about the outcome of abdominal wall reconstruction. This study investigates the role of plastic surgeons in the management and reconstruction of these abdominal wall defects. METHODS: We performed a retrospective review of 82 consecutive critically ill patients who underwent decompressive laparotomy for abdominal compartment syndrome, at a university level 1 trauma center, from April 2000 to May 2004. Patients reconstructed by trauma surgeons alone (n = 15) were compared with patients reconstructed jointly with plastic surgeons (n = 12), using Student t test and chi analysis. RESULTS: Eighty-two patients underwent decompressive laparotomy for abdominal compartment syndrome, yielding 50 survivors (61%). Of the 27 patients who underwent abdominal wall reconstruction, 6 had early primary fascial repair, and 21 had staged reconstruction with primary fascial closure (n = 4), components separation alone (n = 3), components separation with mesh (n = 10), or permanent mesh only (n = 4). Compared with patients whose reconstruction was performed by trauma surgeons, patients who underwent a combined approach with plastic surgeons were older (50.5 versus 31.7 years, P < 0.05), had more comorbidities (P < 0.001), were less likely to have a traumatic etiology (P < 0.001), had a longer delay to reconstruction (407 versus 119 days, P < 0.05), and were more likely to undergo components separation (P < 0.05). Mean follow-up of 11.5 months revealed 2 recurrent hernias in the combined reconstruction group, both of which were successfully repaired. CONCLUSIONS: A multidisciplinary approach is essential to the successful management of abdominal wall defects after decompressive laparotomy for abdominal compartment syndrome. Although carefully selected patients can undergo early primary fascial repair, most of reconstructed patients had staged closure of the abdominal wall via components separation, with a low rate of recurrent hernia. High-risk patients with large defects and comorbidities appear to benefit from the involvement of a plastic surgeon.     

The economic benefit of practice guidelines for stress ulcer prophylaxis

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.     

Antimicrobial prophylaxis for major head and neck cancer surgery with piperacillin and ornidazole.

A prospective study in 53 eligible patients, undergoing major head and neck cancer surgery was carried out to assess the combination of an ureido penicillin, piperacillin with a nitro imidazole agent, ornidazole, in order to prevent post-operative general and wound infections. Both antibiotics were administered for five days. Each patient had piperacillin 4 gm every eight hours and ornidazole 1 gm every 24 hours. The overall rate of infections was 13.2 per cent (n = 7), with 3.8 per cent (n = 2) wound infections and 11.3 per cent (n = 6) general infections (one patient presented both complications). There was no wound infection in the total surgery group (n = 12). General infections who only consisted of pneumonias were respectively 12.2 per cent (n = 5) in the group with partial procedures (n = 41) and 8.3 per cent (n = 1) in the total surgery group. This antibioprophylaxis can be recommended in major oncological neck surgery, specially in the case of partial procedures.     

A novel paraspinal surgical approach for lumbar lateral extraforaminal root entrapment

We describe a new surgical route that we call the crest approach for treating extraforaminal disc herniation in the lumbar spine. This approach is useful only for the levels above L5-S1. It permits perfect root decompression without any bony resection that would contribute to instability. Muscle retraction and devascularization are reduced. Risk of nerve root lesions is minimal since the herniation is removed before root mobilization. Fifteen patients have been treated using this procedure. In all 15, pain and/or neurologic deficits remitted rapidly with no postoperative complications. In conclusion, the crest approach provides highly satisfactory operating conditions by simplifying exposure and greatly limiting the risk of complications. In our relatively limited experience using this procedure, only satisfactory results have been observed.     

Exposure to DDT metabolite p,p′-DDE increases autoimmune type 1 diabetes incidence in NOD mouse model

The incidence of autoimmune Type 1 diabetes (T1D) has been steadily rising in developed countries. Although the exact cause of T1D remains elusive, it is known that both genetics and environmental factors play a role in its immunopathogenesis. Whereas a positive association between p,p′-DDE, a DDT metabolite, and Type 2 diabetes (T2D) has been well established, its role in T1D development in an experimental animal model has never been elucidated. This study seeks to investigate the effects of DDE exposure on the development of T1D in a NOD mouse model. As T1D is a T-cell-mediated disease, the underlying mechanism of DDE action on T-cells was studied in vitro and, in the context of acute and chronic DDE exposure, in vivo by investigating lymphocytes’ viability, proliferation, their subsets and cytokine profiles. Chronic high-dose DDE treatment, initiated in pre-diabetic 8-week-old NOD females administered twice weekly intraperitoneally with 50?mg/kg DDE, significantly increased diabetes incidence and augmented disease severity in treated animals. Whereas T-cell proliferation and cell viability in the spleens of treated mice were not affected, diabetogenic action of chronic DDE exposure was associated with a decrease in regulatory T-cells and a suppression of secretion of protective cytokines, such as IL-4 and IL-10. Interestingly, an acute high-dose in vivo treatment of 8-week-old NOD males with 100?mg DDE/kg, administered intraperitoneally every other day over a period of 10 days, increased T-cell proliferation and potentiated pro-inflammatory and T_H1-type cytokine secretion, without affecting the splenocytes viability and the T-cell sub-populations. These results confirm that high-dose DDE treatments affect the immune system, in particularly T-cell function. In conclusion, this study shows for the first time that high-dose chronic DDE exposure exhibits a diabetogenic potential, with an underlying immunomodulatory mechanism of action, in the development of T1D in an experimental mouse NOD model.