Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass.

METHODS

Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention. There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79).

RESULTS

Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death.

CONCLUSION

SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.

[Self-expandable metallic stent for palliative treatment of colorectal malignant obstructions: risk of perforation]

OBJECTIVE

The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation.

PATIENTS AND METHODS

From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy.

RESULTS

Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively.

CONCLUSION

The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.

[Prophylaxis and treatment of serotonin insufficiency in surgical patients]

The authors demonstrate that appearance in blood of chemical substances (ligands) capable to bind with serotonin receptors of smooth muscles (SM) leads to serotonin insufficiency. Intravenous injection of serotonin adipinat corrects serotonin insufficiency (biochemical stage) which leads to restoration of disordered function of SM (pharmacological stage). Normal function of SM eliminates functional intestinal obstruction (from the first hours after surgery), vascular insufficiency, tissues hypoxia (clinical stage) in surgical patients with different diseases. Serotonin adipinat was used in more than 900 surgical patients. It is concluded that this drug is a necessary component of prophylaxis and treatment of functional intestinal obstruction, vascular insufficiency, local and regional tissues hypoxia.

Laparoscopy and small bowel obstruction in children

Three issues are studied: 1. What is well-known about post-operative small bowel obstructions. The cost of this pathology, the complications associated (blood loss, enterocutaneous fistulas, major bowel resections, abdominal wall damages, death), the distribution of adhesions in the abdominal cavity, and previous surgeries. 2. Small bowel obstructions happen after laparoscopy and the incidence is more than 1% of patients: herniation of the small bowel through a trocar site, herniation of the omentum through a trocar site, peritoneal defect, spillage of stones and stercolitis. Suggestions to avoid small bowel obstruction after laparoscopy include the use of smaller trocars whenever possible, repairing the fascia under direct vision, carefully desufflating the abdominal cavity, avoiding bleeding, spilled stones and staples and washing the abdominal cavity at the end of the surgical procedure. 3. The treatment of small obstruction is feasible by laparoscopy, reliability, and results are studied with a multicentric GECI (Groupe d'Etude en Coelioscopie Infantile) and literature series. We obtained good results for 2/3 children.

Postoperative ileus: progress towards effective management

The pathogenesis of postoperative ileus (PI) is multifactorial, and includes activation of inhibitory reflexes, inflammatory mediators and opioids (endogenous and exogenous). Accordingly, various strategies have been employed to prevent PI. As single-modality treatment, continuous postoperative epidural analgesia including local anaesthetics has been most effective in the prevention of PI. Choice of anaesthetic technique has no major impact on PI. Minimally invasive surgery reduces PI, in accordance with the sustained reduction in the inflammatory responses, while the effects of early institution of oral nutrition on PI per se are minor. Several pharmacological agents have been employed to resolve PI (propranolol, dihydroergotamine, neostigmine, erythromycin, cisapride, metoclopramide, cholecystokinin, ceruletide and vasopressin), most with either limited effect or limited applicability because of adverse effects. The development of new peripheral selective opioid antagonists is promising and has been demonstrated to shorten PI significantly. A multi-modal rehabilitation programme including continuous epidural analgesia with local anaesthetics, enforced nutrition and mobilisation may reduce PI to 1-2 days after colonic surgery.

Inhaled carbon monoxide suppresses the development of postoperative ileus in the murine small intestine

BACKGROUND & AIMS

The induction of heme oxygenase (HO-1), the rate-limiting enzyme in heme metabolism, is protective against injury in acute and chronic inflammation. Inhalation of low levels of carbon monoxide (CO), a byproduct of heme metabolism, has anti-inflammatory effects equal to HO-1 induction. This study examined whether inhaled CO was protective against the development of postoperative ileus.

METHODS

Ileus was induced by surgical anesthesia and gentle manipulation of the mouse small intestine. Animals were exposed to CO (250 ppm) in air 1 hour before and continuously for 24 hours after surgery.

RESULTS

CO inhalation prevented the manipulation-induced suppression of circular muscle contractility in vitro, and significantly improved gastrointestinal transit in vivo. Proinflammatory messenger RNA (mRNA) expression (interleukin [IL]-6, IL-1beta, cyclooxygenase 2 [COX-2], inducible nitric oxide [iNOS]) and anti-inflammatory mediator expression (IL-10 and HO-1) were elevated 3 to 6 hours after surgery relative to controls. CO treatment reduced IL-1beta and iNOS peak expression by 75%, but not IL-6 or COX-2. In manipulated mice treated with CO, HO-1 expression peaked earlier (3 hours after surgery) and at levels 300% higher than in mice not exposed to CO. IL-10 expression at 3 hours also was 300% higher after CO treatment.

CONCLUSIONS

These findings suggest that CO attenuates postoperative ileus by inhibiting selective elements within the inflammatory cascade and by enhanced induction of the anti-inflammatory cytokine IL-10. In addition, the early and enhanced induction of HO-1 potentially amplifies the anti-inflammatory effects of the HO-1 pathway by protection from free radical stress and by increasing the tissue availability of CO directly at the sites of inflammation.

The role of epidural analgesia and anesthesia in surgical outcomes

Recent clinical evidence suggests that EAA used in combination with general anesthesia has a beneficial effect on surgical outcome compared with general anesthesia and systemic analgesia. Those complications with clear evidence of a reduced incidence in prospective, randomized studies are shown in Table 2. The benefits are greatest in high-risk patients who receive thoracic epidural blockade with local anesthetic agents. Besides reducing the incidence of certain major complications, the adjunctive use of EAA reduces ICU care, hastens recovery, and has cost savings.

Adenosine A1 receptor blockade reverses experimental postoperative ileus in rat colon

Inhibition of colonic propulsive motility is the main contributor to postoperative ileus in humans. Experimental models for investigating colonic propulsion in surgically induced postoperative ileus have not previously been available. This study was designed to assess whether adenosine A(1) receptor antagonists (R)-1-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl) acryloyl]-piperidin-2-yl acetic acid (FK352) and 8-cyclopentyl-1, 3-dipropylxanthine (DPCPX) reverse the colonic motility disorder in newly developed rat experimental ileus models. When rats underwent anesthesia (pentobarbital) or surgical traumas (partial gastrectomy, cecectomy or gentle touching of the colon with fingers), colonic propulsive motility was evaluated by migration of intracolonically injected dye in awake unrestrained rats. Propulsive motility resulted in significant decrease after the treatment of the anesthesia or partial gastrectomy. Intravenous administration of either adenosine A(1) receptor antagonist reversed the slowed colonic propulsion in these experimental ileus models. The present study suggests that the blockade of adenosine A(1) receptors has therapeutic potential for postoperative ileus.

[A case of pulmonary embolism and a case of ileus as complications after laparoscopic radical prostatectomy]

In recent years, the use of laparoscopic techniques for surgical operations has been increasing, because this procedure is less invasive and is excellent in regard to patient's quality of life. Normally, complications are rare in laparoscopic surgery. However, we experienced a case of pulmonary embolism and one case of ileus as complications after laparoscopic radical prostatectomy. Especially, in this type of operation, the danger of complications is increased due to the severe head down and lithotomy position, which is employed to ensure a good view during operation. In this particular case, the long duration of operation may have been another related risk factor. There were no risk factors for pulmonary embolism such as those encountered when a patient is aged, obese, or bed ridden for a long time. However, an intermittent air massage must be applied to the lower legs to prevent thrombus due to poor blood circulation of the lower extremities below the knee during the surgery. It is also necessary to change the posture of the patient frequently after the operation. In addition, the administration of low molecular weight heparin may also be effective.

Lipopolysaccharide preconditioning and cross-tolerance: the induction of protective mechanisms for rat intestinal ileus

BACKGROUND & AIMS

Endotoxin elicits an inflammatory response within the intestinal muscularis and causes intestinal muscle dysfunction. Our aims were to investigate intestinal muscle recovery after a single or repeated lipopolysaccharide (LPS) injections. We also investigated the ability of LPS to induce cross-tolerance to postoperative ileus.

METHODS

Motility was measured in vivo and in vitro by transit and organ-bath techniques. Nuclear factor kappa-B, nuclear factor interleukin 6, and signal transducer and activator of transcription were quantified by using electrophoretic mobility shift assay, and tumor necrosis factor alpha, interleukin 6, inducible nitric oxide synthase, and cyclooxygenase 2 were measured with reverse-transcription polymerase chain reaction. Myeloperoxidase histochemistry for neutrophils was performed in jejunal muscularis whole mounts.

RESULTS

Endotoxin-induced suppression of in vitro muscle contractility temporally recovered over 7 days with a similar profile whether after a single dose or during the continuous daily injection of LPS. Functional adaptation to continuous LPS was reflected in a significant blunting of transcription factor activation and cytokine messenger RNA up-regulation compared with the naive LPS-stimulated muscularis. Preconditioning of the muscularis showed significant cross-tolerance to the functional, molecular, and leukocytic sequelae of intestinal manipulation.

CONCLUSIONS

The muscularis externa recovered and developed tolerance to endotoxin over 7 days, which conferred cross-tolerance to intestinal manipulation. Thus, preconditioning induces protective mechanisms to a subsequent insult within the muscularis externa.

Laparoscopic treatment of acute mesenteric torsion

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.

Alpha-melanocyte-stimulating hormone protects against mesenteric ischemia-reperfusion injury

Mesenteric ischemia-reperfusion (I/R) injury to the intestine is a common and often devastating clinical occurrence for which there are few therapeutic options. alpha-Melanocyte-stimulating hormone (alpha-MSH) is a tridecapeptide released by the pituitary gland and immunocompetent cells that exerts anti-inflammatory actions and abrogates postischemic injury to the kidneys and brainstem of rodents. To test the hypothesis that alpha-MSH would afford similar protection in the postischemic small intestine, we analyzed the effects of this peptide on intestinal transit, histology, myeloperoxidase activity, and nuclear factor-kappaB (NF-kappaB) activation after 45 min of superior mesenteric artery occlusion and <or=6 h of reperfusion. Rats subjected to I/R exhibited markedly depressed intestinal transit, histological evidence of severe injury to the ileum, increased myeloperoxidase activity in ileal cytoplasmic extracts, and biphasic activation of NF-kappaB in ileal nuclear extracts. In contrast, rats treated with alpha-MSH before I/R exhibited intestinal transit and histological injury scores comparable to those of sham-operated controls. In addition, the alpha-MSH-treated rats demonstrated less I/R-induced activation of intestinal NF-kappaB and myeloperoxidase activity after prolonged (6 h) reperfusion. We conclude that alpha-MSH significantly limits postischemic injury to the rat small intestine.

Early nasogastric tube removal combined with metoclopramide after postchemotherapy retroperitoneal lymph node dissection for metastatic testicular nonseminomatous germ cell tumor

OBJECTIVES

To evaluate the efficacy of combining early nasogastric tube (NGT) removal and metoclopramide after postchemotherapy retroperitoneal lymph node dissection (RPLND) in decreasing complications, time to diet tolerance, and discharge.

METHODS

We performed a retrospective study of 31 patients who underwent postchemotherapy RPLND at the University of Texas M. D. Anderson Cancer Center between 1994 and 1996, who were treated with a clinical care pathway that included NGT removal on postoperative day 1 and immediate use of promotility agents such as metoclopramide. A comparison was made with 42 historic controls treated from 1988 to 1994 who were managed with an NGT until the return of flatus and minimal promotility agents.

RESULTS

Both groups had comparable age, chemotherapy, and surgical procedures. The study group had fewer complications, with an earlier tolerance of solid food (median 5 +/- 2.5 days compared with 7 +/- 5.1 days in controls, P = 0.000) and discharge (median 6 +/- 2.6 days compared with 9 +/- 6.9 days in controls, P = 0.000). NGT replacement was required in 3.2% of study patients versus 9% of controls. Multiple regression analyses demonstrated that the number of NGT days was an independent predictor of early return of bowel function and length of hospitalization (P = 0.000), and metoclopramide was not.

CONCLUSIONS

Early NGT removal combined with metoclopramide after postchemotherapy RPLND allowed earlier diet tolerance and shortened hospital stays without increased complications. The role that promotility agents play as a necessary component of safe, early NGT removal is unclear.

Use of selective opiate receptor inhibitors to prevent postoperative ileus

Ileus is a common postoperative complication after major abdominal surgery. Surgical manipulation of the bowel and stimulation of opiod receptor are the main causes of ileus. An investigational drug (ADL 8-2698, Alvinopam) a selective opioid antagonist with a very low oral absorption was recently introduced to clinical medicine. Unlike other opioid antagonist its activity is restricted to GI tract, it is potent, has a long duration of action, is orally effective, does not readily cross the blood-brain barrier even after intravenous administration in animals. Two randomized controlled clinical studies tested its effects in humans. Liu et al.'s study confirmed peripheral restriction of ADL 8-2698 by its lack of central effect on morphine analgesia and pupil miosis. They also showed that ADL 8-2698 prevents increases in gastrointestinal transit time. Taguchi et al. concluded that high dose (6 mg) of ADL 8-2698 archived fast recovery of gastrointestinal function, without antagonising analgesic efficacy of systemic opioid. In summary, selective inhibition of gastrointestinal opioid receptor by a peripherally restricted oral antagonist speeds recovery of bowel function, shortens times of hospitalization and preserves the analgesic effects of opiods.

Prevention of postoperative ileus

Postoperative ileus (PI) is a major contributor to postoperative morbidity and prolonged convalescence after major surgical procedures. The pathophysiology of PI is multifactorial, including activation of the stress response to surgery, with inhibitory sympathetic visceral reflexes and inflammatory mediators. We update evidence on the advances in the prevention and treatment on PI. As single interventions, continuous thoracic epidural analgesia with local anesthetics and minimally invasive surgery are the most efficient interventions in the reduction of PI. The effects of pharmacological agents have generally been disappointing with the exception of cisapride and the introduction of the new selective peripherally acting m-opioid antagonists. Presently, introduction of a multi-modal rehabilitation programme (including continuous epidural analgesia with local anesthetics, early oral feeding and enforced mobilization) is the most effective technique to reduce PI in abdominal procedures.

Small bowel obstruction following extended right hemicolectomy and subtotal colectomy: assessing the benefit of prophylactic tube splinting

BACKGROUND/AIMS

Small bowel obstruction (SBO) is a frequent complication of extended right hemicolectomy and subtotal colectomy. This study was conducted to assess the prophylactic effectiveness of intestinal tube splinting.

METHODS

Sixteen patients (study group) undergoing extended right hemicolectomy or subtotal colectomy were treated with and 18 patients (controls) without splinting. Clinical, operative and outcome data were entered into a maintained database. The main endpoint was subsequent SBO.

RESULTS

After a follow-up of 2-13 (median 6.5) years, the study group remained free from SBO. After 1-16 years (median 2), four complete and one partial early and one complete and one complete recurrent late SBO occurred in controls.

CONCLUSION

Intestinal tube splinting was comparatively easy and expeditious from a technical point of view after extended hemicolectomy and subtotal colectomy. The procedure eliminated early and up to date also late postoperative SBO in this study and can be considered as a prophylaxis against SBO in this subset of patients.

Results of bowel plication in addition to primary anastomosis in patients with jejunal atresia

BACKGROUND/PURPOSE

Disturbed intestinal transit (DIT) associated with bowel dilation occurs in some postoperative patients with jejunal atresia. Bowel plication (BP) has been introduced to prevent the DIT, but the long-term results of BP are unclear.

METHODS

The authors reviewed the preoperative and operative records and postoperative clinical courses (for 2.3 to 7.0 years; mean period, 3.7 years) of 19 jejunal atresia patients, 4 of whom had undergone additional BP with primary anastomosis after dilated bowel resection or tapering jejunoplasty at neonatal surgery. The degree of DIT was evaluated by the clinical symptoms, weight gain, whether reoperation was performed, and duration from the operation to receiving an oral feeding volume of at least 130 mL/kg/d. The patients then were assigned 4 grades (0 to 3). To determine the presence or absence of bowel dilation at the BP site, the plain abdominal x-rays were reviewed.

RESULTS

(1) Within 2 months after surgery, 4 patients without BP underwent operation because of severe DIT. The degree of postoperative DIT in patients who had received additional BP at neonatal surgery was less than that in patients without BP (mean grade, 0.50 v. 2.08). (2) The preoperative clinical features, operative method, and postoperative weight gain were almost similar in patients with and without BP. (3) On abdominal x-ray the bowel dilation remained 6 to 12 months after the operation, but was not observed over 1 year after the operation.

CONCLUSIONS

In this preliminary study, the addition of BP after tapering jejunoplasty or resection of dilated bowel may be effective in preventing early postoperative DIT. Further study is necessary to evaluate the long-term results of additional BP at neonatal surgery. J Pediatr Surg 36:1752-1756.

Successful management of malignant bowel obstruction

Although perhaps not one of the most common symptoms encountered in specialist palliative care units, health professionals frequently come across malignant bowel obstruction in general hospital wards, emergency rooms and in the community. The age-old approach to management of this problem using a nasogastric tube and intravenous therapy may still have its place for some patients, but specialists in palliative care have pioneered a kinder approach aimed at treating associated symptoms of colicky pain, nausea and vomiting. We owe it to our patients to ensure that all our colleagues are familiar with the most up-to-date treatment of malignant bowel obstruction to minimize distress and enhance quality of life.

Effects of propranolol on human postoperative ileus

BACKGROUND

The sympathetic nervous hyperactivity present in response to surgical stress has been implicated as an important component of the postoperative paralytic ileus. A randomized and prospective study was conducted, evaluating the effects of the preoperative beta-adrenergic blockade with propranolol in schistosomotic patients during the period of postoperative ileus.

METHODS

The study compared schistosomotic patients submitted, or not, to beta-adrenergic blockade. Basal cardiac frequency was determined and propranolol was used in a dose of 40 mg twice a day. The dose was adjusted weekly until a minimum decrease of 20% in cardiac frequency was achieved. Three coupled bipolar electrodes were placed in the left colon in both groups, and registration of myoelectric activity of the left colon was made twice a day during the period of postoperative ileus using a system of data collection (DATA Q Series 200). The electric signals were previously amplified, filtered and separated into Electric Control Activity (ECA) and Electric Response Activity (ERA).

RESULTS

The dose of propranolol varied from 80 to 160 mg/day. The proportional decrease in basal heart frequency varied from 20 to 33%, with an average of 25.4 +/- 3.9% in the propranolol group, maintaining a mean of 24.3 +/- 3.6% decrease in the postoperative period. Differences on clinical recovery of the postoperative ileus were not found. Significant differences on electromyographic patterns were not observed between the groups, except for the presence of a greater number of short-duration contractions in the second postoperative day in the beta-blocked group.

CONCLUSION

The authors suggest that the preoperative beta-adrenergic blockade with propranolol does not determine myoelectric activity changes that could contribute to an earlier resolution of postoperative ileus.

Preoperative intraluminal application of capsaicin increases postoperative gastric and colonic motility in rats

In a model to investigate postoperative gastrointestinal motility with strain gauge transducers in awake rats, we tested the effects of intraluminal capsaicin infusion into the cecum 2 days or 14 days prior to abdominal surgery. Acute infusion of capsaicin into the cecum for 30 minutes increased the gastric, small intestinal, and colonic motility index by up to 115%, 34%, and 59%, respectively, compared to vehicle infusion. Intraluminal capsaicin infusion 2 days prior to abdominal surgery significantly increased the intraoperative gastric and colonic motility index by 166% and 100%, respectively, compared to vehicle, but had no effect on small intestinal motility. The postoperative decrease in gastric or colonic motility was completely prevented by capsaicin pretreatment, representing a 73% and a 72% increase in the motility index during the first postoperative hour and a 40% and a 29% increase in the motility index during the second postoperative hour compared to vehicle, whereas the postoperative decrease in small intestinal motility was not altered by capsaicin pretreatment. In contrast, intraluminal capsaicin infusion 14 days prior to abdominal surgery had no effect on postoperative inhibition of gastrointestinal motility. Our results suggest that capsaicin-sensitive visceral afferent C-fibers, presumably of the submucosa, play an important role in mediating postoperative ileus. Intraluminal capsaicin does probably ablate these nerve fibers temporarily, with no systemic side effects observed with the use of the tail flick test as a measure of skin nociception.

Management of emergent conditions in palliative care

Emergent conditions arising in patients with advanced terminal disease are inevitable and create stressful situations for patients, caregivers, and health care personnel. Discussions regarding appropriate levels of intervention based on parameters such as patient wishes, proper access to documentation of those wishes, location of care, cognitive status and extent of clinical decline are important to have before crisis situations. Common emergencies to be addressed include those that may or may not be associated with advanced malignancies, including compression syndromes, superior vena cava syndrome, hypercalcemia, acute dyspnea, seizures, acute urinary and bowel obstructions, massive hemorrhage, cardiac tamponade, acute embolic phenomenon, and psychiatric emergencies. Although not all clinical scenarios will be addressed in this article, the more common ones will be discussed.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm) have possible short-term beneficial impact?

PURPOSE

The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity.

METHODS

All patients who had Seprafilm placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatory vs. noninflammatory), and urgency of surgery (elective vs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student's t-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test.

RESULTS

Two hundred fifty-nine patients in whom Seprafilm was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm (3.4 percent) and control (1.1 percent) groups.

CONCLUSION

During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.