Morbidity and mortality of inadvertent enterotomy during adhesiotomy

Nanofiber Hydrogel Drug Delivery System for Prevention of Postsurgical Intestinal Adhesion

Intestinal adhesion is one of the complications that occurs more frequently after abdominal surgery. Postsurgical intestinal adhesion (PIA) can lead to a series of health problems, including abdominal pain, intestinal obstruction, and female infertility. Currently, hydrogels and nanofibrous films as barriers are often used for preventing PIA formation; however, these kinds of materials have their intrinsic disadvantages. Herein, we developed a dual-structure drug delivery patch consisting of poly lactic-co-glycolic acid (PLGA) nanofibers and a chitosan hydrogel (NHP). PLGA nanofibers loaded with deferoxamine mesylate (DFO) were incorporated into the hydrogel; meanwhile, the hydrogel was loaded with anti-inflammatory drug dexamethasone (DXMS). The rapid degradation of the hydrogel facilitated the release of DXMS at the acute inflammatory stage of the early injury and provided effective anti-inflammatory effects for wound sites. Moreover, PLGA composite nanofibers could provide sustained and stable release of DFO for promoting the peritoneal repair by the angiogenesis effects of DFO. The in vivo results indicated that NHP can effectively prevent PIA formation by restraining inflammation and vascularization, promoting peritoneal repair. Therefore, we believe that our NHP has a great potential application in inhibition of PIA.

Appraisal of surgical outcomes and oncological efficiency of intraoperative adverse events in robotic radical gastrectomy for gastric cancer

BACKGROUND

Surgical quality control is a crucial determinant of evaluating the tumor efficacy.

OBJECTIVE

To assess the ClassIntra grade for quality control and oncological outcomes of robotic radical surgery for gastric cancer (GC).

METHODS

Data of patients undergoing robotic radical surgery for GC at a high-volume center were retrospectively analyzed. Patients were categorized into two groups, the intraoperative adverse event (iAE) group and the non-iAE group, based on the occurrence of intraoperative adverse events. The iAEs were further classified into five sublevels (ranging from I to V according to severity) based on the ClassIntra grade. Surgical performance was assessed using the Objective Structured Assessment of Technical Skill (OSATS) and the General Error Reporting Tool.

RESULTS

This study included 366 patients (iAE group: n = 72 [19.7%] and non-iAE group: n = 294 [80.3%]). The proportion of ClassIntra grade II patients was the highest in the iAE group (54.2%). In total and distal gastrectomies, iAEs occurred most frequently in the suprapancreatic area (50.0% and 54.8%, respectively). In total gastrectomy, grade IV iAEs were most common during lymph node dissection in the splenic hilum area (once for bleeding [grade IV] and once for injury [grade IV]). The overall survival (OS) and disease-free survival of the non-iAE group were significantly better than those of the iAE group (Log rank P < 0.001). Uni- and multi-variate analyses showed that iAEs were key prognostic indicators, independent of tumor stage and adjuvant chemotherapy (P < 0.001).

CONCLUSION

iAEs in patients who underwent robotic radical gastrectomy significantly correlated with the occurrence of postoperative complications and a poor long-term prognosis. Therefore, utilization and inclusion of ClassIntra grading as a crucial surgical quality control and prognostic indicator in the routine surgical quality evaluation system are recommended.

Association between the antiadhesion membrane and small bowel obstruction after open gastrectomy: A supplemental analysis of the randomized controlled JCOG1001 trial

Aim

Postoperative small bowel obstruction (SBO) is one of the major complications that is mainly caused by postoperative adhesion. Recently, the antiadhesion membrane has become popular for postoperative SBO prevention. However, its efficacy is yet to be confirmed in the gastric cancer surgery field. Here, we conducted the supplemental analysis of the randomized controlled trial JCOG1001 to investigate the efficacy of the antiadhesion membrane on SBO prevention in patients with open gastrectomy for gastric cancer.

Methods

Of the 1204 patients enrolled in JCOG1001, 1200 patients were included. The development of SBO of Grade ≥ IIIa according to the Clavien-Dindo classification was recorded. Univariable and multivariable analyses were performed using the Fine and Gray model to determine the risk factors for SBO.

Results

Fifty-one patients developed SBO (median follow-up duration: 5.6 years). Total gastrectomy, combined resection, and blood loss significantly increased the risk for SBO development in the univariable analysis. Large amount of blood loss was independently associated with SBO development in the multivariable analysis (hazard ratio [HR], 3.089; 95% confidence interval [CI], 1.562-6.109, p = 0.0012). Antiadhesion membrane did not reduce the risk for SBO (HR, 1.299; 95% CI 0.683-2.470; p = 0.4246). In the patients belonging to subgroup analyses who received distal and total gastrectomy, the antiadhesion membrane was not associated with the incidence of SBO.

Conclusions

Antiadhesion membrane did not decrease SBO occurrence rate after open gastrectomy. Therefore, the use of antiadhesion membrane would not be effective for preventing SBO in gastric cancer surgery.

The use of ultrasound sliding sign for prediction of adhesions in women undergoing repeated caesarean section

We carried out this study to validate the use of ultrasound sliding sign to predict intraperitoneal adhesions in women undergoing repeated caesarean section (CS). A cross-section study was performed in women with at least one CS scheduled for an elective CS. We used the sliding sign of the uterus against the anterior abdominal wall to assess intraperitoneal adhesions, positive sliding sign if uterus moved freely and a negative sliding sign if limited mobility. The obstetrician was blind to the ultrasound results, asked to report if adhesions were absent or present during CS to validate accuracy of the sliding sign. We examined 120 women, negative sliding was reported in 54 patients, positive sliding in 66 women. The presence of intra-abdominal adhesions was confirmed in 44/54 cases assigned to the high-risk group, while the prediction of low risk for adhesions confirmed in 66/66 patients with a sensitivity of 100%, specificity of 86.84%. Sliding sign is an effective method to detect intra-abdominal adhesions in women with a history of repeated caesarean delivery.Impact statementWhat is already known on this subject? There has been a dramatic increase in the caesarean section (CS) rate worldwide; repeated CSs may be associated with intraperitoneal adhesions that result in difficulty during the procedure and may be related to bowel or bladder injuries and neonatal morbidities.What do the results of this study add? The sliding sign by ultrasound has a sensitivity of 100%, specificity of 86.84%, a positive predictive value of 81.5, a negative predictive value of 100, and accuracy of 91.67, considering it rapid, easy and reliable method for prediction of intraperitoneal adhesions.What are the implications of these findings for clinical practice and/or future research? The use of sliding sign by ultrasound in cases with repeated CSs offers a good predictor tool for presence of intraperitoneal adhesions and subsequently avoid severe sequels during surgery and good preparation.

The Role of Prophylactic and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Prevention of Peritoneal Metastases in Advanced Colorectal Cancer

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a locoregional therapy that may be combined with cytoreductive surgery (CRS) to treat patients with colorectal cancer and peritoneal metastases (PM). In recent years, three randomized controlled trials (RCTs) have investigated the role of prophylactic or adjuvant HIPEC in preventing the development of PM in patients with high-risk colorectal cancer: PROPHYLOCHIP and COLOPEC evaluated adjuvant HIPEC, and HIPECT4 studied concurrent HIPEC and CRS. Although PROPHYLOCHIP and COLOPEC were negative trials, a great deal may be learned from their methodology, outcome measures, and patient selection criteria. HIPECT4 is the first RCT to show a clinical benefit of HIPEC in high-risk T4 colorectal cancer, demonstrating improved locoregional disease control with the addition of HIPEC to CRS with no increase in the rate of complications. This review critically examines the strengths and limitations of each major trial and discusses their potential impact on the practice of HIPEC. Several additional ongoing clinical trials also seek to investigate the role of HIPEC in preventing PM in advanced colorectal cancer.

Lumbrokinase, a Fibrinolytic Enzyme, Prevents Intra-Abdominal Adhesion by Inhibiting the Migrative and Adhesive Activities of Fibroblast via Attenuation of the AP-1/ICAM-1 Signaling Pathway

Intra-abdominal adhesion is a complication following abdominal surgery caused by the suppression of fibrinolytic activity and aggravated fibroblast invasion of the injured area, which may lead to chronic illnesses such as chronic pain, intestinal obstruction, and female infertility. This study hypothesized that lumbrokinase, a fibrinolytic enzyme extracted from the earthworm, supports the wound healing process. Therefore, we assessed the effect of lumbrokinase on intra-abdominal adhesion. Lumbrokinase treatment significantly decreased the severity and the area of intra-abdominal adhesion in vivo in a dose-dependent manner compared with the controls (untreated and hyaluronate-treated). Lumbrokinase-associated adverse effects were not observed. Immunohistochemical analysis of adhesion tissues revealed a loosened adhesive band between tissues, coupled with significantly decreased peritoneal thickening in the lumbrokinase-treated group versus the control group. Three-dimensional spheroid, MTT, and scratch wound migration assays using the IMR-90 human fibroblast cell line demonstrated that lumbrokinase significantly attenuated the migration and adhesive activity of fibroblasts without compromising cell proliferation. The luciferase assay and western blot analysis showed that lumbrokinase inhibited the AP-1/ICAM-1 cell adhesion signaling pathway. Therefore, lumbrokinase decreases intra-abdominal adhesion and peritoneal thickening by augmenting fibrinolytic action and inhibiting fibroblast migration and adhesive activity via attenuation of the AP-1/ICAM-1 signaling pathway. Lumbrokinase is thus a promising agent to prevent intra-abdominal adhesion.

Economic Consequences of Surgery for Adhesive Small Bowel Obstruction: A Population-Based Study

Background and Aims

Most patients develop adhesions after abdominal surgery, some will be hospitalized with small bowel obstruction (SBO), and some also require surgery. The operations and follow-up are expensive, but recent data of costs are scarce. The aim of this study was to describe the direct costs of SBO-surgery and follow-up, in a population-based setting. The association between cost of SBO and peri- and postoperative data was also studied.

Methods

In a retrospective cohort study, all patients (n = 402) operated for adhesive SBO in Gävleborg and Uppsala counties (2007-2012) were studied. The median follow-up was 8 years. Costs were calculated according to the pricelist of Uppsala University Hospital, Uppsala, Sweden.

Results

Overall total costs were €16.267 million, corresponding to a mean total cost per patient of €40,467 during the studied period. Diffuse adhesions and postoperative complications were associated with increased costs for SBO in a multivariable analysis (P < 0.001). Most costs, about €14 million (85%), arouse in conjunction with the SBO-index surgery period. In-hospital stay was the dominating cost, accounting for 70% of the total costs.

Conclusion

Surgery for SBO generates substantial economic burden for healthcare systems. Measures that reduce the incidence of SBO, the frequency of postoperative complication, or the length of stay have the potential to reduce this economic burden. The cost estimates from this study may be valuable for future cost-benefit analyses in intervention studies.

Preoperative prediction of inadvertent enterotomy during adhesive small bowel obstruction surgery using combination of CT features

OBJECTIVES

The purpose of this study was to identify the preoperative CT features that are associated with inadvertent enterotomy (IE) during adhesive small bowel obstruction (ASBO) surgery.

METHODS

From January 2015 to December 2019, all patients with ASBO who underwent an abdominal CT were reviewed. Abdominal CT were retrospectively reviewed by two radiologists with a consensus read in case of disagreement. IE during ASBO surgery was retrospectively recorded. Univariate and multivariate analyses of CT features associated with IE were performed and a simple CT score was built to stratify the risk of IE. This score was validated in an independent retrospective cohort. Abdominal CT of the validation cohort was reviewed by a third independent reader.

RESULTS

Among the 368 patients with ASBO during the study period, 169 were surgically treated, including 129 ASBO for single adhesive band and 40 for matted adhesions. Among these, there were 47 IE. By multivariate analysis, angulation of the transitional zone (OR = 4.19, 95% CI [1.10-18.09]), diffuse intestinal adhesions (OR = 4.87, 95% CI [1.37-19.76]), a fat notch sign (OR = 0.32, 95% CI [0.12-0.85]), and mesenteric haziness (OR = 0.13, 95% CI [0.03-0.48]) were independently associated with inadvertent enterotomy occurrence. The simple CT score built to stratify risk of IE displayed an AUC of 0.85 (95% CI [0.80-0.90]) in the study sample and 0.88 (95% CI [0.80-0.96]) in the validation cohort.

CONCLUSION

A simple preoperative CT score is able to inform the surgeon about a high risk of IE and therefore influence the surgical procedure.

KEY POINTS

• In this retrospective study of 169 patients undergoing abdominal surgery for adhesive small bowel obstruction, 47 (28%) inadvertent enterotomy occurred. • A simple preoperative CT score enables accurate stratification of inadvertent enterotomy risk (area under the curve 0.85). • By multivariable analysis, diffuse intestinal adhesions and angulation of the transitional zone were predictive of inadvertent enterotomy occurrence.

Classification of intraoperative adverse events in visceral surgery

BACKGROUND

Intraoperative adverse events (iAEs) are frequent in visceral surgery, but severity and related postoperative outcome are poorly investigated. A novel classification of intraoperative adverse events, ClassIntra, includes surgical and anesthesiologic intraoperative adverse events using 5 severity grades and showed a high criterion and construct validity across all surgical disciplines. ClassIntra was studied for reproducibility in a prespecified group of patients undergoing visceral surgery.

METHODS

iAEs were recorded in all patients enrolled in the ClassIntra validation study (NCT03009929). Postoperative complications were assessed daily according to the Clavien-Dindo classification. Results of the visceral group were compared with those of the non-visceral group and the full cohort. The risk-adjusted association between most severe intra and postoperative complications was investigated in a multivariable proportional odds model. Second, risk-adjusted association between ClassIntra grade and Comprehensive Complication Index, and postoperative length of stay was investigated.

RESULTS

In total, 1,270 out of 2,520 patients (50%) underwent visceral surgery. Compared with the nonvisceral group and full cohort, more intraoperative (337/1270 [27%] vs 273/1250 [22%] vs 610/2520 [24%] patients) and postoperative complications (457/1270 [36%] vs 381/1250 [30%] vs 838/2520 [33%] patients) occurred. The risk for a more severe postoperative complication increased with each ClassIntra grade (odds ratio [95% confidence interval] I vs 0 1.10 [0.73 to 1.66], II vs 0 1.69 [1.10 to 2.60], III vs 0 2.31 [1.21 to 4.41], IV vs 0 2.35 [0.69 to 8.06]). Accordingly, CCI and postoperative length of stay increased with each ClassIntra grade in the visceral group, comparable with the nonvisceral and full cohort.

CONCLUSION

Consistent results for the association of intraoperative adverse events and patient outcomes render ClassIntra a valuable instrument in visceral surgery.

Can minimally invasive surgical techniques reduce the incidence of postoperative adhesions?

<br><b>Introduction:</b> Postoperative intra-abdominal adhesions are a clinical condition that may develop after any abdominal surgery and constitute the leading cause of mechanical small bowel obstructions.</br> <br><b>Aim:</b> This study investigates factors which influence the formation of postoperative adhesion and evaluates the efficiency of applying minimally invasive surgical techniques in reducing adhesion.</br> <br><b>Material and methods:</b> Patients who underwent surgery to diagnose obstructive ileus in our clinic between January 2015 and January 2020 were analyzed retrospectively. Demographic data of the patients, operation details time between the operations and history of hospitalizations, postoperative mortality and morbidity, as well as the severity of complications were recorded. The patients included in the study were divided into groups according to the surgical technique applied in the first operation (laparoscopy/ laparotomy), the abdominal incision line (upper/lower/total), and the etiology of the primarily operated lesion (benign/malignant).</br> <br><b>Results:</b> One hundred eighteen (118) patients were included in the study. The mean age of patients was 61.2 ± 10.8 (39–82) years. Age, ileus history, time to the onset of ileus, length of hospital stay and the number of complications were shorter in the laparoscopy group as compared to the laparotomy group and the difference was found to be statistically significant. In addition, when patients were categorized according to the abdominal incision line, fewer hospitalizations and more frequent postoperative complications due to ileus were observed in the sub-umbilical incision group (p < 0.05).</br> <br><b>Conclusions:</b> Postoperative adhesion formation is currently one of the clinical conditions which pose a challenge to both the patient and the clinician due to its incidence and recurrence. However, adhesion formation can be reduced by applying minimally invasive surgical methods, especially laparoscopic surgery and precise maneuvers during surgery.</br>

[Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons]

OBJECTIVE

To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines.

MATERIAL AND METHODS

Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues.

RESULTS

There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question.

CONCLUSION

This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.

Prevention of Intra-Abdominal Adhesions Using the Combination of Mediclore® and a Statin

PURPOSE

This study investigated the antiadhesive effects of Mediclore®, rosuvastatin, and a combination of Mediclore and rosuvastatin in a rat adhesion model.

METHODS

The adhesion models (a total of 58 adult male rats) were divided into 4 groups. The control group (group C) received no special materials except for a saline. The experimental groups were treated with 5 mL of Mediclore (group M), rosuvastatin (group R), or rosuvastatin and Mediclore (group RM), and these materials were intraperitoneally placed under the incision. At postoperative day 14, the rats underwent re-laparotomy and adhesiolysis. Three investigators blinded to group assignment scored the extent of adhesion formation, the numbers of remote adhesions, and the extent of acute/chronic inflammation, fibrosis, edema, and congestion on resected specimens via histologic examination.

RESULTS

The macroscopic adhesion score in group RM (7.27 ± 3.51) was significantly lower than those in groups C (13.36 ± 2.24) and R (11.71 ± 1.98); group M (9.13 ± 4.09) had a significantly lower adhesion score than group C. The number of remote adhesions was significantly lower in groups R and RM than in group C. The acute inflammation score, chronic inflammation score, and fibrosis score in group RM; the acute inflammation score in group R; and the fibrosis score in group M were significantly lower than those in group C.

CONCLUSION

The intraperitoneal application of Mediclore and a combination of Mediclore and rosuvastatin effectively reduced postoperative adhesions.

Perforated Colon Cancer Associated With Post-operative Recurrent Bowel Perforations

Colon perforation is a major life-threatening condition associated with high morbidity and mortality, which often develops secondary to complicated diverticulitis and, less commonly, colon cancer. We describe the case of a 51-year-old female who had perforated colon cancer with concurrent diverticulosis. Based on history, physical exam, laboratory, and computed tomography (CT) findings on initial presentation, the patient was diagnosed with acute complicated diverticulitis. Despite medical treatment, the patient’s condition worsened, warranting exploratory laparotomy and a left hemicolectomy with transverse end colostomy creation. Surgical pathology revealed stage IIIC colon cancer without evidence of diverticulitis. The patient underwent eight cycles of adjuvant chemotherapy with FOLFOX (folinic acid, fluorouracil, and oxaliplatin). Over the next year, the patient experienced recurrent bowel perforations requiring repeated surgeries. Perforations were identified in both the small and large bowel on different occasions. Even though neither presented with a clear etiology, possible ischemic, infectious, erosive, and iatrogenic etiologies were on the differential. Our case exemplifies the mounting complications we should be wary of when performing repeated invasive abdominal operations.

Nanostructured Non-Newtonian Drug Delivery Barrier Prevents Postoperative Intrapericardial Adhesions

With the increasing volume of cardiovascular surgeries and the rising adoption rate of new methodologies that serve as a bridge to cardiac transplantation and that require multiple surgical interventions, the formation of postoperative intrapericardial adhesions has become a challenging problem that limits future surgical procedures, causes serious complications, and increases medical costs. To prevent this pathology, we developed a nanotechnology-based self-healing drug delivery hydrogel barrier composed of silicate nanodisks and polyethylene glycol with the ability to coat the epicardial surface of the heart without friction and locally deliver dexamethasone, an anti-inflammatory drug. After the fabrication of the hydrogel, mechanical characterization and responses to shear, strain, and recovery were analyzed, confirming its shear-thinning and self-healing properties. This behavior allowed its facile injection (5.75 ± 0.15 to 22.01 ± 0.95 N) and subsequent mechanical recovery. The encapsulation of dexamethasone within the hydrogel system was confirmed by ¹H NMR, and controlled release for 5 days was observed. In vitro, limited cellular adhesion to the hydrogel surface was achieved, and its anti-inflammatory properties were confirmed, as downregulation of ICAM-1 and VCAM-1 was observed in TNF-α activated endothelial cells. In vivo, 1 week after administration of the hydrogel to a rabbit model of intrapericardial injury, superior efficacy was observed when compared to a commercial adhesion barrier, as histological and immunohistochemical examination revealed reduced adhesion formation and minimal immune infiltration of CD3+ lymphocytes and CD68+ macrophages, as well as NF-κβ downregulation. We presented a novel nanostructured drug delivery hydrogel system with unique mechanical and biological properties that act synergistically to prevent cellular infiltration while providing local immunomodulation to protect the intrapericardial space after a surgical intervention.

Risk factors of postoperative adhesive bowel obstruction in children with complicated appendicitis

PURPOSE

Postoperative adhesive bowel obstruction (ABO) is a common complication especially in complicated appendicitis. This study aimed to analyze the risk factors for ABO following appendectomy in children with complicated appendicitis, and establish a scoring model for predicting postoperative ABO and treatment option to relieve the obstruction.

METHODS

From December 2014 to January 2020, all files of consecutive patients with complicated appendicitis underwent appendectomy were reviewed. Univariate and multivariate analyses were used to screen out the risk factors of postoperative ABO, and establish a scoring model for predicting postoperative ABO and surgical relief to relieve the obstruction.

RESULTS

Of the 780 patients, 87 (11.2%) had ABO following appendectomy, including 27 who underwent surgical relief. Age ≤ 6 years, overweight and obesity, duration of symptoms ≥ 36 h, C-reactive protein ≥ 99 mg/L, duration of operation ≥ 60 min, intraoperative peritoneal lavage, and postoperative flatus time ≥ 20 h were independent risk factors for postoperative ABO. The final scoring model for postoperative ABO included factors above, and exhibited a high degree of discrimination (area under the curve [AUC]: 0.937; 95% confidence interval [CI] 0.913-0.960) corresponding to an optimal cut-off value of 6: 82.8% sensitivity, 92.6% specificity. Furthermore, the scoring model showed a sensitivity of 74.1% and a specificity of 91.7% for patients wo underwent surgical relief to relieve obstruction with the optimal cut-off value of 9.

CONCLUSION

Risk factors for postoperative ABO should be taken seriously in children with complicated appendicitis. The scoring model is a novel but promising method to predict postoperative ABO and provide reference for clinical decision-making to relieve the obstruction.

Peritoneal Adhesions and their Prevention - Current Trends

The development of adhesions after gynecologic surgery is a severe problem with ramifications that go beyond the medical complications patients suffer (which most often include pain, obstruction and infertility), since they also impose a huge financial burden on the health care system and increase the workload of surgeons and all personnel involved in surgical follow-up care. Surgical techniques to avoid adhesion formation have not proven to be sufficient and pharmaceutical approaches for their prevention are even less effective, which means that the use of adhesion prevention devices is essential for achieving decent prophylaxis. This review explores the wide range of adhesion prevention products currently available on the market. Particular emphasis is put on prospective randomized controlled clinical trials that include second-look interventions, as these offer the most solid evidence of efficacy. We focused on adhesion scores, which are the most common way to quantify adhesion formation. This enables a direct comparison of the efficacies of different devices. While the greatest amount of data are available for oxidized regenerated cellulose, the outcomes with this adhesion barrier are mediocre and several studies have shown little efficacy. The best results have been achieved using adhesion barriers based on either modified starch, i.e., 4DryField® PH (PlantTec Medical GmbH, Lüneburg, Germany), or expanded polytetrafluoroethylene, i.e., GoreTex (W.L. Gore & Associates, Inc., Medical Products Division, Flagstaff, AZ), albeit the latter, as a non-resorbable barrier, has a huge disadvantage of having to be surgically removed again. Therefore, 4DryField® PH currently appears to be a promising approach and further studies are recommended.

Effectiveness of barrier agents for preventing postoperative bowel obstruction after laparoscopic surgery: a retrospective cohort study

PURPOSE

The effectiveness of using anti-adhesion agents in laparoscopic surgery is controversial. We compared the outcomes of patients exposed to anti-adhesion agents (barrier group) with those of patients not exposed (no barrier group) in laparoscopic surgery.

METHODS

Using a nationwide claim-based database in Japan, we analyzed data from patients who underwent laparoscopic surgery between 2005 and 2019 and compared the patient characteristics and the proportion of those with bowel obstruction between the barrier and no barrier groups. We also performed several sensitivity and subgroup analyses.

RESULTS

Of the 57,499 patients who met the inclusion criteria, 14,360 and 43,139 were assigned to the barrier and no barrier groups, respectively. The proportion of patients with a bowel obstruction in the two groups did not differ among all patients hospitalized for obstruction (1.1 vs. 1.1%, p = 0.63) and those requiring surgery (0.2 vs. 0.2%, p = 0.39). In the sensitivity analysis with propensity score matching, the incidences of bowel obstruction between the barrier and non-barrier groups were equivocal (1.3 vs. 1.6%), but statistically marginal (chi-square test, p = 0.035; log-rank test, p = 0.09).

CONCLUSION

The use of barrier agents for adhesive prevention did not show clear effectiveness for the prevention of bowel obstruction after laparoscopic surgery for unselected cases. Further studies focusing on more specific procedures are needed.

Skin Color May Predict Intra-Abdominal Adhesions During Repeated Caesarean Section Deliveries

OBJECTIVE

Caesarean rates have increased rapidly for various reasons recently. One of the important reasons among these is medicolegal problems. Our aim with this study was to preoperatively predict abdominal adhesion density by combining the scar tissue morphology formed in the post-caesarean Pfannenstiel incision line and the skin color scoring of the patients.

MATERIAL AND METHODS

Patients who had undergone one caesarean section previously, completed their terms (37-39 weeks) and were under 35 years old were included in the study. Skin color scoring of the patients was performed using the Fitzpatrick skin color scale. Intra-abdominal adhesion scoring of the participant patients was performed using Nair's adhesion scoring system.

RESULTS

The change in abdominal adhesion scores was evaluated based on the Fitzpatrick color scale. Adhesion scores per the Nair intra-abdominal adhesion scoring system were found to be 0.04±0.209 in the FP1 group, 0.35±0.662 in the FP2 group, 1.58±0.923 in the FP3 group, and 2.33±0.577 in the FP4 group (p<0.05). These results showed a significant increase in adhesion density with increasing skin color darkness. Based on these results, it was observed that the abdominal adhesion scores and the frequency of depressed skin scar were significantly increased with increasing Fitzpatrick scores (p<0.05).

CONCLUSION

The aim of this study was to increase the prediction rates by adding the skin color scoring to the scar tissue characteristics, which have been used in previous studies. The results of this study indicate that the combination of these two parameters may be more effective in predicting intra-abdominal adhesions. Nevertheless, there is a need for studies with a much higher number of patients and multiple parameters to be able to predict intra-abdominal adhesion density preoperatively with greater accuracy.

Association Between Statin Use at the Time of Intra-abdominal Surgery and Postoperative Adhesion-Related Complications and Small-Bowel Obstruction

IMPORTANCE

Adhesion-related complications (ARCs), including small-bowel obstruction, are common complications of intra-abdominal surgery. Statins, which have antifibrotic pleiotropic effects, inhibit adhesion formation in murine models but have not been assessed in humans.

OBJECTIVE

To assess whether statin use at the time of intra-abdominal surgery is associated with a reduction in ARCs.

DESIGN, SETTING, AND PARTICIPANTS

These 2 separate retrospective cohort studies (The Health Improvement Network [THIN] and Optum's Clinformatics Data Mart [Optum]) compared adults receiving statins with those not receiving statins at the time of intra-abdominal surgery. Individuals undergoing intra-abdominal surgery from January 1, 1996, to December 31, 2013, in the United Kingdom and from January 1, 2000, to December 31, 2016, in the US were included in the study. Those with obstructive events before surgery or a history of inflammatory bowel disease were excluded. Data analysis was performed from September 1, 2012, to November 24, 2020.

EXPOSURE

The primary exposure was statin use at the time of surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was ARCs, defined as small-bowel obstruction or need for adhesiolysis, occurring after surgery. Sensitivity analyses included statin use preceding but not concurrent with surgery, fibrate use, and angiotensin-converting enzyme inhibitor use. All analyses were adjusted for age, sex, and conditions associated with microvascular disease, such as hypertension, hyperlipidemia, obesity, and tobacco use; surgical approach and site; and diagnosis of a malignant tumor.

RESULTS

A total of 148 601 individuals met the inclusion criteria for THIN (mean [SD] age, 49.6 [17.7] years; 70.1% female) and 1 188 217 for Optum (mean [SD] age, 48.2 [16.4] years; 72.6% female). A total of 2060 participants (1.4%) experienced an ARC in THIN and 54 136 (4.6%) in Optum. Statin use at the time of surgery was associated with decreased risk of ARCs (THIN: adjusted hazard ratio [HR], 0.81; 95% CI, 0.71-0.92; Optum: adjusted HR, 0.92; 95% CI, 0.90-0.95). Similar associations were appreciated between statins and small-bowel obstruction (THIN: adjusted HR, 0.80; 95% CI, 0.70-0.92; Optum: adjusted HR, 0.88; 95% CI, 0.85-0.91).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, among individuals in 2 separate cohorts undergoing intra-abdominal surgery, statin use may be associated with a reduced risk of postoperative ARCs. Statins may represent an inexpensive, well-tolerated pharmacologic option for preventing ARCs.

Risk factors for small bowel obstruction after open rectal cancer resection

Background

Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery.

Methods

A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed.

Results

In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129–7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO.

Conclusions

One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Adhesions after Laparoscopic Myomectomy: Incidence, Risk Factors, Complications, and Prevention

Uterine fibroids or uterine myomas are one of the most common benign diseases of the uterus. Symptoms associated with myomas can make surgical removal of myomas necessary. Besides the traditional abdominal route, laparoscopic myomectomy (LM) has gained more acceptances over the last few decades, and it is anticipated that laparoscopy is associated with lower adhesion development. Therefore, we conducted this review to analyze the evidence on adhesions after LM. The PubMed database was searched using the search terms “myomectomy” alone and in combination with “adhesions,” “infertility OR fertility outcome,” and “laparoscopy” among articles published in English and German. Although the well-known advantages of laparoscopy, for example, less pain, less blood loss, or shorter hospital stay, myomectomy belongs to high-risk operations concerning adhesion formation, with at least every fifth patient developing postsurgical adhesions. In laparoscopic surgery, surgeons´ experience as well tissue trauma, due to desiccation and hypoxia, are the underlying mechanisms leading to adhesion formation. Incisions of the posterior uterus may be associated with a higher rate of adhesions compared to anterior or fundal incisions. Adhesions can be associated with severe complications such as small bowel obstruction, chronic pelvic pain, complications in further operations, or impaired fertility. Tissue trauma and the experience of the surgeon in laparoscopic surgery are most of the influencing factors for adhesion formation after myomectomy. Therefore, every surgeon should adopt strategies to reduce adhesion development in daily routine, especially when it conducted to preserve or restore fertility.

Therapeutic effect of gastrografin and predictors of operative intervention in patients with adhesive small bowel obstruction: A randomized controlled study

Objectives

The study aimed to investigate the therapeutic effect of gastrografin for the conservative treatment of patients with adhesive small bowel obstruction (ASBO) and to identify the predictors of failure of conservative treatment in these patients.

Material and Methods

A randomized controlled trial was conducted on 52 patients with the diagnosis of ASBO in 2016. 100 mL of Gastrografin and 100 mL of 0.9% saline solution were gavaged through the nasogastric tube in the case (n= 26) and control (n= 26) groups, respectively. Patients in the case group were subjected to plain abdominal X-Rays at 12, 24 and 48 hours after administration of gastrografin.

Results

Fifty-two patients with a mean age of 57.6 ± 11.4 years (range 37-81), including 34 (65.4%) males were enrolled into the study. The number of patients who were successfully conservatively treated in the case group was 21 (80.8%), which was significantly higher than 13 (50%) in the control group (p= 0.04). Among these patients, mean hospital stay in the case group was 37.2 ± 5.5 hours (range 28-46), which was significantly shorter than 45.8 ± 9.2 hours (range 36-61) in the control group (p= 0.004). In multivariate analysis, more than one previous laparotomy was the only predictor of failure of conservative treatment (p <0.001).

Conclusion

Gastrografin may be associated with improvement of patients with ASBO. Lower number of previous laparotomies may be a predictor of successful conservative treatment of these patients.

Post-surgical adhesions are triggered by calcium-dependent membrane bridges between mesothelial surfaces

Surgical adhesions are bands of scar tissues that abnormally conjoin organ surfaces. Adhesions are a major cause of post-operative and dialysis-related complications, yet their patho-mechanism remains elusive, and prevention agents in clinical trials have thus far failed to achieve efficacy. Here, we uncover the adhesion initiation mechanism by coating beads with human mesothelial cells that normally line organ surfaces, and viewing them under adhesion stimuli. We document expansive membrane protrusions from mesothelia that tether beads with massive accompanying adherence forces. Membrane protrusions precede matrix deposition, and can transmit adhesion stimuli to healthy surfaces. We identify cytoskeletal effectors and calcium signaling as molecular triggers that initiate surgical adhesions. A single, localized dose targeting these early germinal events completely prevented adhesions in a preclinical mouse model, and in human assays. Our findings classifies the adhesion pathology as originating from mesothelial membrane bridges and offer a radically new therapeutic approach to treat adhesions.

Surgical adhesions are organ-joining bands of scar tissue that remain clinically untreatable. Here, the authors show that adhesions are formed through expansive mesothelial membrane bridges, and that blocking these with small molecules prevents formation of adhesions in mice.

[Influence of unmodified and modified sutures on experimental abdominal adhesive process]

OBJECTIVE

Experimental assessment of the effect of modified and unmodified surgical suture material on abdominal adhesive process.

MATERIAL AND METHODS

The study was performed on male rats of the Wistar subpopulation. There were 5 animals in each group. In all animals, midline abdominal incision was followed by suturing the parietal peritoneum with modified and unmodified suture material. All animals were euthanized with carbon dioxide vapors in 14 days after surgery. Macro- and microscopic assessment of severity of abdominal adhesive process was carried out. Two types of preparation of excised complexes 'peritoneum-suture material-adhesion' were applied for histological examination: paraffin sections and embedding in epoxy resin. Specimens were stained by Van Gieson and with methylene blue solution. Histological specimens were examined using Axio Imager A1 light microscope (Zeiss, Germany).

RESULTS

Polypropylene filaments result extensive adhesions occupying about 75% of the area. Adhesions have a dense structure with signs of vascularization. Modification of suture material with solution of polyhydroxybutyrate/hydroxyvalerate and heparin reduce severity of adhesions. The use of modified suture material was followed by adhesions with more loose structure, no signs of vascularization. Adhesions occupied less than 25% of the area. Histological examination of excised complexes 'peritoneum-suture material-adhesion' revealed accumulation of inflammatory cells around the unmodified suture material, while there were no signs of tissue inflammatory process around the modified sutures.

CONCLUSION

Application of polyhydroxybutyrate/hydroxyvalerate and heparin on the surface of surgical sutures is an effective method for prevention of abdominal adhesions.

The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery

PURPOSE

We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD).

METHODS

This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery.

RESULTS

We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02).

CONCLUSION

Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.

Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre

BACKGROUND AND AIMS

Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported.

METHODS

Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records.

RESULTS

A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2.

CONCLUSIONS

IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.

What's New in the Management of Incarcerated Hernia

Management of incarcerated hernias is a common issue facing general surgeons across the USA. When hernias are not able to be reduced, surgeons must make decisions in a short time frame with limited options for patient optimization. In this article, we review assessment and management options for incarcerated ventral and inguinal hernias.

The effect of Allium sativum in experimental peritoneal adhesion model in rats

Purpose:

To evaluate the effect of garlic on formation of postoperative adhesions in rats.

Methods:

Twenty-four Sprague dawley rats were divided into three groups. In Group 1 (sham), laparotomy was performed and stitched up. In Group 2 (control), after laparotomy was performed, punctate hemorrhage was induced by cecal abrasion in the cecum and 2 cc of saline was intraperitoneally administered to each rat. In Group 3 (experimental), after laparotomy was performed, punctate hemorrhage was induced by cecal abrasion in the cecum and each rat was intraperitoneally administered a sterile Allium sativum derivative. The rats in all groups were re-laparotomized on postoperative day 7; samples were obtained from the peritoneal tissue surrounding the cecum

Results:

In Group 3, there was a statistically significant difference in terms of inflammation, lymph node size, and free oxygen radicals; these parameters tended to increase. In terms of fibrosis evaluated using H&E and MT, there was no significant difference between groups 2 and 3.

Conclusions:

No positive outcomes indicating that Allium sativum reduces intra-abdominal adhesions were obtained. However, it caused severe inflammation in the tissue. Additionally, in immunohistochemical analyses conducted to detect oxidative stress, allium sativum increased the production of free oxygen radicals in the tissue.

Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study

Background

Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery.

Methods

A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed.

Results

Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively.

Conclusion

The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.

Preoperative Pneumoperitoneum: Low-Risk Surgical Adjunct to the Surgical Management of Dense Abdominal Adhesions

Surgical lysis of intra-abdominal adhesions is associated with a high rate of complications. This brief report presents 24 patients with dense intra-abdominal adhesions who underwent preoperative progressive pneumoperitoneum (PPP) prior to surgical lysis of adhesions. PPP was successfully performed in 23 patients, with few adverse events, resulting in subjectively improved ease of intraoperative tissue dissection. One patient withdrew due to intractable pain during insufflation. The results suggest that PPP is a low-risk technique with the potential to improve access to intra-abdominal structures in patients for whom conventional surgical therapy is predicted to carry a high rate of complications.

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

BACKGROUND

Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection.

AIMS

The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis.

METHODS

During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years.

RESULTS

Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters.

CONCLUSION

This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction

BACKGROUND/PURPOSE

We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO).

METHODS

Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared.

RESULTS

Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42.

CONCLUSIONS

Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Outcomes of Ileal Pouch Excision: an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Analysis

BACKGROUND

This study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE).

METHODS

ACS-NSQIP database was queried for patients who underwent PE between 2005 and 2015. Main outcome measures were 30-day mortality, major morbidity, overall surgical site infections (SSI), reoperation, and length of stay (LOS). Risk factors associated with these outcomes were assessed using multivariate logistic or quantile regression.

RESULTS

Three hundred eighty-one patients underwent PE (mean age 47.7(±15.3) years; 51.7% female). Mean body mass index (BMI) was 24.6(±5.7) kg/m², 55.4% were ASA class 1-2 and 18.4% were immunosuppressed. Mean operative time was 252(±112.7) min, 98% were elective cases, and median LOS was 7(5-11) days. Twenty-eight percent experienced major morbidity, including SSIs (21.5% overall, 9.2% superficial, 3.7% deep, 10.3% organ space), sepsis (9.5%), urinary tract infection (5.8%), and postoperative pneumonia (2.4%). The observed venous thromboembolism rate was low, with 0.5 and 0.8% of patients suffering pulmonary embolism and deep vein thrombosis, respectively; 5.5% required reoperation. Postoperative mortality was 0.8%. On multivariate logistic regression, smoking (OR 3.03 [95% CI 1.56, 5.88]) and operative time (OR 1.003 [95% CI 1.0003, 1.0005) were associated with increased odds of major morbidity. Smoking (OR 3.29 [95% CI 1.65, 6.54]) and operative time (OR 1.002 [95% CI 1.000, 1.004]) were independent risk factors for overall SSI. LOS was significantly increased in patients with major morbidity (3.29 days [95% CI 1.60, 4.99]) and increased operative time (0.013 days [95% CI 0.007, 0.018]).

CONCLUSIONS

PE is an operation with significant risk of morbidity. However, mortality was low in the present cohort of patients. Patients who were smokers and had longer operative time had increased risk of overall infectious complications and major morbidity. Furthermore, major morbidity and operative time were associated with increased hospital length of stay following PE.

A Significant Proportion of Small Bowel Obstructions Require >48 Hours to Resolve After Gastrografin

BACKGROUND

Gastrografin (GG)-based nonoperative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO). Absence of X-ray evidence of GG in the colon after 8 h is predictive of the need for operation, and a recent trial used 48 h to prompt operation. We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen.

METHODS

A post hoc analysis of an Eastern Association for the Surgery of Trauma multi-institutional SBO database was performed including only those receiving GG challenge. Successful nonoperative management (NOM) was defined as passage of flatus or nasogastric tube (NGT) removal. NOM was considered a failure if operative intervention was required. Multiple logistic regression was performed to identify predictors of delayed (>48 h) GG challenge effect and expressed as odds ratios with 95% confidence intervals.

RESULTS

Of 286 patients receiving GG, 208 patients (73%) were successfully managed nonoperatively. A total of 60 (29%) NOM patients had NGT decompression for >48 h (n = 54) or required >48 h to pass flatus (n = 34), with some requiring both (n = 28). Prior abdominal operations and SBO admission were protective of delayed GG effect (0.411 [0.169-1.00], P < 0.05; 0.478 [0.240-0.952], P < 0.036).

CONCLUSIONS

A significant proportion of patients at 48 h (29%) "failed" the GG challenge as they had yet to pass flatus or still required NGT but were nonetheless successfully managed nonoperatively. Extending the GG challenge beyond 48 h may help avoid unnecessary operations.

LEVEL OF EVIDENCE

Level II.

Laparoscopic Colorectal Surgery in Patients With Previous Abdominal Surgery: A Single-center Experience and Literature Review

To present the outcomes of laparoscopic colorectal surgery in colorectal cancer patients with a previous history of abdominal surgery. Data of a total of 121 patients with primary colorectal cancer who underwent laparoscopic surgery were retrospectively analyzed. The patients were divided into 2 groups as those with previous abdominal surgery (PAS, n=34) and those without (non-PAS, n=87). Gastric and colonic surgeries were the most common procedures in the major PAS group, whereas gynecologic and obstetric surgeries and appendectomy were the most common procedures in the minor PAS group. However, there were statistically significant differences in the overall complication rates, wound complications, and anastomotic leaks, although there were no significant differences in the rates of postoperative ileus, pneumonia, port site herniation, and postoperative bleeding between the groups. Our study results suggest that laparoscopic colorectal surgery can be safely performed in patients with colorectal cancer who underwent abdominal surgery previously.

Human-Derived Amniotic Membrane Is Associated With Decreased Postoperative Intraperitoneal Adhesions in a Rat Model

BACKGROUND

Complications from adhesions after intra-abdominal surgery accounts for ~6% of hospital admissions. Currently, hyaluronate/carboxymethylcellulose represents the main option to prevent postoperative adhesion formation. Human amniotic membrane contains inherent anti-inflammatory properties that mitigate adhesion formation.

OBJECTIVE

This study aimed to evaluate adhesion generation after surgical trauma with amniotic membranes compared with standard intraperitoneal adhesion barriers.

DESIGN

This study is a double-blinded, prospective evaluation.

SETTING

This study was conducted at an animal research facility.

ANIMALS

Forty male rats were studied.

INTERVENTION

Laparotomy was performed with peritoneal disruption to the cecum. Animals were randomly assigned to 1 of 5 groups: sham, control, saline, hyaluronic acid membrane, or amniotic membrane. Animals were euthanized at 14 days.

MAIN OUTCOME MEASURES

Independent gross and histological assessments of adhesions were analyzed between groups by using adhesion scoring and microscopy. Scoring was based on the percentage of the cecum involved (0-4), vascularity of adhesions (0-3), strength (0-3), inflammation (0-3), and fibrosis (0-3). Adhered tissue was harvested for polymerase chain reaction analysis for gene regulation activity.

RESULTS

All rats survived 14 days. Adhesions were observed in all animals. There were significantly fewer adhesions in the amniotic membrane group (2) versus hyaluronic acid (3) group (p = 0.01). The percentage of adhesion to the cecum was lower in the amniotic membrane group (29%) than in the hyaluronic acid group (47%, p = 0.04). Histological examination showed no significant difference between or within the 3 groups for inflammation or fibrosis. Genetic analysis of adhered tissues supported high rates of epithelialization and inhibition of fibrosis in the amniotic membrane group.

LIMITATIONS

We are limited by the small sample size and the preclinical nature of the study.

CONCLUSION

Human-derived amniotic membrane is effective at reducing intraperitoneal adhesion after surgical trauma and is superior to the current antiadhesion barriers. Amniotic membranes are well absorbed and demonstrate short-term safety. See Video Abstract at http://links.lww.com/DCR/A554.

An in vivo analysis of safe laparoscopic grasping thresholds for colorectal surgery

Background

Analysis of safe laparoscopic grasping thresholds for the colon has not been performed. This study aimed to analyse tissue damage thresholds when the colon is grasped laparoscopically, correlating histological changes to mechanical compressive forces.

Methods

An instrumented laparoscopic grasper was used to measure the forces applied to porcine colon, with data captured and plotted as a force–time (f–t) curve. Haematoxylin and eosin histochemistry of tissue subjected to 10, 20, 40, 50 and 70 N for 5, 30 and 60 s was performed, and the area of colonic circular and longitudinal muscle was compared in grasped and un-grasped regions. The area under the f–t curve was calculated as a measure of the accumulated force applied, known as the force–time product (FTP).

Results

FTP ranged from 55.7 to 3793 N.s. Significant differences were observed between the muscle area of the grasped and un-grasped regions in both longitudinal and circular muscle at 50 N and above for all grasping times. For the longitudinal muscle, significant differences were observed between grasped and un-grasped areas at 20 N force for 30 s (mean difference = 59 mm², 95% CI 41–77 mm², P = 0.04), 20 N force for 60 s (mean difference = 31 mm², 95% CI 21.5–40.5 mm², P = 0.006) and 40 N force for 30 s (mean difference 37 mm², 95% CI 27–47 mm², P = 0.006). Changes in histology correlated with mechanical forces applied to the longitudinal muscle at a FTP over 300 N s.

Conclusions

This study characterizes the grasping forces that result in histological changes to the colon and correlates these with a mechanical measurement of the applied force. The findings will contribute to the development of smart laparoscopic graspers with active constraints to prevent excessive grasping and tissue injury.

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes

Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratio = 1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.

Attempting a Laparoscopic Approach in Patients Undergoing Left-Sided Colorectal Surgery Who Have Had a Previous Laparotomy: Is it Feasible?

BACKGROUND

The feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery.

METHODS

A retrospective review (2007-2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed.

RESULTS

We identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2).

CONCLUSIONS

Prior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.

A practical technique in laparoscopic diaphragm pacing surgery: Retrospective analyse of 43 patients

Introduction:

Diaphragm pacing stimulation (DPS) is a treatment method used in respiratory failure occurs in diseases such as high-level cervical spinal cord injury, central hypoventilation syndrome and amyotrophic lateral sclerosis.

Materials and Methods:

A total of 43 patients, who had undergone DPS implantation surgery were evaluated retrospectively. The patients were divided into two groups according to the surgical technique (Group 1: classical surgical technic and Group 2: modified surgical technic) applied. The patients with previous abdominal surgery or percutaneous endoscopic gastrostomy were excluded from the study.

Results:

The mean operation duration was significantly shorter in modified DPS implantation technic (105.1 min in Group 1 and 87.4 min in Group 2) (P < 0.001). Capnothorax is seen 11% of the cases in classical surgery procedure. In the modified group, capnothorax was not observed. Pneumothorax rate was found similar in both groups. Post-operative atelectasis was determined 16% of the cases in classical surgery procedure and also in the modified group atelectasis was not observed. The complications were higher in classical surgery procedure group but not differed statistically in this study. Total hospitalisation duration was significantly shorter in the modified surgical technique group compared to the other group (8.0 days in Group 1 and 6.0 days in Group 2) (P = 0.03).

Conclusion:

With modification in DPS implantation surgery, shorter operation and hospitalisation durations, and less complications may be achieved.

The Improvement of Laparoscopic Surgical Skills Obtained by Gynecologists after Ten Years of Clinical Training Can Reduce Peritoneal Adhesion Formation during Laparoscopic Myomectomy: A Retrospective Cohort Study

OBJECTIVE

To evaluate if improvement of laparoscopic skills can reduce postoperative peritoneal adhesion formation in a clinical setting.

STUDY DESIGN

We retrospectively evaluated 25 women who underwent laparoscopic myomectomy from January 1993 to June 1994 and 22 women who underwent laparoscopic myomectomy from March 2002 to November 2004. Women had one to four subserous/intramural myomas and received surgery without antiadhesive agents or barriers. Women underwent second-look laparoscopy for assessment of peritoneal adhesion formation 12 to 14 weeks after myomectomy. Adhesions were graded according to the Operative Laparoscopy Study Group scoring system. The main variable to be compared between the two cohorts was the proportion that showed no adhesions at second-look laparoscopy.

RESULTS

Demographic and surgical characteristics were similar between the two cohorts. No complications were observed during surgery. No adverse events were recorded during postoperative course. At second-look laparoscopy, a higher proportion of adhesion-free patients was observed in women who underwent laparoscopic myomectomy from March 2002 to November 2004 (9 out of 22) compared with women who underwent the same surgery from January 1993 to June 1994 (3 out of 25).

CONCLUSION

The improvement of surgeons' skills obtained after ten years of surgery can reduce postoperative adhesion formation.

Sutures impregnated with carbazate-activated polyvinyl alcohol reduce intraperitoneal adhesions

BACKGROUND

Intraperitoneal adhesions cause significant morbidity. They occur after peritoneal trauma, which induces oxidative stress with production of inflammatory cytokines, peroxidized proteins (carbonyls) and lipids (aldehydes). This study aimed to investigate if carbazate-activated polyvinyl alcohol (PVAC), an aldehyde-carbonyl inhibitor, can reduce intraperitoneal adhesions in an experimental model.

MATERIAL AND METHODS

Male Sprague-Dawley rats (n=110) underwent laparotomy, cecal abrasion and construction of a small bowel anastomosis. They either were treated with intraperitoneal instillation of PVAC or were sutured with PVAC-impregnated sutures. Thromboelastography analysis was performed using human blood and PVAC. The lipid peroxidation product malondialdehyde (MDA) and inflammatory cytokines IL-1β and IL-6 were quantified in peritoneal fluid. At day 7, bursting pressure of the anastomosis was measured and adhesions were blindly scored.

RESULTS

PVAC in human blood decreased the production of the fibrin-thrombocyte mesh without affecting the coagulation cascade. MDA, IL-1β and IL-6 were increased after 6h without significant difference between the groups. PVAC-impregnated sutures reduced intraperitoneal adhesions compared to controls (p=0.0406) while intraperitoneal instillation of PVAC had no effect. Anastomotic bursting pressure was unchanged.

CONCLUSIONS

Intervention with an aldehyde-carbonyl inhibitor locally in the wound by PVAC-impregnated sutures might be a new strategy to reduce intraperitoneal adhesions.

Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management

Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment.

Laparoscopic and Robotic Surgeries for Patients With Colorectal Cancer Who Have Had a Previous Abdominal Surgery

PURPOSE

The impact of previous abdominal surgery (PAS) on surgical outcomes from laparoscopic and robot surgeries is inconclusive. This study aimed to investigate the impact of PAS on perioperative outcomes from laparoscopic and robotic colorectal surgeries.

METHODS

From March 2007 to February 2014, a total of 612 and 238 patients underwent laparoscopic and robotic surgeries, respectively. Patients were divided into 3 groups: those who did not have a PAS (NPAS), those who had a major PAS, and those who had a minor PAS. We further divided the patients so that our final groups for analysis were: patients with NPAS (n = 478), major PAS (n = 19), and minor PAS (n = 115) in the laparoscopy group, and patients with NPAS (n = 202) and minor PAS (n = 36) in the robotic surgery group.

RESULTS

In the laparoscopy group, no differences in the conversion rates between the 3 groups were noted (NPAS = 1.0% vs. major PAS = 0% vs. minor PAS = 1.7%, P = 0.701). In the robotic surgery group, the conversion rate did not differ between the NPAS group and the minor PAS group (1.0% vs. 2.8%, P = 0.390). Among the groups, neither the operation time, blood loss, days to soft diet, length of hospital stay, nor complication rate were affected by PAS.

CONCLUSION

PAS did not jeopardize the perioperative outcomes for either laparoscopic or robotic colorectal surgeries. Therefore, PAS should not be regarded as an absolute contraindication for minimally invasive colorectal surgeries.

Defining the association between operative time and outcomes in children's surgery

INTRODUCTION

Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery.

METHODS

182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications.

RESULTS

Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28).

CONCLUSIONS

Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement.

LEVEL OF EVIDENCE

Level III.

Injectable thermosensitive hydrogel containing hyaluronic acid and chitosan as a barrier for prevention of postoperative peritoneal adhesion

Peritoneal adhesion is one of the common complications after abdominal surgery. Injectable thermosensitive hydrogel could serve as an ideal barrier to prevent this postoperative tissue adhesion. In this study, poly(N-isopropylacrylamide) (PNIPAm) was grafted to chitosan (CS) and the polymer was further conjugated with hyaluronic acid (HA) to form thermosensitive HA-CS-PNIPAm hydrogel. Aqueous solutions of PNIPAm and HA-CS-PNIPAm at 10%(w/v) are both free-flowing and injectable at room temperature and exhibit sol-gel phase transition around 31°C; however, HA-CS-PNIPAm shows less volume shrinkage after gelation and higher complex modulus than PNIPAm. Cell culture studies indicate both injectable hydrogel show barrier effects to reduce fibroblasts penetration while induce little cytotoxicity in vitro. From a sidewall defect-bowel abrasion model in rats, significant reduction of postoperative peritoneal adhesion was found for peritoneal defects treated with HA-CS-PNIPAm compared with those treated with PNIPAm and untreated controls from gross and histological evaluation. Furthermore, HA-CS-PNIPAm did not interfere with normal peritoneal tissue healing and did not elicit acute toxicity from blood analysis and tissue biopsy examination. By taking advantage of the easy handling and placement properties of HA-CS-PNIPAm during application, this copolymer hydrogel would be a potentially ideal injectable anti-adhesion barrier after abdominal surgeries.