Comparison of the long-term outcome of two therapeutic strategies for the management of abdominal abscess complicating Crohn's disease: percutaneous drainage or immediate surgical treatment

AIM

The management of abdominal abscesses complicating Crohn's disease is complex and involves a difficult choice between medical, radiological and surgical procedures. The long-term outcome was compared for two strategies for the management of abdominal abscess: percutaneous drainage (PD) followed by rescue surgery in the case of failure vs direct immediate surgery (IS). We also compared the results of IS with surgery performed after PD failure.

METHODS

We retrospectively identified 44 patients with Crohn's disease with an abdominal abscess from January 2000 to December 2009. Therapeutic success was defined as abscess resolution and no reappearance within 1 year of follow-up.

RESULTS

The first therapeutic approach was PD in 22 cases and IS in the other 22 cases. IS had a higher therapeutic success rate than PD (95.5% vs 27.2% respectively; P < 0.001). PD was the only independent variable related to treatment failure in the multivariate analysis after adjustment for possible confounders such as abscess size, multilocularity, presence of fistula and corticosteroid use (OR 88.26, 95% CI 7.38-1055.36; P < 0.001). Surgery after failure of PD (n = 16) was associated with longer total hospitalization (56.12 ± 35.89 vs 27.52 ± 15.11 days; P = 0.017) and longer postoperative stay (44.0 ± 83.7 vs 14.3 ± 30 days; P = 0.179) and needed a second operation more often (5/16, 31% vs 1/22, 4.5%; P = 0.065) than IS.

CONCLUSIONS

Percutaneous drainage provided durable abscess resolution in only one-third of the patients compared with more than 90% of those treated with IS. In addition, surgery performed after PD failure results in a poorer outcome than IS.

Long-term urinary dysfunction after rectal cancer surgery

OBJECTIVE

Urinary dysfunction is a well-known complication of rectal surgery, secondary to injury to the autonomic nervous plexus. The object of this study was to evaluate the incidence, prevalence and type of micturition disorders following rectal cancer surgery and their reversibility during long-term follow-up.

PATIENTS AND METHODS

A prospective study of 45 patients who underwent surgery for rectal cancer between 1993 and 1998 was undertaken. Those with pre-operative urinary dysfunction were excluded after sequential uroflowmetry and clinical interview. Ten of the surgical interventions were high anterior resections, 18 low anterior resections, and 17 abdominoperineal amputations. Pre-operative radiotherapy was performed in 47.9% of patients. All patients underwent sequential uroflowmetry and a clinical interview 3 and 12 months after the intervention. Subjects who presented micturition disorders underwent urodynamic examination The follow up period was three years.

RESULTS

Three months after surgery alterations were found in 14 (31.3%) patients; the most frequent were stress incontinence, urinary tenesmus and the urge to urinate. At the 12-month assessment only 6 (13.3%) patients had urinary symptomatology or uroflowmetry abnormalities. After three years, micturition disorders persisted in 3 (6.6%) patients.

CONCLUSION

Urinary dysfunction after rectal cancer excision is associated with a high degree of reversibility. Seventy-eight percent of the alterations detected after three months and 50% of those that persisted after a year disappeared during follow up.

Protective effect of ischemic preconditioning on cold preservation and reperfusion injury associated with rat intestinal transplantation

OBJECTIVE

To define the protective effect of ischemic preconditioning on cold ischemia and reperfusion injury associated with intestinal transplantation, and the role of nitric oxide in this process.

SUMMARY BACKGROUND DATA

Ischemia/reperfusion injury continues to be a significant obstacle in small bowel transplantation. Preconditioning is a mechanism that protects against this injury.

METHODS

To study the capacity of preconditioning to prevent cold ischemia-associated injury and the inflammatory response associated with intestinal transplantation, the authors studied a control group of animals, cold ischemia groups with or without previous preconditioning and with or without previous administration of L-NAME or NONOS, and intestinal transplantation groups with or without previous preconditioning and with or without previous administration of L-NAME or NONOS.

RESULTS

Histologic findings and the release of lactate dehydrogenase into the preservation solution showed that preconditioning protects against cold ischemic preservation-associated injury. Preconditioning also prevented the inflammatory response associated with intestinal transplantation, measured by the above parameters and by neutrophil recruitment in the intestine. Inhibition of nitric oxide eliminates the protective effect.

CONCLUSIONS

Preconditioning protects the intestinal grafts from cold preservation and reperfusion injury in the rat intestinal transplantation model. Nitric oxide is involved in this protection.

Prognostic factors for mortality in left colonic peritonitis: a new scoring system

BACKGROUND

Perforating lesions of the colon affect a heterogeneous group of patients, often elderly, and usually present as abdominal emergencies, with high morbidity and mortality. The aims of this study were to assess the prognostic value of specific factors in patients with left colonic peritonitis and to evaluate the utility of a scoring method that allows one to define groups of patients with different mortality risks.

STUDY DESIGN

Between January 1994 and December 1999, 156 patients (77 men and 79 women), with a mean (SD) age of 63.2 years (15.5 years) (range 22 to 87 years), underwent emergency operation for a distal colonic perforation. Intraoperative colonic lavage was the first choice operation and it was performed in 74 patients (47.4%). There were three alternative procedures: the Hartmann operation was performed in 69 patients (44.2%), subtotal colectomy in 9, and colostomy in 4 patients. We analyzed specific variables for their possible relation to death including gender, age, American Society of Anesthesiologists (ASA) score, immunocompromised status, etiology, and degree of peritonitis, preoperative organ failure, time (hours) between hospital admission and surgical intervention, and degree of temperature elevation (38 degrees C). Univariate relations between predictors and outcomes (death) were analyzed using logistic regression. Multivariate logistic regression analysis was used to assess the prognostic value of combinations of the variables. Significant factors identified in univariate and multivariate logistic regression analyses were used to define a left colonic Peritonitis Severity Score (PSS). Factors that were significant only in univariate analysis scored 2 points if present and 1 if not. Variables significant in multivariate analysis were scored from 1 to 3 points. Patients were randomly split into two groups, one to calculate the scoring system and the other to validate it.

RESULTS

Overall postoperative mortality rate was 22.4%. Septic-related mortality was observed in 24 patients (15.4%). Age, peritonitis grade, ASA score, immunocompromised status, and ischemic colitis were significant for postoperative death in univariate analysis. But only ASA score and preoperative organ failure were significantly associated with postoperative mortality in multivariate logistic regression analysis. The PSS, as defined in this study, was related to outcomes of patients. Mortality rate increased from 0%, when PSS was 6 points (minimum possible score), to 100% in patients with a PSS of 13 (maximum possible PSS = 14).

CONCLUSIONS

Left colonic peritonitis continues to have a persistently high mortality in patients with septic complications. ASA score and preoperative organ failure are the only factors that are significantly associated with mortality in the multivariate analysis. The PSS classification may help uniformly define the mortality risk of patients with distal large bowel peritonitis, and may help to increase the comparability of studies carried out at different centers.

Selective bowel decontamination, nutritional therapy and bacterial translocation after burn injury

We studied the influence of selective bowel decontamination (SBD) with neomycin, on bacterial translocation (BT) in rats treated with early post-burn parenteral nutrition (TPN) or enteral nutrition (TEN). Male Wistar rats were randomly assigned to receive either TPN (groups 1, 2) or an isonitrogenous, isocaloric polymeric diet (TEN, groups 3, 4) or a standard rat chow ad libitum (group 5), for 5 days after burn injury (30% b. s. area). In addition, groups 1 and 3 received a daily oral dose of neomycin (30 mg/kg) during the same period. At the end of the study, animals were killed and the mesenteric lymph nodes (MLN), liver (L) and spleen (S) were removed for microbiological cultures. The overall incidence of BT was MLN: 67%, L: 58% and S: 42% with a mortality rate of 12.2% In MLN and L, group 5 showed significantly less BT than groups 1 and 2 (30% vs 84%, p < 0.02) and groups 3 and 4 (38% vs 76%, p < 0.05), respectively. No differences were found between TPN and TEN groups. SBD (groups 1 and 3) resulted in a significantly lower mortality rate (26% vs 0%, p < 0.05) and BT in the liver (38% vs 100%, p < 0.001) than rats without antibiotic treatment (groups 2 and 4). It is concluded that early post-injury TPN or TEN promote BT to a greater extent than a standard chow. In addition, SBD with neomycin prevents mortality and BT after burn injury.

[Nutritional status and heart valve surgery: response to surgical aggression]

Malnutrition is a condition of increased risk for surgical patients, yet incompletely understood. Its role in the prognosis of neoplastic, gastrointestinal and infective disease undergoing surgery is now better underlined; unfortunately the same attention is still lacking for the majority of cardiac diseases. Nowadays many methods are at hand for evaluation of nutritional status, and it is possible to restore the correct condition before surgery by various techniques of artificial nutrition. Here the authors consider the possibility of discovery and evaluation of various hidden conditions of malnutrition in patients suffering of valvular heart disease--depending or not from the cardiopathy itself--and their complex pathogenesis, to correct at the end such condition and offer the patients an optimal prognosis with therapeutical procedures.

[Nutritional and immunologic state of patients undergoing heart valve surgery]

A series of 60 consecutive patients treated by heart valve replacement surgery under extracorporeal circulation were reviewed. Poor nutrition was assessed in 28% of these cases, the cardiac index in these patients being significantly smaller than in operated patients with normal nutritional states (2.07 +/- 0.8 as against 2.46 +/- 0.7, p less than 0.01). Furthermore, 58% of those with poor nutrition presented postoperative complications: mediastinitis, wound infection, ventricular arrhythmias or secondary pulmonary infection. One death occurred in this group. Postoperative complications in patients with normal nutritional states developed in only 6% and there were no deaths. Duration of hospital stay was significantly longer in patients with poor nutrition (p less than 0.05). Apart from immunoglobulin levels, all immunologic parameters underwent postoperative modifications related to nutritional state. Physiopathologic hypotheses are proposed as well as a programme for increasing nutritional intake in patients in a precarious metabolic state which predisposes them to complications.