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Abstract
BACKGROUND Medications used to treat inflammatory bowel disease (IBD) have significantly improved patient outcomes and delayed time to surgery. However, some of these therapies are recognized to increase the general risk of infection and have an unclear impact on postoperative infection risk. OBJECTIVES To assess the impact of perioperative IBD medications on the risk of postoperative infections within 30 days of surgery. SEARCH METHODS We searched the Cochrane IBD Group's Specialized Register (29 October 2019), MEDLINE (January 1966 to October 2019), Embase (January 1985 to October 2019), the Cochrane Library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception up to October 2019, and reference lists of articles. SELECTION CRITERIA Randomized controlled trials, quasi-randomized controlled trials, non-randomized controlled trials, prospective cohort studies, retrospective cohort studies, case-control studies and cross-sectional studies comparing participants treated with an IBD medication preoperatively or within 30 days postoperatively to those who were not taking that medication (either another active medication, placebo, or no treatment). We included published study reports and abstracts. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts and extracted data. The primary outcome was postoperative infection within 30 days of surgery. Secondary outcomes included incisional infections and wound dehiscence, intra-abdominal infectious complications and extra-abdominal infections. Three review authors assessed risks of bias using the Newcastle-Ottawa Scale. We contacted authors for additional information when data were missing. For the primary and secondary outcomes, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) using the generic inverse variance method. When applicable, we analyzed adjusted and unadjusted data separately. We evaluated the certainty of the evidence using GRADE. MAIN RESULTS We included 68 observational cohort studies (total number of participants unknown because some studies did not report the number of participants). Of these, 48 studies reported including participants with Crohn's disease, 36 reported including participants with ulcerative colitis and five reported including participants with indeterminate colitis. All 42 studies that reported urgency of surgery included elective surgeries, with 31 (74%) of those also including emergency surgeries. Twenty-four studies had low risk of bias while the rest had very high risk. Based on pooling of adjusted data, we calculated ORs for postoperative total infection rates in participants who received corticosteroids (OR 1.70, 95% CI 1.38 to 2.09; low-certainty evidence), immunomodulators (OR 1.29, 95% CI 0.95 to 1.76; low-certainty evidence), anti-TNF agents (OR 1.60, 95% CI 1.20 to 2.13; very low-certainty evidence) and anti-integrin agents (OR 1.04, 95% CI 0.79 to 1.36; low-certainty evidence). We pooled unadjusted data to assess postoperative total infection rates for the use of aminosalicylates (5-ASA) (OR 0.76, 95% CI 0.51 to 1.14; very low-certainty evidence). One secondary outcome examined was wound-related complications in participants using: corticosteroids (OR 1.41, 95% CI 0.72 to 2.74; very low-certainty evidence), immunomodulators (OR 1.35, 95% CI 0.96 to 1.89; very low-certainty evidence), anti-TNF agents (OR 1.18, 95% CI 0.83 to 1.68; very low-certainty evidence) and anti-integrin agents (OR 1.64, 95% CI 0.77 to 3.50; very low-certainty evidence) compared to controls. Another secondary outcome examined the odds of postoperative intra-abdominal infections in participants using: corticosteroids (OR 1.53, 95% CI 1.28 to 1.84; very low-certainty evidence), 5-ASA (OR 0.77, 95% CI 0.45 to 1.33; very low-certainty evidence), immunomodulators (OR 0.86, 95% CI 0.66 to 1.12; very low-certainty evidence), anti-TNF agents (OR 1.38, 95% CI 1.04 to 1.82; very low-certainty evidence) and anti-integrin agents (OR 0.40, 95% CI 0.14 to 1.20; very low-certainty evidence) compared to controls. Lastly we checked the odds for extra-abdominal infections in participants using: corticosteroids (OR 1.23, 95% CI 0.97 to 1.55; very low-certainty evidence), immunomodulators (OR 1.17, 95% CI 0.80 to 1.71; very low-certainty evidence), anti-TNF agents (OR 1.34, 95% CI 0.96 to 1.87; very low-certainty evidence) and anti-integrin agents (OR 1.15, 95% CI 0.43 to 3.08; very low-certainty evidence) compared to controls. AUTHORS' CONCLUSIONS The evidence for corticosteroids, 5-ASA, immunomodulators, anti-TNF medications and anti-integrin medications was of low or very low certainty. The impact of these medications on postoperative infectious complications is uncertain and we can draw no firm conclusions about their safety in the perioperative period. Decisions on preoperative IBD medications should be tailored to each person's unique circumstances. Future studies should focus on controlling for potential confounding factors to generate higher-quality evidence.
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Affiliation(s)
- Cindy Cy Law
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Conor Bell
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Deborah Koh
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Yueyang Bao
- Department of Biology, McMaster University, Hamilton, Canada
| | - Vipul Jairath
- Department of Medicine, University of Western Ontario, London, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Canada
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2
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Abstract
Steroids inhibit primary wound healing and delay the formation of granulation tissue, but it has been controversial whether long-term steroid treatment by itself increases the risk of abdominal wound dehiscence. The aim of this study was to determine whether the pre-operative dose and post-operative total dose of steroids influence abdominal wound dehiscence. Of 28 patients who had surgery while receiving long-term steroid treatment, seven had abdominal wound dehiscence and 21 did not have dehiscence. The two groups differed significantly in the post-operative dose of steroids (404.3 ± 147.1 and 135.6 ± 118.7 mg, respectively) and the duration of wound healing (57.3 ± 18.0 and 12.4 ± 3.8 days), but no other differences were found. Abdominal wound dehiscence may be influenced by the post-operative rather than the pre-operative steroid dose.
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Affiliation(s)
- A Kihara
- Department of Coloproctological Surgery, Juntendo University School of Medicine, Tokyo, Japan
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3
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Stitely ML, Craw S, Africano E, Reid R. Uterine Scar Dehiscence Associated with Misoprostol Cervical Priming for Surgical Abortion: A Case Report. J Reprod Med 2015; 60:445-448. [PMID: 26592074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Cervical priming prior to pregnancy termination is a common treatment. Both osmotic agents such as laminaria and Dilapan or pharmacologic agents such as misoprostol and mifepristone have been used for this purpose. CASE A 30-year-old patient with a previous cesarean delivery was undergoing surgical termination of pregnancy at 13 weeks' gestation for a lethal fetal malformation. During preoperative cervical priming with misoprostol the uterine scar dehisced. Interval laparoscopic repair was performed. CONCLUSION Uterine scar dehiscence can occur with misoprostol preoperative cervical priming for second trimester surgical termination of pregnancy.
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Eveno C, Soyer P, Teixeira L, Staudacher L, Pocard M. Anastomotic dehiscence during treatment with bevacizumab 5 years after colo-anal anastomosis with proposition for management without stopping chemotherapy. Clin Res Hepatol Gastroenterol 2011; 35:594-6. [PMID: 21816701 DOI: 10.1016/j.clinre.2011.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 04/16/2011] [Indexed: 02/04/2023]
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Koskas M, Chereau E, Ballester M, Selle F, Rouzier R, Daraï E. Wound complications after bevacizumab treatment in patients operated on for ovarian cancer. Anticancer Res 2010; 30:4743-4747. [PMID: 21115934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
UNLABELLED The aim of this study was to report and analyze the rate of wound complications in patients treated for ovarian cancer with or without adjuvant bevacizumab. PATIENTS AND METHODS Were included in a prospective cohort study, all the patients with advanced ovarian cancer who received adjuvant chemotherapy with or without bevacizumab in our center from April 2007 to January 2009. The patients were separated into a bevacizumab adjuvant therapy group (n=13) and a control group without bevacizumab (n=12). All the patients underwent upfront surgery and received standard chemotherapy (carboplatin with paclitaxel). The patients were examined every two months by a gynecological surgeon and underwent abdomino pelvic CT-scan regularly. RESULTS Among the 25 patients included in the study, six experienced wound dehiscence (24%). Five out of these six patients had received bevacizumab in addition to standard chemotherapy (p=0.078). CONCLUSION We report a high rate of wound complications in ovarian cancer patients receiving bevacizumab after surgery.
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Affiliation(s)
- Martin Koskas
- Department of Obstetrics and Gynecology, Hospital Tenon,Assistance Publique des Hôpitaux de Paris, CancerEst, University Pierre et Marie Curie Paris 6, France.
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Kramer E, Hadad E, Westreich M, Shalom A. Lack of complications in skin surgery of patients receiving clopidogrel as compared with patients taking aspirin, warfarin, and controls. Am Surg 2010; 76:11-14. [PMID: 20135932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Clopidogrel, a new antiplatelet agent that irreversibly inhibits platelet aggregation, is widely used today. This prospective work was conducted to evaluate the safety of performing skin surgery on patients taking clopidogrel. Patients undergoing surgery for excision of skin or subcutaneous lesions under local anesthesia taking clopidogrel were the study group. The control group comprised 2073 historical patients who had undergone a similar procedure. Data collected included: age, sex, past medical history, medications, and late complications. Follow-up was done at 1 to 2 weeks and 3 to 6 months. There were 32 patients on clopidogrel, having 38 lesions removed. Of these, seven patients were on aspirin and clopidogrel combined. The groups taking clopidogrel, aspirin, and warfarin had significantly more males, were older, and had significantly more comorbid medical conditions. There was no significant difference in the incidence of any of the complications in any of the groups. This study shows that patients taking clopidogrel before skin surgery, though older and with more associated medical conditions, do not experience a greater rate of complications. We conclude that patients undergoing minor excisional cutaneous surgery should continue taking clopidogrel because there is no apparent risk for increased complications when good meticulous surgical techniques are used.
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Affiliation(s)
- Eyal Kramer
- Department of Plastic Reconstructive and Aesthetic Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Kemeny MM. How many patients and how many complications does it take to decide if a drug is safe to use before surgery? J Clin Oncol 2009; 27:1917-8; author reply 1918. [PMID: 19255303 DOI: 10.1200/jco.2008.21.2811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ersoy E, Akbulut H, Moray G. Effects of oxaliplatin and 5-fluorouracil on the healing of colon anastomoses. Surg Today 2009; 39:38-43. [PMID: 19132466 DOI: 10.1007/s00595-008-3795-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 04/01/2008] [Indexed: 12/12/2022]
Abstract
PURPOSE Oxaliplatin (OX) and 5-fluorouracil (5-FU) are the most widely used chemotherapeutic agents in the adjuvant treatment of colon cancer. Although the early initiation of adjuvant chemotherapy can improve the outcome of surgery, it carries potentially fatal risks. This experimental study investigates the effects of 5-FU and OX on colon anastomoses. METHODS We used 60 rats, divided into six groups. After being subjected to bowel resection and anastomosis, the rats were given 5-FU on days 1-3, or OX 130 mg/m(2) on days 1 or 5, or 5% dextrose as a control. The bursting pressures and hydroxyproline content of the anastomoses were measured, and complications and adhesions were recorded. RESULTS There were no major complications in the treatment groups. The bursting pressures of the 5-FU group were significantly lower than those of the control and OX groups. The bursting pressures of the OX groups were not significantly different from those of the control groups. The hydroxyproline levels of the rats treated with OX on day 1 were significantly lower than those of the rats treated with OX on day 5 and the 5-FU groups. CONCLUSION Oxaliplatin and 5-FU did not compromise wound healing of the colon significantly. Our results indicate that OX is less detrimental to the healing of colonic anastomoses, when administered on days 1 and 5 after resection, than 5-FU.
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Affiliation(s)
- Eren Ersoy
- Department of General Surgery, Ankara Atatürk Research and Education Hospital, Acar Beytepe Evleri No: 154/27, Beytepe, Ankara, Turkey
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9
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Affiliation(s)
- F Lordick
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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10
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Abstract
BACKGROUND Bevacizumab (Avastin) is a monoclonal antibody against vascular endothelial growth factor (VEGF) receptor that has demonstrated increased overall survival when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. Gastrointestinal perforation is a known risk factor of unknown etiology associated with the use of bevacizumab. OBJECTIVE We report a 61-year-old woman with adenocarcinoma of the colon ascendens who underwent hemicolectomy and adjuvant chemotherapy with oxaliplatin, 5-fluorouracil, and leucovorin. Eight months after the operation, we started therapy with bevacizumab combined with irinotecan, 5-fluorouracil, and leucovorin due to disease progression. Two months after completion of this therapy, ischemic anastomotic bowel perforation occurred and a resection of the anastomosis was performed. Because of anastomotic insufficiency 8 days later, a further revision had to be done and the terminal ileum and the colon were brought out through a stoma. DISCUSSION This case is unusual because the time interval between the primary operation and the application of bevacizumab is regarded as safe with regard to the risk of perforation. An ischemic genesis of the perforation was considered on the basis of the histopathological workup. In case of perforations during therapy with bevacizumab, a safe surgical approach should be preferred, i.e., a transient stoma instead of a primary reconstruction of the bowel passage.
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MESH Headings
- Anastomosis, Surgical
- Angiogenesis Inhibitors/adverse effects
- Angiogenesis Inhibitors/therapeutic use
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bevacizumab
- Camptothecin/adverse effects
- Camptothecin/analogs & derivatives
- Camptothecin/therapeutic use
- Colectomy
- Colitis, Ischemic/chemically induced
- Colitis, Ischemic/diagnosis
- Colitis, Ischemic/pathology
- Colitis, Ischemic/surgery
- Colonic Neoplasms/pathology
- Colonic Neoplasms/surgery
- Female
- Fluorouracil/adverse effects
- Fluorouracil/therapeutic use
- Humans
- Ileostomy
- Ileum/blood supply
- Ileum/pathology
- Ileum/surgery
- Intestinal Perforation/chemically induced
- Intestinal Perforation/diagnosis
- Intestinal Perforation/pathology
- Intestinal Perforation/surgery
- Ischemia/chemically induced
- Ischemia/diagnosis
- Ischemia/pathology
- Ischemia/surgery
- Leucovorin/adverse effects
- Leucovorin/therapeutic use
- Lymphatic Metastasis/pathology
- Middle Aged
- Neoplasm Staging
- Reoperation
- Surgical Wound Dehiscence/chemically induced
- Surgical Wound Dehiscence/diagnosis
- Surgical Wound Dehiscence/pathology
- Surgical Wound Dehiscence/surgery
- Tomography, X-Ray Computed
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Affiliation(s)
- K Abbrederis
- III Medizinische Klinik und Poliklinik (Hämatologie und Internistische Onkologie), Klinikum rechts der Isar, Technische Universität München, Ismaninger, München, Germany.
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11
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Taniguchi Y, Horio H, Suzuki Y, Nakamura H. Bronchoplastic lobectomy with wide wedge resection for lung cancer with long-term steroid medication. Ann Thorac Cardiovasc Surg 2007; 13:403-406. [PMID: 18292724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 02/05/2007] [Indexed: 05/25/2023] Open
Abstract
A 57-year-old man with erythrodermia, who was given 5-10 mg/day of prednisolone for 2.5 years, was admitted to our hospital for squamous cell lung carcinoma of the right upper lobe. A bronchoscopy revealed a tumor nearly obstructing the right upper lobe bronchus. A bronchoplastic lobectomy was performed with wide wedge resection of the main bronchus and truncus intermedius. A postoperative bronchoscopy revealed good healing of the anastomosis and a 3-dimensional construction of the bronchus with chest computed tomography demonstrated no stenotic change and no kinking change in the anastomosis. One year and 6 months after surgery, no local recurrence was seen in the region of bronchoplasty. Bronchoplastic lobectomy with wide wedge resection is a useful procedure in cases with risk factors of anastomotic dehiscence, such as after induction therapy or during long-term administration of adrenal cortical steroids.
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Zakrison T, Nascimento BA, Tremblay LN, Kiss A, Rizoli SB. Perioperative Vasopressors Are Associated with an Increased Risk of Gastrointestinal Anastomotic Leakage. World J Surg 2007; 31:1627-34. [PMID: 17551781 DOI: 10.1007/s00268-007-9113-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown. PATIENTS AND METHODS Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications RESULTS A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002). CONCLUSIONS Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.
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Affiliation(s)
- Tanya Zakrison
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite H1-71, M4N 3M5, Toronto, Ontario, Canada
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13
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Abstract
Tumor necrosis factor (TNF) blocking agents, such as adalimumab, are well tolerated and provide improvement in the symptoms and signs of rheumatoid arthritis (RA). Due to its immunosuppressive effect, an increased risk of infection has been suggested, but so far no differences between adalimumab and placebo groups have been found in pivotal trials. Patients with RA succumb to postoperative complications because they have a systemic disease and use medication with immunosuppressive effects. We report on a patient with longstanding, active RA who had received adalimumab 40 mg every other week with prolonged infection, wound dehiscence and pseudoarthrosis following reconstructive forefoot surgery due to deformities secondary to RA. The postoperative infection occurred although adalimumab therapy had been stopped 8 days before surgery. The half-life of adalimumab is 10.0-13.6 days following a single intravenous dose. Whether patients under therapy with adalimumab are at an increased risk of developing postoperative complications is unclear, a retrospective analysis of the pivotal studies would be helpful in estimating the risk of perioperative (wound) infections in patients receiving anti-TNF. Moreover, it is not clear when therapy should be stopped prior to surgical intervention. Obviously prospective clinical trials would be more convincing.
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MESH Headings
- Adalimumab
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antirheumatic Agents/adverse effects
- Antirheumatic Agents/therapeutic use
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/surgery
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Foot Deformities, Acquired/surgery
- Forefoot, Human/surgery
- Humans
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Injections, Subcutaneous
- Male
- Middle Aged
- Pseudarthrosis/chemically induced
- Pseudarthrosis/diagnosis
- Pseudarthrosis/surgery
- Reoperation
- Surgical Wound Dehiscence/chemically induced
- Surgical Wound Dehiscence/diagnosis
- Surgical Wound Dehiscence/surgery
- Surgical Wound Infection/chemically induced
- Surgical Wound Infection/diagnosis
- Surgical Wound Infection/surgery
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Affiliation(s)
- M Pfeiffer
- Universitätsklinik für Orthopädie, Medizinische Universität, Währinger Gürtel 18-20, 1090, Wien, Osterreich.
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de Lathouwer OG, de Fontaine S. Iterative wound dehiscence in augmentation mammaplasty as a systemic side effect of hidden topical corticotherapy. Plast Reconstr Surg 2006; 117:2097-8. [PMID: 16652010 DOI: 10.1097/01.prs.0000214738.97424.ff] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Praessler J, Bauer A, Elsner P, Kaatz M. Contact dermatitis to quinoline, corticosteroids and antibiotics after short time treatment of delayed wound healing following malignant melanoma excision in a young woman. Skin Res Technol 2005; 11:218-9. [PMID: 15998335 DOI: 10.1111/j.1600-0846.2005.00113.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND We describe a 20-year old woman with retarded healing after a melanoma excision. After short time application of several creams containing antiseptic, antibiotic and anti-inflammatory ingredients she developed a severe contact dermatitis. Patch testing revealed sensitizations against corticosteroids, an antibiotic and quinoline. CONCLUSION In our case multiple relevant contact sensitizations appeared within a short period of two months after excision of a malignant tumour.
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Affiliation(s)
- Jana Praessler
- Department of Dermatology and Allergology, Friedrich Schiller University Jena, Jena, Germany
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Zieliński M, Kuzdzał J, Staniec B, Harazda M, Nabiałek T, Pankowski J, Szlubowski A, Medoń J. Safety for preoperative use of steroids for transsternal thymectomy in myasthenia gravis☆. Eur J Cardiothorac Surg 2004; 26:407-11. [PMID: 15296906 DOI: 10.1016/j.ejcts.2004.01.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Revised: 01/17/2004] [Accepted: 01/21/2004] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Effects of preoperative steroids on morbidity and mortality after transsternal thymectomy are analyzed. METHODS There were 620 transsternal thymectomies for myasthenia gravis performed in the period 1973-2002. There were 547 patients with nonthymomatous myasthenia, including 17 patients submitted to repeated thymectomy (rethymectomy) and 46 patients with thymoma. There were 522 upper median sternotomies performed in the period 1973-1997 and 98 complete median sternotomies performed in the period 1998-2002 (74 patients without thymoma, 7 thymomas and 17 rethymectomies). One hundred and seventeen of these 620 patients were taking steroids preoperatively. The impact of steroids use on postoperative respiratory insufficiency (ventilator), need for tracheostomy, superficial wound dehiscence, superficial wound suppuration, sternal dehiscence and mortality was analyzed. RESULTS The rate of morbidity and mortality in the steroids and the no-steroids groups included respiratory insufficiency necessitating the use of a ventilator in 46/503 patients from the no-steroids group (9.1%) and 8/117 patients from the steroids group (6.8%; P = 0.4260), need for tracheostomy in 14/503 patients from the no-steroids group (2.8%) and 3/117 patients from the steroids group (2.6%; P = 9054). Complications with wound healing (including sternal dehiscence, superficial wound dehiscence and superficial wound suppuration) occurred in 47/503 (9.3%) patients from the no-steroids group and in 1/117 (0.9%) patient from the steroids group (P = 0.0023) The overall complications rate was 30.6% (154/503) in the no-steroids group and 11.1% (13/117) in the steroids group (P = 0.0001). Mortality rate in the no-steroids group was 0.4% (2/503 patients) and none in the steroids group. Morbidity in patients with complete sternotomy was low, respiratory insufficiency in three patients (3.1%), and superficial wound suppuration in one patient (1.0%), no other morbidity and no mortality. Changing morbidity in periods 1973-1980, 1981-1990 and 1991-2002 is analyzed. CONCLUSIONS Preoperative use of steroids for transsternal thymectomy in patients with myasthenia gravis had no negative impact on morbidity and mortality, conversely, the results in patients taking steroids were better, with significant difference of results regarding the overall complication rates and the overall complication rates of wound healing.
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Affiliation(s)
- Marcin Zieliński
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, ul. Gładkie 1, 34-500 Zakopane, Poland.
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Abstract
BACKGROUND Muscle relaxation is administered to patients undergoing laparotomy for colonic surgery. At the end of the procedure, relaxation needs to be reversed to facilitate extubation. This may be achieved by administering anticholinesterases such as neostigmine. PATIENT PRESENTATION We present a case of colonic anastomotic dehiscence in the immediate postoperative period following the use of neostigmine to reverse intra-operative muscle relaxation. CONCLUSION Neostigmine is frequently used to reverse muscle relaxation at the end of colonic surgery. However, the drug should be used with caution as it has been implicated as a cause of early anastomotic disruption.
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Affiliation(s)
- G R Hirst
- Singleton Hospital, Sketty Lane, Swansea, SA2 8QA, UK.
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Abstract
Seventy two rats underwent small bowel resection followed by end-to-end anastomosis. The octreotide group consisted of 36 rats treated with octreotide (subcutaneously, 7 microg/kg/day, in two equal doses), and the control group consisted of 36 rats treated with the same volume saline. Twelve animals from each group were re-explored on the 4th, 8th and 15th postoperative day. Leakages, adhesions, obstructions were the clinical postoperative findings identified and recorded. Anastomotic bursting pressures were measured. Histochemical studies included haematoxylin-eosin and Van Gieson staining techniques and focused on the microscopic characterization of the healing process. Adhesions, leakages and obstructions were not different between octreotide and control groups. Anastomoses of the octreotide group had increased bursting pressures on the 8th and the 15th day (p < .05 , p < .05, respectively). Regarding the histogical results, on the 8th day the octreotide group compared to the control group, showed healing in more layers (p < .05), increased bright red collagen fibers and quantity of fibroblasts (p < .05), and on the 15th day, the octreotide group showed fewer gaps (p < .05), increased bright red collagen fibers and quantity of fibroblasts (p < .05). In this experimental model, it appeared that octreotide does not impair healing of small bowel anastomoses, but in contrast, there is some evidence that it enhances healing on the 8th and the 15th postoperative day.
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Affiliation(s)
- E Papalambros
- Department of Surgery, University of Athens Medical School, Laiko Hospital, Athens, Greece
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20
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Abstract
OBJECTIVE To report 3 separate cases of wound dehiscence in liver transplant recipients receiving sirolimus for immunosuppressive therapy. CASE SUMMARIES Three patients who had received liver transplants experienced a delay in wound granulation and healing after being placed on an immunosuppressive regimen containing sirolimus and steroids. Each patient was admitted and treated for wound dehiscence, at which time sirolimus was discontinued. When other immunosuppressive agents were substituted for sirolimus, each incisional wound granulated and closed without complication. DISCUSSION Sirolimus is an important adjunctive immunosuppressant used to prevent acute rejection episodes in patients who have undergone transplant, particularly when nephrotoxic effects from first-line calcineurin inhibitors become problematic. The unique ability of sirolimus to inhibit smooth muscle cell proliferation and intimal thickening by blocking important growth factors may subsequently become a significant feature to prevent the development of chronic rejection. Theoretically, by this same mechanism, sirolimus may play a role in forestalling wound healing and may even promote dehiscence. CONCLUSIONS These case reports describe patients who underwent liver transplant who developed wound dehiscence possibly secondary to sirolimus therapy. Although the cases were complicated by acute rejection, wound infections, and comorbidities, wound granulation and healing began after discontinuation of sirolimus. Substitution with another immunosuppressant may be necessary for patients who experience wound dehiscence after transplant.
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Affiliation(s)
- Jane M Guilbeau
- Department of Pharmacy, Ochsner Clinic Foundation, 1516 Jefferson Highway, New Orleans, LA, 70121-2484, USA.
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Humar A, Ramcharan T, Denny R, Gillingham KJ, Payne WD, Matas AJ. Are wound complications after a kidney transplant more common with modern immunosuppression? Transplantation 2001; 72:1920-3. [PMID: 11773889 DOI: 10.1097/00007890-200112270-00009] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The most common surgical complication after a kidney transplant is likely related to the wound. The purpose of this analysis was to determine the incidence of, and risk factors for, wound complications (e.g., infections, hernias) in kidney recipients and to assess whether newer immunosuppressive drugs increase the risk for such complications. METHODS Between January 1, 1984 and September 30, 1998, we performed 2013 adult kidney transplants. Of these 2013 recipients, 97 (4.8%) developed either a superficial or a deep wound infection. Additionally, 73 (3.6%) recipients developed either a fascial dehiscence or a hernia of the wound. We used univariate and multivariate techniques to determine significant risk factors and outcomes. RESULTS Mean time to development of a superficial infection (defined as located above the fascia) was 11.9 days posttransplant; to development of a deep infection (defined as located below the fascia), 39.2 days; and to development of a hernia or fascial dehiscence, 12.8 months. By multivariate analysis, the most significant risk factor for a superficial or deep wound infection was obesity (defined as body mass index>30 kg/m2) (RR=4.4, P=0.0001). Other significant risk factors were a urine leak posttransplant, any reoperation through the transplant incision, diabetes, and the use of mycophenolate mofetil (MMF) (vs. azathioprine) for maintenance immunosuppression (RR=2.43, P=0.0001). Significant risk factors for a hernia or fascial dehiscence were any reoperation through the transplant incision, increased recipient age, obesity, and the use of MMF (vs. azathioprine) for maintenance immunosuppression (RR=3.54, P=0.0004). Use of antibody induction and treatment for acute rejection were not significant risk factors for either infections or hernias. Death-censored graft survival was lower in recipients who developed a wound infection (vs. those who did not); it was not lower in recipients who developed an incisional hernia or facial dehiscence (vs. those who did not). CONCLUSIONS Despite immunosuppression including chronic steroids, the incidence of wound infections, incisional hernias, and fascial dehiscence is low in kidney recipients. As with other types of surgery, the main risk factors for postoperative complications are obesity, reoperation, and increased age. However, in kidney recipients, use of MMF (vs. azathioprine) is an additional risk factor -one that potentially could be altered, especially in high-risk recipients.
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Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, MMC 195, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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Irvine C, Whyman M. Systemic thrombolysis causing anastomotic dehiscence of an aortobifemoral graft. Ann R Coll Surg Engl 1999; 81:72. [PMID: 10325696 PMCID: PMC2503244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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Abstract
The efficacy of vasoconstrictor infiltration in reducing blood loss is well known. However, adrenaline infiltration is potentially harmful to tissues. The question of whether or not adrenaline infiltration is harmful in breast reduction surgery remains unanswered. We retrospectively reviewed the notes of 100 consecutive cases after bilateral breast reduction (n = 200 breasts) with preoperative infiltration of a vasoconstrictor solution (10 ml adrenaline 1:10,000, 20 ml lignocaine 1%, 70 ml saline 0.9%, resulting in an adrenaline concentration of 1:100,000), looking specifically at postoperative complications that could be secondary to adrenaline infiltration. Two breasts developed a 'haematoma'; both were of small volume. Six breasts developed a 'minimal wound' problem which involved the T-junction. 'Wound breakdown' was noted in five breasts and again involved the T-junction in most cases. 'Wound infection' occurred in eleven breasts. There was one case of partial 'nipple necrosis'. Complications occurred in 12.5% of breasts and 21% of patients. We feel that this complication rate is within acceptable limits.
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Affiliation(s)
- R DeBono
- Department of Plastic Surgery, Shotley Bridge Hospital, Consett, UK
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Bauer G, O'Connell S, Devereux D, Martin A. Reversal of doxorubicin-impaired wound healing using triad compound. Am Surg 1994; 60:455-9. [PMID: 8198340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Triad is composed of Na pyruvate, vitamin E, and unsaturated fatty acids. We found that Triad, administered orally or topically, reverses wound healing that is impaired by doxorubicin (Doxo) in rats. Rats given Doxo (6 mg/kg i.v.) were wounded with linear dermal incisions, and the wound-breaking strength (WBS) was compared among groups of rats differently treated with Triad. Five groups of five rats each were studied. Triad was given orally using a 20 per cent Triad/rat chow mixture and topically as a 50 per cent Triad/petroleum base salve administered daily. All groups were wounded at postoperative day 0, at which time Doxo was given to groups II-IV. Group IV was fed oral Triad 7 days prior to wounding and until POD 21. All wounds were harvested at POD 21, and the mean WBS of each group was obtained using an Instron Tensiometer. Doxorubicin impaired normal wound healing by 40 per cent. Oral Triad restored WBS in Doxo-treated rats to 88 per cent of control values; topical Triad restored WBS to 80 per cent of control values. Moreover, treatment with topical Triad and oral Triad increased the WBS by 30 per cent and 50 per cent when compared with Doxo-only-treated animals. In conclusion, Triad has been shown to restore wound healing to nearly normal levels in doxorubicin-impaired wounds.
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Affiliation(s)
- G Bauer
- University of Medicine and Dentistry of New Jersey, Robert Wood Johnson University Hospital, New Brunswick
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Kolb BA, Buller RE, Connor JP, DiSaia PJ, Berman ML. Effects of early postoperative chemotherapy on wound healing. Obstet Gynecol 1992; 79:988-92. [PMID: 1579328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Wound complications were investigated in 100 patients undergoing chemotherapy for epithelial ovarian cancer and compared with wound complications in patients with other gynecologic malignancy who did not receive chemotherapy but were operated on by the same gynecologic oncologists. The incidence of wound complications in the chemotherapy-treated population was 11%. Complications developed with equal frequency regardless of when postoperative chemotherapy was initiated. Thus, chemotherapy did not increase the risk of wound complications despite efforts to begin chemotherapy as soon as possible after cytoreductive surgery. Low postoperative albumin levels (P less than .01), postoperative hemoglobin of 10 g/dL or less (P less than .02), advanced stage of disease (P less than .004), and electrocautery use (P less than .05) were all risk factors for development of wound complications, whereas the frequency of bowel resection and type of fascial or skin closure did not adversely influence the risk. Patients who received chemotherapy and developed wound breakdown actually healed faster than our control population. They healed at the same rate as did obstetric and gynecologic patients from the literature. Because delays in administering chemotherapy postoperatively have been associated with decreased survival, we recommend that chemotherapy for advanced-stage epithelial cancer not be delayed solely because of concern for wound healing.
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Affiliation(s)
- B A Kolb
- Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange
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Novick RJ, Menkis AH, McKenzie FN, Reid KR, Pflugfelder PW, Kostuk WJ, Ahmad D. The safety of low-dose prednisone before and immediately after heart-lung transplantation. Ann Thorac Surg 1991; 51:642-5. [PMID: 2012424 DOI: 10.1016/0003-4975(91)90325-k] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Preoperative steroid use has been considered a contraindication to heart-lung as well as lung transplantation. Moreover, most centers delay prednisone administration until 2 to 3 weeks postoperatively until airway healing is secure. We have performed 19 heart-lung transplantations and four single-lung transplantations since 1983. Five recipients (4 heart-lung, 1 single lung) had received prednisone, 5 to 40 mg daily, for 2 to 10 years preoperatively. All recipients were administered prednisone, 0.5 mg/kg daily, starting on postoperative day 1, with a taper to 0.2 mg/kg daily by 4 weeks. Minnesota antilymphocyte globulin (for 10 days), cyclosporine, and azathioprine were also employed. Bronchoscopy, lavage, and transbronchial biopsies were performed every 2 weeks for 3 months postoperatively. No patient had a serious airway complication; 2 heart-lung recipients, not on prednisone preoperatively, had a minor tracheal slough detected on bronchoscopy that resolved spontaneously. Actuarial survival after heart-lung transplantation is 84% +/- 8% and 69% +/- 16% at 1 year and 2 years, respectively. We conclude that prednisone commencing at a dose of 0.5 mg/kg daily from the first postoperative day is a safe practice after heart-lung transplantation. The long-term use of low-dose prednisone before heart-lung transplantation does not preclude normal tracheal healing. The safety of prednisone before and immediately after single-lung transplantation awaits confirmation by further experience.
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Affiliation(s)
- R J Novick
- Division of Cardiovascular-Thoracic Surgery, University Hospital, London, Ontario, Canada
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Fechner PU, Wichmann W. Retarded corneoscleral wound healing associated with high preoperative doses of systemic steroids in glaucoma surgery. Refract Corneal Surg 1991; 7:174-6. [PMID: 2043563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We compared two groups of human eyes with corneoscleral wounds. One group consisted of 100 phakic myopic eyes which received an iris fixated "claw" intraocular lens with a minus power optic. Prior to the operation, 350 mg of prednisone was administered systemically. Ten of these eyes (10%) developed a wound dehiscence requiring resuturing. The other group consisted of 1002 cataract operations where 20 mg of prednisone was administered subconjunctivally after the operation. No wound dehiscences occurred in this group. Pretreatment may be of value where fistual formation is desired, ie, with glaucoma surgery.
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Affiliation(s)
- P U Fechner
- Department of Ophthalmology, Robert Koch Hospital, Hannover-Gehrden, Germany
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Engelmann U, Sonntag W, Jacobi GH. Influence of perioperative cis-platinum on breaking strength of bowel anastomoses in rats. Recent Results Cancer Res 1985; 98:35-9. [PMID: 4041068 DOI: 10.1007/978-3-642-82432-6_4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Henzes MJ, Fine A, Chiavacci A, Bondi R. The effects of gastrografin in postoperative intestinal anastamoses in animals. Curr Surg 1984; 41:92-4. [PMID: 6723359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
Sodium hyaluronate (Healon) is an ideal material for protecting the cornea during intraocular lens implantation and protecting donor corneal material during corneal transplantation. Although it has been advocated for maintaining filtering blebs during trabeculectomy and as a vitreous replacement, its main benefit to ophthalmic surgeons is its protection of the cornea during anterior segment surgery.
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Buzello W, Krieg N, Brobmann GF. [Neostigmine and dehiscence of intestinal anastomoses (author's transl)]. Anasth Intensivther Notfallmed 1982; 17:81-5. [PMID: 7091589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In a study from 1968, anastomotic leakage was reported to be nine times as frequent if neostigmine was used for reversal of curare action than in control patients. Subsequent studies did not confirm this finding although it is not disputed that neostigmine activates bowel peristalsis. Both animal experiments and clinical observations indicate that anastomoses in undamaged bowel, if properly done, withstand all kinds of hyperperistalsis. However, it cannot entirely be excluded that coincident pathologic conditions (cachexia, damaged bowel, chronic steroid medication, anaemia etc.) may occur, in which neostigmine administration is unsafe. Appropriate anaesthesiological techniques to avoid the need for neostigmine include titration of the individual relaxant requirement by means of a peripheral nerve stimulator, preference of intermediate or short-acting nondepolarizing muscle relaxants and primary postoperative mechanical ventilation. If nevertheless reversal of residual nondepolarizing block is decided, it should be performed with deep halothane anaesthesia still maintained and by means of an anticholinesterase agent with little muscarinic side effect such as edrophonium (0.5-1.0 mg/kg).
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Abstract
Experiments were performed to test the hypothesis that 5-Fluorouracil (5-FU) would delay or prevent healing of large-bowel anastomoses. The caecums of 120 specific-pathogen-free rats were transected and reanastomosed at once. Daily intravenous injections of 5-FU were given to half the rats, the other half being controls and receiving an equal volume of saline. At Days 5, 7 and 10, standard-sized sections of sutire line were pulled apart, and the force required to do this was recorded. At five days the strengths of the anastomoses in the 5-FU treated animals were only 25% of that of the controls, but by ten days they were over 60% of the strength of the controls. It was concluded that 5-FU delayed, but did not prevent, healing, and that it would be safe to use it in the early postoperative period, but not until several days after operation.
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Burry HC. Penicillamine and wound healing--a potential hazard? Postgrad Med J 1974; 50 Suppl 2:75-6. [PMID: 4467185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Schima E. [Dehiscence of intestinal anastomoses caused by intraperitoneal administration of Trasylol]. Langenbecks Arch Chir 1969; 325:336-40. [PMID: 5309034 DOI: 10.1007/bf01255933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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