Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature

INTRODUCTION

Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation.

METHODS

A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery".

RESULTS

Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction.

CONCLUSIONS

The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients

BACKGROUND

Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores.

METHODS

From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration.

RESULTS

The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively).

CONCLUSION

The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Use of icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL Registry

INTRODUCTION

Intra-abdominal adhesions occur in many patients following major abdominal surgery and represent a serious burden to patients and healthcare providers. The multicentre ARIEL (Adept Registry for Clinical Evaluation) Registry was established to gather clinical experiences in the use of icodextrin 4% solution, an approved adhesion-reduction agent, during routine general surgery.

PATIENTS AND METHODS

General surgeons from five European countries completed anonymised data collection forms for patients undergoing laparotomy or laparoscopy. Surgeons recorded patient demographics, use of icodextrin 4% solution and adverse events, and made subjective assessments of ease of use and patient acceptability with the agent.

RESULTS

The general surgery registry included 1738 patients (1469 laparotomies, 269 laparoscopies). Leakage of fluid from the surgical site did not appear to be affected by icodextrin 4% solution and was classified as 'normal' or 'less than normal' in most patients (laparotomies 86%, laparoscopies 88%). Overall, satisfaction with ease of use was rated as 'good' or 'excellent' by the majority of surgeons (laparotomies 77%, laparoscopies 86%). Patient acceptability was also good, with ratings of 'as expected' or 'less than expected' in most cases for both abdominal distension (laparotomies 90%, laparoscopies 91%) and abdominal discomfort (laparotomies 91%, laparoscopies 93%). Adverse events occurred in 30.6% of laparotomy patients and 16.7% of laparoscopy patients; the most common events were septic/infective events (4.2% and 3.4% in the laparotomy and laparoscopy groups, respectively). Anastomotic wound-healing problems were reported in 7.6% of patients in the subset of laparoscopy patients undergoing anastomotic procedures (n = 66).

DISCUSSION

Volumes of icodextrin 4% solution used as an irrigant and instillate were in line with recommendations. Surgeons considered the agent to be easy to use and acceptable to patients. The reported frequencies of adverse events were in line with those published in the literature for surgical procedures, supporting the good safety profile of this agent.

CONCLUSIONS

Icodextrin 4% solution can be used in a wide range of surgical procedures. In combination with good surgical technique, it may play an important role in adhesion reduction.

[Digestive surgery in the elderly]

The dramatic increase in digestive surgery among patients of advanced age is the logical consequence of the aging population demographics in developed countries. Surgery in the aged is not fundamentally different, but it demands precise and tailored assessment and management of surgical indications and surgical and anesthetic techniques. Advanced age is not a contraindication to even major digestive surgery, but every effort must be made to avoid urgent operations by attention to pre-existing symptoms which are all-too-often neglected in the aged. Intensive care may help to shorten the hospital stay which should ideally occupy only a minor portion of the numbered days of the patient (whose life expectancy may be significantly longer than one may intuitively foresee).

[Post-operative bowel obstruction. Part 2: Mechanical post-operative small bowel obstruction by bands and adhesions]

Small Bowel obstruction due to post-operative adhesions is a common problem in a general surgical practice. Any laparotomy initiates the lifelong risk of this complication. Mortality rates have improved dramatically in the last three decades. The basic evaluation and treatment of small bowel obstruction is well defined but many individual strategies may result from the variety of clinical presentations and from techniques and equipment available to a local surgical practice. Recent advances in surgical techniques and preventive strategies may improve overall results. Results will remain linked to the continuous aging of the populations of Western countries.

[Gastrointestinal tract in the elderly]

Patient's age no longer is a major factor when discussing the diagnosis and treatment of hepatobiliary and gastrointestinal diseases. However, discussing with the physician in charge of the patient is the only adequate way to propose the quickest, least invasive and most comfortable imaging modality that will give a proper answer to the clinical problem. Cross sectional imaging, especially ultrasound, CT and in some cases MRI, plays an important role in the diagnosis of these diseases.

[Post-operative bowel obstruction. Part 1: Intraperitoneal bands and adhesions--causes and prevention]

Postoperative peritoneal bands and adhesions are very common and may occur after any surgical procedure within the peritoneal cavity. Certain factors have been shown to contribute to their formation. The abdominal surgeon should take account of these factors in his daily practice; a reasoned and preventive surgical approach and the use of techniques and products with proven clinical efficacity are to be recommended. This should permit the surgeon to simplify and minimize post surgical work and to diminish the incidence and complications of adhesions in both the immediate and long-term post-operative periods such as post-surgical pain syndromes, mechanical bowel obstruction, and adhesive peritonitis complicating reinterventional surgery.

[Acute intestinal occlusions]

Acute intestinal obstruction comprises a vast clinical entity characterized by the items of the obstruction syndrome. It encompasses numerous etiologies, and in Western countries adhesions are currently the main cause. The work up of this urgent surgical condition must above all be clinical, even though new techniques will probably improve their diagnosis and treatment (CT scan, stent). These new technologies still have to be documented and validated. Likewise, the laparoscopic approach of acute intestinal obstruction has to be prudent. The overall mortality of this urgent condition is still high, more than 10% of the patients.

[Patients, surgeons and surgical gloves]

Consumption of surgical gloves in progressing constantly. All proposed products do not have the same qualities in terms of protection, comfort, and safety for the surgeon, the surgical team and the patient. Latex is the basic material used to manufacture surgical gloves even if it does raise the problem of side-effects and requires use of starch powder for lubrification. The surgeon should be aware of the different products and participate in choosing this indispensable tool. There is a general and advisable trend to using non-powdered gloves.

Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. French Association for Surgical Research

HYPOTHESIS

The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively.

DESIGN

Retrospective review of cases of intestinal obstruction after laparoscopic surgery.

SETTING

Sixteen surgical units performing laparoscopy in France.

PATIENTS

Twenty-four patients with intestinal obstruction.

MAIN OUTCOME MEASURES

Prevalence values and descriptive data.

RESULTS

The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred.

CONCLUSION

Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

[Pancreatectomy and diabetes]

Post total pancreatectomy diabetes is a clearly defined form of unstable diabetes, requiring low doses of insulin, with frequent and severe hypoglycemic events. This is due to both deficiency of pancreatic glucagon, hormone of primary importance for hepatic gluconeogenesis and glycogenolysis, and exocrine failure. The management of this form of diabetes is difficult, involving exact correction of malabsorption and low doses of insulin. Whenever possible, partial pancreatectomy should therefore to be preferred. After partial pancreatectomy, the likelihood of diabetes depends on the volume of the remaining pancreas, the type of resection and above all the preexisting pancreatic status. Prevention of postoperative hyperglycemia could minimize the risk of long-term diabetes. Pancreatic cancer is a particular case: the onset of diabetes could be a manifestation of occult pancreatic cancer and glucose metabolism may improve after tumour excision with preservation of some pancreatic tissue.

Survey of the impact of randomised clinical trials on surgical practice in France. French Associations for Research in Surgery (AURC and ACAPEM). Association Universitaire de Recherche en Chirurgie. Association des Chirurgiens de l'Assistance Publique pour l'Evaluation Médicale

OBJECTIVE

To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France.

DESIGN

Telephone questionnaire.

SETTING

Multicentre study, France.

SUBJECTS

A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice.

RESULTS

148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results.

CONCLUSIONS

French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

[Preoperative skin preparation in abdominal surgery]

Mechanical skin preparation is a daily nursing procedure in abdominal surgery. Even though a single procedure has not yet been adopted, several evidence-based points can be found in the literature: non-shaving or depilation of the surgical field with and electric clipper give the lowest rate of wound infection. The same is true for shaving of the operative field just before the operation. The beneficial effects of depilatory cream have not been demonstrated. Finally, there are no current data dealing with the acceptability and the overall cost of depilation procedures.

Differential transferrin receptor density in human colorectal cancer: A potential probe for diagnosis and therapy

Transferrin receptor density was investigated in human colorectal surgical specimens. Crude membranes were prepared from 23 cancer tumors (adenocarcinoma or malignant villous tumor) and 3 non-cancer tumors (polyadenoma or villous tumor) and 26 adjacent control mucosa. Contrary to non-cancer tumors, Scatchard analysis of 125I-transferrin binding data evidenced higher maximal transferrin binding capacity and lower dissociation constant in cancer tissues (Bmax cancer 1.828+/-0.320 nmol/g, Kd 24.1+/-4.7 nM), as compared to paired control colonic mucosa (Bmax contol 0.851+/-0.182 nmol/g, Kd 30.7+/-7.3 nM), paired t-tests: Bmax p<0.001, Kd p<0.05). As the cancer/control Bmax ratio was 2.6+/-0.4,transferrin carrier constructs should be proposed for cancer imaging or therapy.

[Acute mesenteric ischemia: changes in 1985-1995. Surgical Research Associations]

AIM OF THE STUDY

Acute mesenteric ischaemia (AMI) resulting in intestinal ischaemia and/or infarction is associated with an extremely serious prognosis and a mortality rate ranging from 40% to 100%. The aim of the study is to appreciate the epidemiological, therapeutic and prognostic changing aspects of the AMI over a decade.

PATIENTS AND METHODS

Two retrospective and multicentric series (492 and 305 patients, respectively) identically collected between 1980-1985 and 1990-1995 by the French Associations of Surgical Research were compared. Comparisons concerned the patients' clinical features, the aetiology of AMI and the surgical management. The mortality was analysed taking into account the former items.

RESULTS

The overall mortality rate decreased from 77% to 59% (P < 0.0001). The patients' preoperative clinical features improved but collapse remained the main serious factor. The rate of venous origin AMI increased significantly (P < 0.02) with a mortality decrease (51% to 19%, P < 0.0001). The mortality rate of thrombotic origin AMI decreased (83% to 63%, P < 0.0001). The results of surgical management improved, even though the frequency of angiographies, vascular and second-look procedures did not increase.

CONCLUSION

Even though the prognosis of AMI remains extremely serious, a significant decrease of the overall mortality rate is observed. Two ways of progress can be recommended: the first, successfully initiated involving better management of the patients with a greater number of classical surgical procedures; the second, more aggressive treatment advocated by more specialised surgical teams.

Post-operative peritoneal adhesions and foreign bodies

One of the proven causes of adhesions is foreign microbodies which are present in up to 93% of all re-operated patients in which adhesions are analysed for evidence of external contamination. Studies are described which show the changing nature of foreign microbodies with time, associated with the development of new surgical practices. This paper concludes that although foreign bodies found today may not be the same as those found 30 years ago, they remain prominent in the aetiology of adhesions--the main cause of postoperative intestinal obstruction. Every effort should be made to minimise tissue contamination during operations with particulate debris such as glove powder.

Foreign bodies and intraperitoneal post-operative adhesions

The presence of foreign bodies is one of the recognized causes of fibrous bands and intraperitoneal post-operative adhesions. The objective of this study was to identify foreign bodies actually present in fibrous bands and intraperitoneal post-operative adhesions. From a series of 211 consecutive patients re-laparotomized by the same surgeon over a period of two years, 193 (91%) showed fibrous bands or adhesions; of these, 133 (69%) also showed reactions to foreign bodies. Comparison with a reference list established in animal work showed than in 127 (66%) of the cases the foreign bodies were of cellulose textile origin; in 3% of the cases, they were of diverse origin--starch powder, synthetic textiles, sutures, or unidentifiable particles.

Efficacy of double gloving with a coloured inner pair for immediate detection of operative glove perforations

OBJECTIVE

To compare the efficacy of double gloving with an inner coloured pair of gloves and double gloving with classic gloves, for prompt detection of perforation during a single standard operation.

DESIGN

Prospective, randomised study.

SETTING

Teaching hospital, France.

SUBJECTS

100 Consecutive patients with haematological malignancy or AIDS, who were referred for implantation of a vascular access port.

INTERVENTIONS

Insertion of a central line with an implantable chamber under local anaesthesia. The use of double gloving with an inner coloured pair or with classic gloves was decided preoperatively by random allocation.

MAIN OUTCOME MEASURES

Visual detection of one or more perforations on one or more gloves during operation, localisation of the perforation(s), and post-operative evaluation of the water tightness of the gloves.

RESULTS

There were a total of 14 perforations of the outer gloves, 9 were detected during operation in the coloured inner pair group compared with none in the standard gloves group. Postoperative testing showed that there were no undetected perforations in the coloured inner pair group compared with 5 in the standard gloves group.

CONCLUSIONS

Double gloving with a coloured inner pair is effective in the peroperative detection of accidental perforations in surgical gloves.

Foreign material in postoperative adhesions

OBJECTIVE

The authors determined the prevalence of foreign body granulomas in intra-abdominal adhesions in patients with a history of abdominal surgery.

PATIENTS AND METHODS

In a cross-sectional, multicenter, multinational study, adult patients with a history of one or more previous abdominal operations and scheduled for laparotomy between 1991 and 1993 were examined during surgery. Patients in whom adhesions were present were selected for study. Quantity, distribution, and quality of adhesions were scored, and adhesion samples were taken for histologic examination.

RESULTS

In 448 studied patients, the adhesions were most frequently attached to the omentum (68%) and the small bowel (67%). The amount of adhesions was significantly smaller in patients with a history of only one minor operation or one major operation, compared with those with multiple laparotomies (p < 0.001). Significantly more adhesions were found in patients with a history of adhesions at previous laparotomy (p < 0.001), with presence of abdominal abscess, hematoma, and intestinal leakage as complications after former surgery (p = 0.01, p = 0.002, and p < 0.001, respectively), and with a history of an unoperated inflammatory process (p = 0.04). Granulomas were found in 26% of all patients. Suture granulomas were found in 25% of the patients. Starch granulomas were present in 5% of the operated patients whose surgeons wore starch-containing gloves. When suture granulomas were present, the median interval between the present and the most recent previous laparotomy was 13 months. When suture granulomas were absent, this interval was significantly longer--i.e., 30 months (p = 0.002). The percentage of patients with suture granulomas decreased gradually from 37% if the previous laparotomy had occurred up to 6 months before the present operation, to 18% if the previous laparotomy had occurred more than 2 years ago (p < 0.001).

CONCLUSIONS

The number of adhesions found at laparotomy was significantly larger in patients with a history of multiple laparotomies, unoperated intra-abdominal inflammatory disease, and previous postoperative intra-abdominal complications, and when adhesions were already present at previous laparotomy. In recent adhesions, suture granulomas occurred in a large percentage. This suggests that the intra-abdominal presence of foreign material is an important cause of adhesion formation. Therefore intra-abdominal contamination with foreign material should be minimized.

Giant cavernous hepatic hemangiomas in adults: enucleation under selective blood inflow control

Among hepatic hemangiomas (the most common solid hepatic tumor in adults), "giant hemangiomas" are those defined by a diameter greater than 4 cm. The natural history of such lesions is unclear, and many surgical procedures have been described. In five women and one man (mean age 49), we successfully used enucleation of the tumor under blood inflow control. This technique was made possible by a cleavage plane between the hepatic parenchyma and the hemangioma. This straightforward and safe procedure required a low rate of transfusion (mean 200 mL/patient) and spared a maximum amount of hepatic tissue.

Liver metastases: safety and efficacy of detection with superparamagnetic iron oxide in MR imaging

PURPOSE

To evaluate the clinical and biologic safety of superparamagnetic iron oxide (SPIO) as a contrast agent in magnetic resonance (MR) imaging and to assess its efficacy in the detection of liver metastases.

MATERIALS AND METHODS

Twenty adults with liver metastases underwent MR imaging at 1.5 T before and 1 hour after infusion of SPIO. Four spin-echo (SE) sequences and one gradient-echo (GRE) sequence were used.

RESULTS

There were no adverse reactions. Alterations in serum protein, serum iron, transferrin, and ferritin levels and transferrin saturation coefficient were statistically significant. The mean tumor-to-liver contrast-to-noise ratio (C/N) increased markedly with all sequences. The best postcontrast tumor-to-liver contrast was obtained with the GRE sequence (repetition time msec/echo time msec = 300/15). The mean number of apparent lesions detected after administration of SPIO increased by 12 with the proton-density-weighted SE sequences (800/30 and 2,500/30), four with the T2-weighted SE sequence (2,500/90), and seven with the GRE sequence (300/15).

CONCLUSION

SPIO is safe, increases tumor-to-liver C/Ns with some sequences, and improves the detection of liver metastases.

[Intravenous glucose tolerance test in the functional exploration of segmental pancreatic autografts in the dog]

The aim of the present study is based on the comparison of intravenous tolerance testing before and after segmental pancreas autotransplantation in the dog. The results show that such testing must take in account the "glucose diffusion space", using the same glucose load in order to avoid the bias related to the post-operative loss of body weight.

Common bile duct stricture as a late complication of upper abdominal radiotherapy

We report the cases of two patients who developed symptomatic common bile duct stricture 10 years after upper abdominal radiotherapy for malignant lymphoma. Both patients were in complete remission and presented with marked obstructive jaundice. Endosonography was useful in both cases and showed segmental thickening of the bile duct wall narrowing in the lumen. Both patients underwent surgical exploration, confirming biliary obstruction due to intrinsic wall thickening, and had successful biliary drainage by Roux-en-Y hepatico-jejunostomy. Histological examination of the resected bile duct, in one case, and of a bile duct biopsy, in the other, was consistent with late irradiation injury. We conclude that stricture may be a delayed consequence of radiotherapy applied to normal bile ducts.

[Catheters with implantable chamber, technique of implantation. 168 consecutive patients in a single year]

Our experience with 168 consecutive implantable chamber catheters over a one year period led us to establish the criteria for this implantation technique. Implantation should be carried out under local anaesthesia and be well tolerated and comfortable for the patient who is often weak. It should be a first indication technique in order to save the venous capital. Based on our experience, subclavian implantation corresponds best to these criteria.

[Natural history of postoperative intraperitoneal adhesions. Surely, a question of the day]

Postoperative intraperitoneal adhesions are known to occur after conventional surgery. The prospective study that we have performed in 1992 shows that the frequency of postoperative intraperitoneal adhesions is very high (93% of patients). It is higher than was stated 20 years ago, while so-called "spontaneous" adhesions seem to be decreasing. The histological study of postoperative intraperitoneal adhesions shows a specific evolution in time and a very high frequency of foreign bodies (starch, variably decayed textile fibers) (92%). The very great frequency of such foreign bodies in postoperative intraperitoneal adhesions, logically involving them in the genesis of this condition, may be an argument in favor of the new surgical techniques, especially of celioscopy.

[Lymphangioma of the mesentery. A rare cause of acute abdominal pain syndrome in adults]

We report about one case of cystic lymphangioma of the jejunum in a 27-year-old woman admitted to hospital for abdominal pain. The study of this case and the review of the literature enabled us to bring out the main characteristics of the lesion: rarity in adults, benignancy, mode of occurrence--most often painful--, radiological--and particularly CT--features, diagnosis based on histological findings only, and lastly, treatment with surgical exeresis that must be complete to prevent recurrence.

Primary retroperitoneal teratoma in the adult: correlation of MRI features with CT and pathology

Primary benign teratoma of the retroperitoneum is a rare tumor in the adult population. Only one case with an MRI examination has been reported in the English literature. This paper describes the CT and MRI features of a retroperitoneal teratoma in a 24-year-old male and discusses the value of MRI in the diagnosis and the preoperative imaging of such a tumor.

Ex vivo evaluation in normal dogs of insulin released by a bioartificial pancreas containing isolated rat islets of Langerhans

In bioartificial pancreatic systems, isolated islets of Langerhans are protected against immune rejection by an artificial membrane, permeable to glucose and insulin, but not to immunoglobulins and lymphocytes. Some of these devices, referred to as vascular systems, are set up to be connected to a vascular site in the recipient, with blood circulating in contact with one side of the membrane, and the islets on the other side. Such a bioartificial pancreas, containing isolated rat islets of Langerhans, was connected to an arteriovenous shunt of a normal anesthetized dog. The aim of this experiment was to investigate the kinetics of the insulin secretory response of the system to a glucose load. Glucose was infused upstream of the system, increasing the glucose concentration inside the bioartificial pancreas from 7 to 14 mmol/l, without altering the blood glucose concentration of the dog. Insulin concentration was determined simultaneously upstream and downstream of the bioartificial pancreas. Insulin production was calculated by multiplying the difference between these values by the blood flow rate. Blood flow rate (Q) was estimated from the change in the glucose concentration produced by the glucose infusion using a mass transfer analysis derived from Fick's principle. Insulin production increased from 20 +/- 8 to 59 +/- 15 microU/100 islets/min within 15 min following the beginning of the stimulation (n = 6, p less than 0.05). Five min after the end of the stimulation, insulin production decreased from 75 +/- 13 to 50 +/- 9 microU/100 islets/min (p less than 0.05) to reach the basal level (21 +/- 3 microU/100 islets/min) 30 min after the end of the glucose stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin release from isolated islets of Langerhans after segmental-pancreas autotransplantation in dogs

Pancreas transplantation is warranted essentially by the quality of glucose regulation. Although the fasting blood glucose is invariably normal, this may not be the case during glucose load tests. The purpose of this study was to examine dysregulation within the isolated islet originating from a segmental-pancreas autograft in the dog. Results show an increased basal insulin secretion by the graft islets in static incubation compared with that of islets originating from the head of the pancreas and left in situ. This abnormal secretion may be accounted for by various factors intervening within the graft or the isolated islet, thus suggesting a possible improvement in the surgical model.

The arteriovenous fistula in segmental pancreatic transplantation in dogs--a hemodynamic study

Arterial and/or venous thrombosis is a frequent complication in experimental or human pancreatic transplantation. A canine experiment was used to study the hemodynamic effects of spleno-splenic arteriovenous fistula during segmental pancreatic transplantation. An increase in blood flow, without "steal" syndrome in the pancreatic blood supply or pressure increase, was found. Thus this technique can help prevent vascular thrombosis in pancreatic transplant in dogs.

Biliary lithiasis in the over seventy-five age group: a new therapeutic strategy

Sixty-four gallstone patients aged 75 or more (mean age 83 +/- 5.1 years) were divided prospectively into two groups. They were mostly high-risk patients (average number of major risk factors, 2.2 +/- 0.9). Thirty-three showed one or several signs of lithiasis of the common bile duct and were treated with endoscopic sphincterotomy (ES) (31 successful cases, two technical problems) followed by early cholecystectomy (33 cases). Choledocholithiasis was present in 26 cases and stones were extracted in 25 cases. Two patients (6 per cent) died. ES caused no complications. Thirty-one other patients showed no sign of choledocholithiasis and were treated by cholecystectomy with operative cholangiography. Choledocholithiasis was found in two of these patients and treated by extraction and external drainage. Five of these patients (16 per cent) died. In 30 cases acute cholecystitis was found at operation, 15 in each group. ES is therefore an efficient procedure in high-risk patients, which facilitates operation, especially in cases of acute cholecystitis, and it is recommended in all cases of complicated biliary lithiasis. Early cholecystectomy is justified for these patients by the high frequency of associated acute cholecystitis.

[Heterotopic segmental autotransplantation of the pancreas with digestive system anastomosis in the dog]

Segmental autotransplantation of pancreas in the heterotopic position, with digestive anastomosis protected by an epiploplasty was performed in a series of 22 dogs. Twenty dogs survived the operation and nine were followed up for 4 weeks: the histologic and morphologic qualities of the graft were very favorable from both endocrine and exocrine points of view. This morphohistologic quality can be related to the digestive anastomosis performed, which failed to provoke any specific complications to a large extent. This study should be completed by improvement in the vascularization of the graft by a splenic arteriovenous fistula and a concomitant study of the endocrine function of the transplanted pancreas in dogs with experimentally-induced diabetes.

Large abdominal incisional hernias: repair by fascial approximation reinforced with a stainless steel mesh

One hundred and fifty large abdominal incisional hernias were treated following a standardized operating technique using metallic mesh (Toilinox) and approximation of the anterior sheath of the rectus abdominis. The average follow-up was four years. Good clinical results without pain were found in more than 95 per cent of the patients. Recurrence occurred in 9.5 per cent of the patients. The complications, wound infection or parietal necrosis, never necessitated removal of the prosthesis. These results justify the use of this technique even when intra-abdominal septic procedure is associated.

[Early enteral feeding with a jejunal catheter in digestive surgery. 100 cases]

Catheterization through a jejunostomy was employed in 100 patients undergoing major digestive surgery. Early enteral feeding was possible by this route in 69 cases, using either simple or, more frequently, complex nutrient solutions. In spite of several incidents due mainly to the initiation of this procedure, and a high proportion of functional disorders (diarrhoea and meteorism in 23 and 28% of cases respectively), this method appears to be favorable both in respect of nutrition and from the practical point of view.

Aorto-digestive fistulae

On the basis of a case of aorto-duodenal fistula due to fissuration of a tuberculous sub-renal aneurysm, the authors review the difficult question of primary and secondary aorto-digestive fistulae. Primary fistulae are due to the rupture of an artheromatous or infectious aneurysm. The latter possibility must always be borne in mind. Aneurysms secondary to an aortic suture are more common in practice. There is also often a troublesome infectious element, requiring axillobifemoral bypass prior to treatment of the aneurism itself.

[Early jejunal catheter feeding in heavy gastrointestinal surgery (author's transl)]

Fifty patients undergoing extensive gastrointestinal surgery were fed through a jejunal catheter introduced during the operation. After surgery, feeding was started 48 hours, except for 10 patients who had pre-operative intestinal obstruction or a suture below the site of liquid food instillation. The decision to feed patients enterally must by taken during surgery, and the method requires a trained nursing team, but it considerably improves the patient's nitrogen balance and, accessorily, his comfort. There does not seem to be any contra-indication. The onset of enteral feeding only depends upon the type of operation performed.