Elective Laparotomy Research Articles

A double blind randomized clinical trial as preemptive and preclosure analgesia using bupivicaine in post operative pain

Background: Post-operative pain management has been a constant challenge to many of the surgeons. Effective relief of pain has got physiological and psychological benefits. Because of their side effects most of the analgesic dosage is inadequate. There is need for developing newer modalities which can provide good analgesia with fewer side effects. The aim of the study was to compare preemptive and preclosure infiltration of bupivacaine in reducing post-operative pain and analgesic requirement.Methods: Double blind randomized clinical trial was done in GIMS Hospital Gadag, Karnataka, India. Total of 40 patients, 10 undergoing open cholecystectomy, 10 undergoing laparoscopic cholecystectomy, 20 undergoing elective laparotomy were included in study. Post-operative pain measured using numerical VAS and amount of analgesic use.Results: In the whole group comparison though the pain score was less in preemptive group but it was not significant. Requirement of rescue analgesia occurred early in preclosure group and also there was significant difference in analgesic requirement at 6th hour and at 10th hour.Conclusions: Overall, though preemptive infiltration of bupivacaine reduces pain better than preclosure infiltration in common abdominal surgeries but it may be not significant. Preemptive infiltration of bupivacaine delays the time duration for the requirement of first analgesic dose and may also be helpful in reducing the number of analgesic doses in postoperative period when compared to preclosure infiltration in common abdominal surgeries.

Clinical Outcome of Emergency Laparotomy: Our Experience at tertiary care centre (A case series)

Introduction: Laparotomy is broadly used for any surgery requiring opening of abdominal wall and exploration of the underlying structures. Elective laparotomy indirectly implies that there is ample time for preoperative assessment and preparation of the patient. On the other hand, an emergency laparotomy is a lifesaving procedure, undertaken mostly in acute cases, without much preparation of the patient. Materials and methods: This retrospective study included cases that underwent laparotomy for acute abdominal conditions between Jan 2013 to Jan 2014.We also studied the morbidity associated with each case and compared the results. Results: Morbidity and mortality after emergency laparotomy is high. This incidence increases in cases with associated co morbidities like COPD, asthma, diabetes mellitus, hypertension, pneumonia, renal failure. Out of 100 cases of emergency exploratory laparotomy performed 56 cases were due to hollow viscus perforation in which duodenal perforation was most common accounting for 28 cases. However, the maximum mortality rate was seen with gastric (26%) followed by ileal (10.5%), duodenal (10.5%), and jejunal and colonic perforations (5.25%). Conclusion: Most common condition for which emergency laparotomy was done was perforated peptic ulcer . The mortality and morbidity after emergency laparotomy is closely related to presence or absence of diabetes mellitus, hypertension, chronic renal impairment, cardiovascular disease (angina), asthma, liver disease, chronic obstructive pulmonary disease and metastatic disease and morbidity and mortality of patients who underwent emergency laparotomy is high when associated with these conditions.

The first successful elective laparotomy.

From time to time I ask a group of nurses or medical students or even surgeons if they can tell me when the first successful elective laparotomy was performed, where it took place and who was the surgeon. After much thought, someone will guess "end of the 19th century", suggest some great teaching hospital in London or Edinburgh or Vienna and hazard the name of Joseph Lister. To date, no one has given me the correct answer--the date was 1809, the place Danville, in Kentucky USA and the surgeon was Ephraim McDowell.

A-Part Gel, an adhesion prophylaxis for abdominal surgery: a randomized controlled phase I-II safety study [NCT00646412

BackgroundIntra-abdominal surgical intervention can cause the development of intra-peritoneal adhesions. To reduce this problem, different agents have been tested to minimize abdominal adhesions; however, the optimal adhesion prophylaxis has not been found so far. Therefore, the A-Part® Gel was developed as a barrier to diminish postsurgical adhesions; the aim of this randomized controlled study was a first evaluation of its safety and efficacy.MethodsIn this prospective, controlled, randomized, patient-blinded, monocenter phase I–II study, 62 patients received either the hydrogel A-Part-Gel® as an anti-adhesive barrier or were untreated after primary elective median laparotomy. Primary endpoint was the occurrence of peritonitis and/or wound healing impairment 28 ± 10 days postoperatively. As secondary endpoints anastomotic leakage until 28 days after surgery, adverse events and adhesions were assessed until 3 months postoperatively.ResultsA lower rate of wound healing impairment and/or peritonitis was observed in the A-Part Gel® group compared to the control group: (6.5 vs. 13.8 %). The difference between the two groups was −7.3%, 90 % confidence interval [−20.1, 5.4 %]. Both treatment groups showed similar frequency of anastomotic leakage but incidence of adverse events and serious adverse events were slightly lower in the A-Part Gel® group compared to the control. Adhesion rates were comparable in both groups.ConclusionA-Part Gel® is safe as an adhesion prophylaxis after abdominal wall surgery but no reduction of postoperative peritoneal adhesion could be found in comparison to the control group. This may at least in part be due to the small sample size as well as to the incomplete coverage of the incision due to the used application.Trial Registration: NCT00646412

전신마취하 개복술 환자의 수술중 체온에 영향을 미치는 요인

Purpose: The study was conducted to identify factors affecting the intraoperative core body temperature (CBT) of surgical patients under general anesthesia. Methods: This study was performed through a prospective descriptive research design. The sample consisted of 138 patients who had undergone elective laparotomy surgery. Age, weight, height, the basal preoperative CBT, blood pressure, and heart rate were collected. CBT was again measured at induction of anesthesia, 1 hour, 2 hours, and 3 hours following induction of general anesthesia. Results: Factors affecting intraoperative hypothermia < 36˚C at 1 hour following induction, were CBT at induction and total body fat (TBF) (R 2 = .569, p < .001); at 2 hours after induction, CBT at induction and TBF (R 2 = .507, p < .001); at 3 hours after induction, CBT at induction (β = 0.34), TBF, age and the ambient temperature in the operating room (R 2 = .449, p < .001). Conclusion: CBT at induction and TBF appear to be factors affecting intraoperative CBT within 2 hours after induction of anesthesia; CBT at induction, TBF, advanced age and the ambient temperature after 3 hours following induction. We recommend keeping surgical patients warm before induction of anesthesia and providing intraoperative warming for surgical patients of advanced age with low TBF and when the duration of general anesthesia will last more than 3 hours.

Adhesiolysis in Patients Undergoing a Repeat Median Laparotomy.

Adhesiolysis during repeat surgery is associated with a high incidence of iatrogenic enterotomies and an increase in postoperative complications. Identification of risk factors would improve preoperative counseling and operating room strategy. The aim of this study was to identify preoperative risk factors for prolonged and difficult adhesiolysis in a repeat median laparotomy. This is a prospective cohort study. Univariate and multivariate analyses were used to assess the risk factors for prolonged and difficult adhesiolysis. This study was conducted at Radboud University Medical Center. Patients participating in the LAPAD study (ClinicalTrials.gov Identifier: NCT01236625) undergoing an elective repeat median laparotomy were selected. Detailed data regarding adhesiolysis to gain entry to the abdomen and adhesions underneath the previous incision were gathered by direct observation. A total of 259 patients underwent a repeat median laparotomy. Adhesiolysis was required for 230 patients (89%); the remaining 29 patients (11%) did not have adhesions underneath the incision. Median adhesiolysis time underneath the midline incision was 10 minutes (interquartile range, 5-25). Seventy-six patients (29%) had grade 1 or grade 2 adhesions; 108 (42%) had grade 3; and 46 (18%) had grade 4. The number of previous laparotomies was the only independent risk factor for prolonged (p ≤ 0.01; 95% CI, 2.5-14.10) and difficult adhesiolysis (p ≤ 0.01; OR, 4.21; 95% CI, 1.74-10.17). History of peritonitis, anatomical location of previous surgery, and the time interval between consecutive median laparotomies did not prolong adhesiolysis. This study involved retrospective data collection of patients' medical histories. No data were collected on the severity of previous peritonitis. This study demonstrates that 4 or more previous laparotomies and the presence or history of an intraperitoneal synthetic mesh are independently associated with a longer duration of adhesiolysis needed to gain access to the abdomen. A short time interval between median laparotomies or a history of peritonitis did not prolong the duration of adhesiolysis.

Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia

Although hernia repair with mesh can be successful, prophylactic mesh augmentation (PMA) represents a potentially useful preventative technique to mitigate incisional hernia risk in select high-risk patients. The efficacy, cost-benefit, and societal value of such an intervention are not known. The aim of this study was to determine the cost-utility of using prophylactic mesh to augment fascial incisions. A decision tree model was employed to evaluate the cost-utility of using PMA relative to primary suture closure (PSC) after elective laparotomy. The authors adopted the societal perspective for cost and utility estimates. A systematic review of the literature on PMA was performed. The costs in this study included direct hospital costs and indirect costs to society, and utilities were obtained through a survey of 300 English-speaking members of the general public evaluating 14 health state scenarios relating to ventral hernia. PSC without mesh demonstrated an expected average cost of $17,182 (average quality-adjusted life-year [QALY] of 21.17) compared with $15,450 (expected QALY was 21.21) for PMA. PSC was associated with an incremental cost-efficacy ratio (ICER) of -$42,444/QALY compared with PMA such that PMA was more effective and less costly. Monte Carlo sensitivity analysis was performed demonstrating more simulations resulting in ICERs for PSC above the willingness-to-pay threshold of $50,000/QALY, supporting the finding that PMA is superior. Cost-utility analysis of PSC compared to PMA for abdominal laparotomy closure demonstrates PMA to be more effective, less costly, and overall more cost-effective than PSC.

Abdominal fascia closure following elective midline laparotomy: a surgical experience at a tertiary care hospital in Tanzania.

BackgroundThe optimal strategy of abdominal wall closure after midline laparotomy has remained an issue of ongoing debate. This study was undertaken to describe our own experiences with abdominal fascial closure following elective midline laparotomy and compare with what is described in literature.MethodsThis was a descriptive prospective study of patients who underwent elective midline laparotomy at Bugando Medical Centre between March 2009 and February 2014.ResultsA total of 872 patients (M:F = 2.8:1) were studied. The median age was 38 years. The fascia closure was performed with a continuous and interrupted sutures in 804 (92.2%) and 68 (7.8%) patients, respectively. Mass closure and layered closure were performed in 842 (96.6%) and 30 (3.4%) patients, respectively. Monofilament sutures were applied for fascia closure in 366 (42.0%) patients, multifilament sutures in 506 (58.0%) patients. Non-absorbable sutures were chosen in 304 (34.9%) patients, slowly absorbable sutures in 506 (58.0%), and moderately absorbable sutures in 62 (7.1%) patients. Sutures used for fascial closure were vicryl 464 (53.2%), nylon 250 (28.7%), prolene 62 (7.1%), PDSII 54 (6.2%) and silk 42 (4.8%). Sutures with the strength of 0 were used in 214 (24.4%) patients, with strength of 1 in 524 (60.1%) patients, and with strength of 2 in 134 (15.4%) patients. The mean time required for massive closure of the midline incision was 8.20 ± 6.12 min whereas in layered closure, the mean time required for closure was 12.22 ± 7.11 min and this was statistically significant (p = 0.002). Mass closure was significantly associated with low incidence of wound dehiscence and incisional hernia (p < 0.001). Continuous suture was significantly associated with low incidence of wound dehiscence and incisional hernia as compared to interrupted suture (p < 0.001). Non-absorbable sutures were significantly associated with increased incidence of persistent wound pain and stitch sinus as compared to absorbable sutures (p < 0.001). The use of monofilament sutures was insignificantly associated with low incidence of surgical site infection as compared to multifilament sutures (p = 0.051). Prolene was significantly associated with persistent wound pain as compared to vicryl (p = 0.017).ConclusionContinuous mass closure with vicryl is commonly used for abdominal fascial closure following elective midline laparotomy in our setting and gives satisfactory results.

PWE-299 Evaluation of wound infusion catheters as analgesia in elective and emergency colorectal surgery

<h3>Introduction</h3> Wound infusion catheters are becoming increasingly popular to control post-operative pain as an alternative to thoracic epidurals, which have a significant failure rate and complication profile. The aim of this was to review our experience with the OnQ® (Bbraun) wound infusion catheter in patients undergoing elective and emergency colorectal laparotomy in terms of usage, safety and efficacy. <h3>Method</h3> Retrospective analysis of a prospectively maintained database of all patients undergoing elective and emergency colorectal laparotomy at Leicester Royal Infirmary October 2013–2014. Emergency patients ventilated post-operatively were excluded. OnQ® wound catheters were inserted in the preperitoneal plane in combination with morphine PCA, and delivered levobupivicaine 0.25% 5 ml/hr for 56 h. <h3>Results</h3> Since 2008, 727 patients have received wound catheters as analgesia following colorectal laparotomy. Complication rate was low (1.5%), mainly related to catheter displacement (n = 11). During the 12 month study period 179 patients underwent elective colorectal laparotomy. 120 of these had an OnQ® inserted (67%), with a significantly lower total morphine consumption compared to PCA alone (109 vs 193 mg p &lt; 0.05 Mann-Whitney). 239 patients underwent emergency laparotomy during this period. Of these, only 28 had an OnQ® inserted (11%), again with a significantly lower total morphine consumption compared to PCA alone (92 vs. 154 mg p &lt; 0.05 Mann-Whitney). The only complications directly related to the OnQ® during this period were due to catheter displacement (n = 2). <h3>Conclusion</h3> Wound infusion catheters are safe, effective and simple to use. They are a good addition to multimodal analgesia in patients undergoing elective colorectal laparotomy. They are equally effective in patients undergoing emergency laparotomy, however are considerably under-used - an area which will be addressed. <h3>Disclosure of interest</h3> None Declared.

Systematic Nasogastric Tube in Aortic Surgery: Is It Necessary?

Routine nasogastric tube (NGT) decompression has been traditionally used to prevent nausea and vomiting after abdominal surgery. Besides, many studies having demonstrated no benefits derived from this practice after an elective laparotomy, little evidence has been published regarding its use in aortic surgery. In this study, we analyze the effects of the selective use of the NGT in patients undergoing infrarenal aortic surgery in our center. Prospective cohort study including patients who underwent elective infrarenal aortic surgery between January 2011 and December 2012. Patients were prospectively included in group A (systematic NGT placement) and group B (nonsystematic NGT). The main end point was the occurrence of postoperative nausea and vomiting (PONV). Secondary end points were postoperative complications, time to first oral intake, and hospital stay. One hundred patients were finally included in the study, 50 patients per group. Preoperative and intraoperative data were similar between both groups. Higher incidence of PONV (48% vs. 10%; relative risk, 2.4; 95% confidence interval [CI], 1.3-4.5; P=0.003) was observed in group A. Selective NGT behaved as a protective factor regarding earlier first oral intake in first postoperative 48hours (hazard ratio, 0.67; 95% CI, 0.45-0.99; P=0.05). There were no differences in other adverse events although a trend toward fewer respiratory complications was observed in patients with nonsystematic NGT. This study demonstrates higher incidence of PONV and longer time to first oral intake in patients with systematic NGT with no benefits derived from this practice. Based on these results, selective NGT decompression should be encouraged in patients undergoing infrarenal aortic surgery.

Comment on "Trichobezoar Causing Airway Compromise during Esophagogastroduodenoscopy".

We read with great interest the article by Kao et al. [1] published in the September 2015 issue of Case Reports in Medicine, which highlighted how important is the careful attention to airway management during esophagogastroduodenoscopy for removal of a trichobezoar and similar foreign body. However, until today, it is still controversial which is the best option for the treatment of gastric bezoar. Endoscopic therapy can be efficient for bezoars composed of milk curd (lactobezoars) and vegetable matter (phytobezoars) because usually they are small in size, but it is difficult to be efficient for trichobezoars, especially those that are large (>20 cm) [2]. Several factors should be taken into consideration before the final decision, such as the presence of complications and the trichobezoar's consistency as well as the size and localization. The complications during the esophagogastroduodenoscopy for removal of a trichobezoar are estimated which are not uncommon but just unreported. Park et al. [3] have reported a 12.8% morbidity rate for endoscopic treatments of 39 patients. In another earlier study, Erzurumlu et al. [4] reported a 14% endoscopic morbidity rate, while Spyridon et al. [5] have reported only 11% morbidity rate. The most common complications that have been reported after treatment are bleeding, obstruction, ileus, fever, and perforation. Last but not least, piecemeal removal of large size lesions should be avoided because secondary bezoars are possible to migrate leading to more complications. According to our experience with similar cases which were treated by surgical treatment, the combination of trichobezoars and gastric ulcers is very common [6]. In this case report, the authors do not mention if they repeat gastroscopy after the extraction of the trichobezoar, or if they intend to do so at the follow-up. Many cases related to trichobezoars are presented to the emergency department with symptoms of perforative acute abdomen and epigastric mass [7]. According to the literature, the presence of gastric ulcers simultaneously with trichobezoars is not an uncommon combination, which means that it is necessary for the surgeon to inspect carefully for peptic ulceration after the extraction of the trichobezoar. While it is certainly true that endoscopic approach has excellent results for small trichobezoars (i.e., <6 cm), for larger masses, surgical approach is simple, with high success rate and low complication rate. Furthermore, elective laparotomy gives to the surgeon the chance to examine carefully the total gastrointestinal track for possible satellites.

Comparison between dexmedetomidine and fentanyl on intubation conditions during awake fiberoptic bronchoscopy: A randomized double-blind prospective study.

Background and Aims:Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them cause respiratory depression and airway obstruction leading to hypoxemia. The aim of this study was to compare intubation conditions, and incidence of desaturation between dexmedetomidine and fentanyl group during AFOI.Material and Methods:This randomized double-blind prospective study was conducted on a total of 60 patients scheduled for elective laparotomies who were randomly allocated into two groups: Group A received dexmedetomidine 1 mcg/kg and Group B received fentanyl 2 mcg/kg over 10 min. Patients in both groups received glycopyrrolate 0.2 mg intravenous, nebulization with 2% lidocaine 4 ml over 20 min and 10% lidocaine spray before undergoing AFOI. Adequacy of intubation condition was evaluated by cough score and post-intubation score. Incidence of desaturation, hemodynamic changes and sedation using Ramsay sedation scale (RSS) were noted and compared between two groups.Results:Cough Score (1-4), post-intubation Score (1-3) and RSS (1-6) were significantly favorable (P < 0.0001) along with minimum hemodynamic responses to intubation (P < 0.05) and less oxygen desaturation (P < 0.0001) in Group A than Group B.Conclusion:Dexmedetomidine is more effective than fentanyl in producing better intubation conditions, sedation along with hemodynamic stability and less desaturation during AFOI.

Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial

BackgroundThoracic epidural analgesia (TEA) is recommended for post-operative pain relief in patients undergoing major abdominal surgery via a midline incision. However, the effectiveness of TEA is variable with high failure rates reported post-operatively. Common side effects such as low blood pressure and motor block can reduce mobility and hinder recovery, and a number of rare but serious complications can also occur following their use.Rectus sheath catheters (RSC) may provide a novel alternative approach to somatic analgesia without the associated adverse effects of TEA. The aim of this study is to compare the efficacy of both techniques in terms of pain relief, patient experience, post-operative functional recovery, safety and cost-effectiveness.Methods/designThis is a single-centre randomised controlled non-blinded trial, which also includes a nested qualitative study. Over a two-year period, 132 patients undergoing major abdominal surgery via a midline incision will be randomised to receive either TEA or RSC for post-operative analgesia. The primary outcome measures pain scores on moving from a supine to a sitting position at 24 hours post wound closure, and the patient experience between groups evaluated through in-depth interviews. Secondary outcomes include pain scores at rest and on movement at other time points, opiate consumption, functional recovery, morbidity and cost-effectiveness.DiscussionThis will be the first randomised controlled trial comparing thoracic epidurals to ultrasound-guided rectus sheath catheters in adults undergoing elective midline laparotomy. The standardised care provided by an Enhanced Recovery Programme makes this a comparison between two complex pain packages and not simply two analgesic techniques, in order to ascertain if RSC is a viable alternative to TEA.Trial registrationCurrent Controlled Trials ISRCTN81223298 (16 January 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/1745-6215-15-400) contains supplementary material, which is available to authorized users.

Dynamic preload indicators decrease when the abdomen is opened.

BackgroundOptimizing cardiac stroke volume during major surgery is of interest to many as a therapeutic target to decrease the incidence of postoperative complications. Because dynamic preload indicators are strongly correlated with stroke volume, it is suggested that these indices can be used for goal directed fluid therapy. However, threshold values of these indicators depend on many factors that are influenced by surgery, including opening of the abdomen. The aim of this study was therefore to assess the effect of opening the abdomen on arterial pressure variations in patients undergoing abdominal surgery.MethodsBlood pressure and bladder pressure were continuously recorded just before and after opening of the abdomen in patients undergoing elective laparotomy. Based on waveform analysis of the non-invasively derived blood pressure, the stroke volume index, pulse pressure variation (PPV) and stroke volume variation (SVV) were calculated off-line.ResultsThirteen patients were included. After opening the abdomen, PPV and SVV decreased from 11.5 ± 5.8% to 6.4 ± 2.9% (p < 0.005, a relative decrease of 40 ± 19%) and 12.7 ± 6.1% to 4.8 ± 1.6% (p < 0.05, a relative decrease of 53 ± 26%), respectively. Although mean arterial pressure and stroke volume index tended to increase (41 ± 6 versus 45 ± 4 ml/min/m2, p = 0.14 and 41 ± 6 versus 45 ± 4 ml/min/m2, p = 0.05), and heart rate tended to decrease (73 ± 15 versus 68 ± 11 1/min, p = 0.05), no significant change was found. No significant change was found in respiratory parameter (tidal volume, respiratory rate or inspiratory pressure; p = 0.36, 0.34 and 0.17, respectively) or bladder pressure (6.0 ± 3.7 versus 5.6 ± 2.7 mmHg, p = 0.6) either.ConclusionsOpening of the abdomen decreases PPV and SVV. During goal directed therapy, current thresholds for fluid responsiveness should be changed accordingly.

Delayed Gastrointestinal Bleeding in a Case of Failed Graft Pancreatic and Kidney Transplant: Presidential Poster

Introduction: Arterioenteric fistulae and pseudoaneuryms, although rare, are potentially lifethreatening complications of simultaneous kidney and pancreatic transplants (SPAK). We describe a case of a 53-year-old white man, a recipient of SPAK transplant in 2003, who presented to the emergency department with near syncope following 2 episodes of maroon-colored stools. The kidney and pancreas grafts failed, and he was being treated with insulin and hemodialysis, respectively. The transplanted kidney was resected in 2009, following an infection. A screening colonoscopy done in 2010 was unremarkable. Upon presentation, he was resuscitated with intravenous fluids and multiple blood transfusions for hypovolemic shock from acute blood loss. (Hemoglobin had decreased from 11 gm/dL 1 month ago to 6.9 gm/dL on admission.) Abdominal exam was unremarkable. Gastric lavage revealed bilious fluid, but no blood. Rectal exam revealed maroon stool. An emergent CT angiography showed a 12 mm x 20 mm pseudoaneurysm arising from the right external iliac artery. An emergent stent-assisted coil embolization was performed by interventional radiology; hemostasis and hemodynamic stability were achieved. Three days after the index embolization, he had further episodes of hematochezia,warranting an emergent pelvic angiogram, which demonstrated continued patency of the pseudoaneurysm. Occlusion of the right external iliac artery with a covered stent was subsequently performed. A colonoscopy on day 4 revealed only a few scattered sigmoid diverticula and ulcerated mucosa of the ileocecal valve without active bleeding. An elective exploratory laparotomy revealed the site of the fistula. The renal graft remnant was found to be anastamosed to the iliac artery. Bowel was dissected from the underlying graft, and a 5-cm resection of the bowel was performed. The patient had no further episodes of bleeding and was stable at the time of discharge. Arterial pseudoanerysms and areterio-enteric fistuale are known complications of SPAK transplants. Most of these occur early in the post-operative period. Fistulae are seen in the setting of pancreatic graft failure. This can occur because of anatomic apposition of the arterial and enteric anastomoses or a result of proteolytic enzymes released from the pancreatic graft. Lower gastrointestinal bleeding in patients with failed SPAK transplants should raise a high suspicion for arterioenteric fistulae, and early diagnosis with angiography can be life-saving. Multimodality treatment with percutaneous stenting, coil embolization, and operative correction usually achieve satisfactory results.

Outcome of Abdominal Wound Closure Following Continuous and Interrupted Suture in Elective Laparotomy

Closure is a crucial factor in laparotomy wound. Fascial layers provide the major tensile strength in wound closure. Poor wound healing and development of wound infection in incisional wounds are the common complications of open abdominal surgery. Continuous fascial closure commonly practiced and the interrupted closures are also practiced by some surgeon with an assumption that it causes less pain and less wound infection. The aim of this study was to determine the rate of postoperative wound infection and severity of wound pain following interrupted and continuous abdominal wound closure. A comparative cross-sectional study was done at the Department of surgery, Sylhet MAG Osmani Medical College Hospital from 1st July 2007 to 30th June 2008. A total 100 patients of clean-contaminated elective laparotomy were selected. The patients were randomly divided into two groups. Every odds number was included in group-I (interrupted suture) and every even number was included in group-II (continuous suture). Total 14% wound infection was detected in interrupted suture group where as wound infection was 18% in continuous suture group of wound closure. Though the wound infection is higher in group-II but the difference of wound infection is not statistically significant between two groups. The wound pain assessed in seven postoperative days was higher in continuous closure group than interrupted group but the difference was not significant. There is no significant difference of wound infection and wound pain between interrupted and continuous suture group in clean-contaminated laparotomy. DOI: http://dx.doi.org/10.3329/fmcj.v8i2.20373 Faridpur Med. Coll. J. 2013;8(2): 73-76

Risk of new or recurrent cancer after a high perioperative inspiratory oxygen fraction during abdominal surgery

Administration of supplemental oxygen in the perioperative period is controversial, as it may increase long-term mortality. Our aim was to assess the association between 80% oxygen and occurrence of subsequent cancer in patients undergoing abdominal surgery in a post hoc analysis of the PROXI trial. The 1386 patients in the PROXI trial underwent elective or emergency laparotomy between 2006 and 2008 with randomization to either 80% or 30% oxygen during and for 2 h after surgery. We retrieved follow-up status regarding vital status, new cancer diagnoses, and new histological cancer specimens. Data were analysed using the Cox proportional hazards model. Follow-up was complete in 1377 patients (99%) after a median of 3.9 yr. The primary outcome of new cancer diagnosis or new malignant histological specimen occurred in 140 of 678 patients (21%) in the 80% oxygen group vs 150 of 699 patients (21%) assigned to 30% oxygen; hazards ratio 1.06 [95% confidence interval (CI) 0.84, 1.34], P=0.62. Cancer-free survival was significantly shorter in the 80% oxygen group; hazards ratio 1.19 (95% CI 1.01, 1.42), P=0.04, as was the time between surgery and new cancer, median 335 vs. 434 days in the 30% oxygen group. In patients with localized disease, non-significant differences in cancer and cancer-free survival were found with hazard ratios of 1.31 and 1.29, respectively. Although new cancers occurred at similar rate, the cancer-free survival was significantly shorter in the 80% oxygen group, but this did not appear to explain the excess mortality in the 80% oxygen group. ClinicalTrials.gov (NCT01723280).

English

BACKGROUND: Postoperative wound complications are of common occurrence. The incidence of postoperative wound infections ranged from <2% to 38%. Based on NNIS (National Nosocomial Infections Surveillance) system reports, surgical site infections are the third most frequently reported nosocomial infections among hospitalized patient. Aim is to compare the complications of laparotomy wound in elective and emergency surgery and to study the various determinants affecting it. MATERIALS AND METHODS: It is a prospective randomized study of 216 patients undergoing emergency and elective laparotomy. Postoperative wound complications and various factors affecting it are compared between emergency and elective surgery. RESULTS: The study was conducted on 216 patients, aged between 13-80 years, who underwent major elective and emergency laparotomy surgery in Shri B. M. Patil Medical College, Hospital and Research Centre Bijapur, between October 2008 – May 2014 (5 year 6 month). Among the 216 patients, 15(14%) out of 108 patients were in elective laparotomy group and 27(25%) out of 108 patients were in emergency laparotomy who developed complications. CONCLUSION: In conclusion, laparotomy wound complications are multifactorial, this study demonstrated no significant increase in incidence of postoperative tissue and wound complications in emergency (25%) and elective surgery (14%) p=0.08. It mainly depends on higher ASA score, anemia and higher wound class who are more likely to be associated with development of wound complications.

Effect of memory training using the "method of loci" before operation on early postoperative cognitive function in elderly patients undergoing laparotomy under general anesthesia

Objective To evaluate the effect of memory training using the method of loci before operation on the early postoperative cognitive function in the elderly patients undergoing laparotomy under general anesthesia.Methods Ninety-six ASA physical status Ⅱ or Ⅲ patients of both sexes,aged ≥60 yr,with body mass index 16-31 kg/m2,scheduled for elective laparotomy under general anesthesia,were randomly divided into 2 groups using a random number table:control group (group C,n =49) and memory training group (group T,n =47).The patients in T group received the memory training using the method of loci once a day (about 30-40 min for each time) starting from 3 days before operation until 1 day before operation.Neuropsychological tests were performed before training and on 7 days after operation.The development of postoperative cognitive dysfunction (POCD) was recorded.The patients were divided into POCD group and non-POCD group depending on whether or not POCD occurred.The risk factors of which P values were less than 0.05 between POCD group and non-POCD group would enter the logistic regression analysis to stratify POCD-related risk factors.Results The incidence of POCD was 36％ (16 cases) and 16％ (7 cases) in C and T groups,respectively.The incidence of POCD was significantly lower in group T than in group C.Compared with non-POCD group,the age was significantly older and the ratio of patients who received memory training before operation was decreased in POCD group.Logistic regression analysis showed that old age and no preoperative memory training were risk factors for POCD.Conclusion Memory training using the method of loci before operation can improve the early postoperative cognitive function in the elderly patients undergoing laparotomy under general anesthesia. Key words: Location directories and signs; Language therapy; Cognition disorders; Postoperative complications; Aged

Effectiveness of triclosan-coated PDS Plus versus uncoated PDS II sutures for prevention of surgical site infection after abdominal wall closure: the randomised controlled PROUD trial

Postoperative surgical site infections are one of the most frequent complications after open abdominal surgery, and triclosan-coated sutures were developed to reduce their occurrence. The aim of the PROUD trial was to obtain reliable data for the effectiveness of triclosan-coated PDS Plus sutures for abdominal wall closure, compared with non-coated PDS II sutures, in the prevention of surgical site infections. This multicentre, randomised controlled group-sequential superiority trial was done in 24 German hospitals. Adult patients (aged ≥18 years) who underwent elective midline abdominal laparotomy for any reason were eligible for inclusion. Exclusion criteria were impaired mental state, language problems, and participation in another intervention trial that interfered with the intervention or outcome of this trial. A central web-based randomisation tool was used to randomly assign eligible participants by permuted block randomisation with a 1:1 allocation ratio and block size 4 before mass closure to either triclosan-coated sutures (PDS Plus) or uncoated sutures (PDS II) for abdominal fascia closure. The primary endpoint was the occurrence of superficial or deep surgical site infection according to the Centers for Disease Control and Prevention criteria within 30 days after the operation. Patients, surgeons, and the outcome assessors were masked to group assignment. Interim and final analyses were by modified intention to treat. This trial is registered with the German Clinical Trials Register, number DRKS00000390. Between April 7, 2010, and Oct 19, 2012, 1224 patients were randomly assigned to intervention groups (607 to PDS Plus, and 617 to PDS II), of whom 1185 (587 PDS Plus and 598 PDS II) were analysed by intention to treat. The study groups were well balanced in terms of patient and procedure characteristics. The occurrence of surgical site infections did not differ between the PDS Plus group (87 [14·8%] of 587) and the PDS II group (96 [16·1%] of 598; OR 0·91, 95% CI 0·66-1·25; p=0·64). Serious adverse events also did not differ between the groups-146 of 583 (25·0%) patients treated with PDS Plus had at least one serious adverse event, compared with 138 of 602 (22·9%) patients treated with PDS II; p=0·39). Triclosan-coated PDS Plus did not reduce the occurrence of surgical site infection after elective midline laparotomy. Innovative, multifactorial strategies need to be developed and assessed in future trials to reduce surgical site infections. Johnson & Johnson Medical Limited.