General Abdominal Surgery Research Articles

Aspects of the less traumatic surgical procedures and some adjuvant therapies in prevention of postoperative adhesions

Postoperative abdominal adhesions are more common after gynaecological surgery and appendectomy than after general abdominal surgery (Raf, 1969). They may cause infertility, bowel obstruction and abdominal pain. About 20% of bowel obstructions occur within a year and a further 20% are registered ten years or more after surgery (Menzies and Ellis, 1990). The exact mechanism of adhesion formation is not fully understood. However, adhesions are only formed in the peritoneum when it is damaged by either surgical trauma or inflammatory disease. In a study of rabbits, Elkins et al. (1987) reported that a specific inflammatory reaction occurred in the peritoneum during the 12 h after surgery irrespective of the type of procedure used (excision, abrasion, electrocautery), that is, polymorphonuclear leukocytosis, surface fibrin deposition, white cell exudation, and muscle and mesothelial tissue necrosis. Surface fibrin was not observed 24 h after surgery: the other reactions decreased more slowly. However, the damage caused by electrocautery persisted throughout the 3 week study. Various anti-inflammatory drugs have been used as adjuvant therapies to prevent adhesions without adversely influencing the normal healing process. Swolin (1967a,b) emphasised the importance of high doses of cortisone and Larsson et al. (1977) reported the beneficial effect of oxyphenebutazone in a study on rats. The fibrin matrix appears to play a crucial role in the healing process as well as in the formation of adhesions and the induction of fibroblast activity. Therefore, the use of fibrinolytic activators (plasminogen activators (PA), for example, urokinasetype plasminogen activator (u-PA) and tissue-type plasminogen activator (t-PA)) or the inactivation of fibrinolytic inhibitors (plasminogen activator inhibitors (PAI), for example, PAI-1 and PAI-2) as part of the surgical technique could reduce the number of postoperative adhesions. In a study of monkeys, Tisseel

Intraperitoneal hyperthermic perfusion (IPHP)

Intraperitoneal hyperthermic perfusion (IPHP) with a solution that contains CDDP (25 mg/m(2)/l) and MMC (3.3 mg/m(2)/l) was clinically introduced in the treatment of peritoneal carcinomatosis. Twenty-six patients underwent surgical treatment and IPHP. Peritoneal carcinomatosis was classified at laparotomy using the Japanese classification: P1 (n=3), P2 (n=5), P3 (n=15), unclassifiable (n=3). In this series of patients only the creatinine and amylase values were significant in biological toxicity evaluation. The surgical complication rate (2 duodenal fistulas) does not differ from the general extensive abdominal surgery.

Clinical relevance of the fibrinogen uptake test in patients undergoing elective general abdominal surgery—relation to major thromboembolism and mortality

Postoperative thromboembolic complications were evaluated in 2578 patients undergoing elective abdominal surgery, all receiving prophylaxis with low molecular weight heparin. A positive fibrinogen uptake test (FUT) developed in 217 patients (8.4%), while 37 patients (1.4%) had major thromboembolism (TE, defined as proximal deep vein thrombosis and/or pulmonary embolism, verified with phlebography, pulmonary scintigraphy or autopsy). In only 14% a positive FUT was associated with a major TE event. In 19% of the patients with major TE the FUT was negative. In multiple logistic regression the independent predictors for major TE were partially different from those for positive FUT. Thirty day mortality was 3.0%. There were significant associations between both positive FUT and major TE on one hand and mortality on the other (relative risks 2.4 and 5.8, respectively). FUT is not a good predictor of major TE. Both positive FUT and major TE indicate a significant risk of postoperative death.

Lipolysis during abdominal surgery.

Subcutaneous adipose tissue lipolysis has been monitored with microdialysis during elective cholecystectomy by laparotomy in otherwise healthy nonobese subjects. Eight of the subjects received saline and seven received glucose iv during the operation. In both groups the glycerol level in the microdialysate (lipolysis index) started to increase steadily from the start of the general anesthesia until the abdominal wall was closed. Thereafter it leveled off and remained elevated until after extubation. Plasma glycerol started to rise after the surgical incision. The levels of noradrenaline and adrenaline, but not of insulin, glucagon, and cortisol in plasma, changed in parallel with that of glycerol in the microdialysate. The glycerol response in adipose tissue in the group receiving iv glucose was three times more marked than in the saline group (P = 0.01) in spite of marked hyperinsulinemia, but there was no difference between the groups in plasma glycerol response. The plasma noradrenaline response was 50% higher (P = 0.03) in the glucose group than in the saline group, but there was no difference between the groups in the plasma adrenaline, glucagon, or cortisol responses. Adipose tissue blood flow was measured by the escape of ethanol from the dialysis solvent into the extracellular space. It was constant throughout the experimental period in both groups. In conclusion, the lipolysis rate is accelerated during general anesthesia and abdominal surgery because of increased catecholamine production. Perioperative glucose infusion is associated with a further acceleration of the lipolytic rate in subcutaneous adipose tissue due to an additional activation of the sympathetic nervous activity that overrides the antilipolytic effect of the glucose-induced hyperinsulinemia. Other adipose regions may be less sensitive to glucose infusions and anesthesia.

Venous Surgery in Resection for Abdominal Malignancy

Vascular surgical techniques were applied to the radical resection of carcinoma of the liver, biliary tract and pancreas. Distal and proximal portal vein reconstruction, respectively, was carried out in 16 patients with carcinoma of the pancreas and 16 with cancer of the liver and biliary tract. Hepatic vein trunks with tumour involvement were resected and reconstructed by various techniques in six patients. A suprarenal segment of the inferior vena cava was completely replaced by a prosthetic graft in three patients with retroperitoneal malignancy. Venous surgery increased the resectability of malignant tumours and preserved circulation in the organ remnant, although the long-term effect on survival is not yet clear. Vascular surgical techniques should be applied more widely in the field of general abdominal surgery.

Methyl tert-butyl ether.

Journal of Applied ToxicologyVolume 12, Issue 1 p. 73-74 Article Toxicology Update R. von Burg, R. von Burg ICF Kaiser Engineering 1800 Harrison Street Oakland CA 94612, USASearch for more papers by this author R. von Burg, R. von Burg ICF Kaiser Engineering 1800 Harrison Street Oakland CA 94612, USASearch for more papers by this author First published: February 1992 https://doi.org/10.1002/jat.2550120116Citations: 6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume12, Issue1February 1992Pages 73-74 RelatedInformation

Value of Liquid Crystal Contact Thermography and Plasma Level of D-Dimer for Screening of Deep Venous Thrombosis Following General Abdominal Surgery

Because the use of radioactive fibrinogen uptake test (FUT) has become questionable both for ethical (risk of virus transmission) and technical (lack of sensitivity) reasons, we investigated the potential value of two alternative methods for screening of asymptomatic deep venous thrombosis following elective digestive surgery: liquid crystal contact thermography (LCCT) and measurement of plasma concentration of D-dimer (DD), as compared with bilateral ascending phlebography. Out of 194 patients, 185 underwent phlebography on the 8th (0-19, median and range) postoperative day. Despite prophylaxis with low-molecular-weight heparin and elastic stockings, DVT was detected on phlebography in 58 legs of 45 patients. Sensitivity of LCCT with respect to the presence of DVT was 55% (n = 184 patients) or 28% (n = 368 legs) with a specificity of 67% and 82%, respectively. These poor performances were obtained despite a good interobserver agreement for the LCCT assessments (overall kappa coefficient of 0.66 between three experts). The most accurate cut-off of DD for discriminating patients with or without DVT was 3,000 micrograms/l, as determined by ROC curve analysis. Sensitivity of a DD level of more than 3,000 micrograms/l for the presence of phlebographically documented DVT on the 8th postoperative day was 89% for a specificity of 48%. Thus, LCCT cannot be used for screening of postoperative, mainly asymptomatic DVT following general surgery. On the other hand, measurement of plasma DD may be useful for initial screening, a negative result (level less than 3,000 micrograms/l) allowing to exclude DVT (negative predictive value of 93%) and a positive result (positive predictive value of 35%) requiring confirmation by phlebography.(ABSTRACT TRUNCATED AT 250 WORDS)

Pelviscopic Surgery: A Key for Conserving Fertility

As a result of experience with more than 16,000 pelviscopic operative procedures performed at the Kiel University Women's Clinic from 1971 to 1988 which in this time had been adapted and used around the world, it may be said that the pelviscopic operative techniques, based completely on the laparotomy techniques which employ the microscissors, needles and suture material, is superior for many of the classical gynecological indications to operation. Minimally invasive surgery reduces hospitalization for even the most difficult cases to approximately 3 days. Convalescence is also reduced to approximately 1 week. Postoperative complaints are few, particularly when the primary exudate is removed through an abdominal drain. Late complications are practically unknown. It must be said that even the most minimal of operative procedures can produce late postoperative complaints or can be ascribed as the source of late postoperative complaints. Experiences gathered from around the world with endoscopically guided intraabdominal surgery have shown that for some gynecological procedures laparotomy is now indicated only in the rare case. The leading example of this switch can be seen in the operative treatment of the ectopic pregnancy. Following closely are operations to correct sterility such as salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. Finally pelviscopic treatment is increasing for all benign ovarian tumors, and the enucleation of myomas of up to 400 grams in weight. Endoscopically guided intraabdominal surgery also has a place in the field of general abdominal surgery--that of treatment of chronic abdominal adhesions. These procedures in the future should basically commence with endoscopic adhesiolysis, the patient having had the proper preoperative bowel preparation. Because of this minimally invasive technique the surgeon will only rarely be forced to perform laparotomy. In the case of abdominal adhesions a prerequisite for pelviscopic treatment is the visually controlled perforation of the peritoneum. Endoscopic surgery, in contrast to open laparoscopy, has a large periumbilical radius of action and produces no postoperative scars. In Kiel operative pelviscopy has replaced 80% of the classic gynecological laparotomies. The recurrence rate of adhesions is 84% with laparotomy compared with a recurrence rate of less than 40% with postendoscopic adhesiolysis. Forty to sixty percent of the patients who underwent pelviscopic adhesiolysis are complaint-free; this is a result not attained with classical abdominal surgery. Adhesiolysis per laparotomy is now limited to the emergency situation, as in the cases of ileus, for example. Endoscopically guided intraabdominal surgery has now improved the quality of life for surgical patients.

Cough following general anaesthesia and abdominal surgery

Postoperative chest infection is a common complication of general surgery. We have assessed some of the risk factors implicated and reviewed the role of the cough reflex in the immediate postoperative period.

Reflex bradycardia during surgery

Reflex bradycardia and sinus arrest may occur in a variety of surgical procedures, from neurosurgery to general abdominal, laparoscopic, ophthalmic and facial surgery and even procedures such as liver biopsies and electroconvulsive therapy. In most cases a vagally-mediated reflex has been implicated, although experimental support for this is often lacking. Drugs such as vecuronium, atracurium, halothane, fentanyl and succinylcholine may predispose to this reflex. Premedication with an anticholinergic is usually effective in preventing its occurrence.

Unanticipated Admission to the Hospital Following Ambulatory Surgery

We conducted a case-control study to identify clinical and demographic risk factors for admission to the hospital following ambulatory surgery. Of 9616 adult patients who underwent ambulatory surgery at a university-affiliated hospital between 1984 and 1986, one hundred were admitted. The most common reasons for admission were pain (18), excessive bleeding (18), and intractable vomiting (17). The mean age (+/- SD) of patients who were admitted was 37 +/- 13 years, and 96% had American Society of Anesthesiologists' physical status scores of 1 or 2. Factors that were independently associated with an increased likelihood of admission were general anesthesia (odds ratio, 5.2), postoperative emesis (odds ratio, 3.0), lower abdominal and urologic surgery (odds ratio, 2.9), time in the operating room greater than 1 hour (odds ratio, 2.7), and age (odds ratio, 2.6). Our results indicate that the likelihood of unanticipated admission is related more to the type of anesthesia and surgical procedure rather than to the patient's clinical characteristics.

Time course of aldosterone and corticosterone plasma levels in rats during general anaesthesia and abdominal surgery.

The transepithelial voltage (psi ms) of rat rectum in vivo increases for several hours in experiments under general anaesthesia. So far this was attributed by indirect evidence to increasing aldosterone plasma levels during the course of the experiment. We performed direct measurements of aldosterone and corticosterone plasma concentrations during intestinal perfusion experiments on barbiturate anaesthetized rats. Experiments were terminated for blood sampling at 10, 75, 300, 400, 800, or 1,800 min, respectively. (i) After 75 min of anaesthesia, surgical preparation was finished and plasma levels of aldosterone and of corticosterone were found increased by the factors 5 and 3, respectively, as compared to conscious controls. (ii) During the following 12 h, aldosterone further increased to levels 10 times as high as those of controls. In contrast, during the same period corticosterone slowly decreased but still remained elevated as compared to controls. (iii) The increase of both hormones was attenuated when abdominal surgery was omitted. (iv) The use of pentobarbital (Nembutal) instead of thiobarbital (Inactin) did not influence the adrenal response. (v) In adrenalectomized rats a continuous substitution with 65 ng X h-1 X kg-1 BWT aldosterone resulted in plasma levels as high as in conscious intact animals. (vi) Rectal psi ms started to move to higher lumen-negative values with a time delay of 1-1 1/2 h as compared with the increase of hormone levels. psi ms then stayed elevated until to the end of the experiments. We conclude that in vivo experiments of several hours duration in thio- or pentobarbital anaesthetized rats take place under conditions of aldosterone and corticosterone plasma levels which are high as compared to those of conscious unstressed animals.(ABSTRACT TRUNCATED AT 250 WORDS)

The cardiovascular effects of high-dose butorphanol-nitrous oxide anaesthesia before and during operation.

The cardiovascular effects of high doses of butorphanol (0.3-0.45 mg . kg-1) plus 60 per cent N2O anaesthesia were measured at unconsciousness, following tracheal intubation, and immediately before and at one and ten minutes after surgical stimulation in 17 A.S.A. class I and II patients undergoing elective gastric or gall bladder surgery. Butorphanol and N2O produced unconsciousness with only small decreases in heart rate and cardiac output but did not result in sufficient analgesia to block or treat stimulation of the cardiovascular system secondary to tracheal intubation or surgical incision, even when supplemented with additional butorphanol to high cumulative dose levels (1.0 mg . kg-1). The data suggest that even high dose butorphanol - N2O anaesthesia requires supplementation with other anaesthetics or anaesthetic adjuvants to prevent cardiovascular stimulation during general abdominal surgery.

Tinidazole: a review of clinical experience in anaerobic infections.

Oral and intravenous tinidazole have been evaluated in an extensive series of clinical trials for the treatment of anaerobic infections and for the prevention of infection after gastrointestinal and gynaecological surgery. In almost all studies simple dosage regimens were used; these were based on the pharmacokinetic properties of tinidazole and its in-vitro activity against almost all clinically relevant anaerobic bacteria. These characteristics permit the use of single pre-operative dpse in surgical prophylaxis and once daily dosage in treatment. Results in the therapy of proven and strongly suspected anaerobic infections in approximately 264 patients are summarized. Patients received tinidazole alone or together with an agent active against aerobes, usually an aminoglycoside. Very good efficacy and an almost complete freedom from significant side effects were observed in patients treated for a wide variety of anaerobic infections. These included septicaemia. upper respiratory infections and sinusitis, anginose infectious mononucleosis, broncho-pulmonary infections, osteomyelitis. pelvic infections. septic abortion, peritonitis and post-operative intra-abdominal sepsis, cellulitis and post-operative wound infection. Chemotherapy was often associated with surgical drainage. Findings with intravenous or oral tinidazole for the prophylaxis of post-operative infections after gastrointestinal and gynaecological surgery are reviewed. Almost all studies involved comparison with another drug regimen, double-blind comparison with placebo or the inclusion of a control group. Although tinidazole alone was used in most trials, an agent active against aerobic bacteria was included in some. A significant reduction in the incidence of infection after colorectal surgery, general abdominal surgery and gynaecological surgery (especially vaginal hysterectomy) was found in all studies. In addition, the prophylactic use of tinidazole was shown in several studies to cause a marked reduction in post-operative antibiotic usage and a shorter hospital stay. Few side effects were reported.

Intermittent pneumatic calf compression for prevention of deep venous thrombosis in general abdominal surgery

A prospective randomized trial is described in 119 patients undergoing major abdominal general surgical procedures. Half of the patients were treated prophylactically with intermittent pneumatic calf compression, begun after the induction of anesthesia and continued until the patient was walking; the other half acted as controls. Deep venous thrombosis was detected by iodine-125 fibrinogen scanning and confirmed by venography, and did not differ significantly in the control and treated groups. One fatal pulmonary embolism occurred in each group. The presence of malignancy of the gastrointestinal tract did not influence the results. The findings suggest that pneumatic compression delayed the development of deep venous thrombosis postoperatively and that perhaps it should be continued until discharge from hospital.

Operative Surgery: General Principles and Breast

<h3>Operative Surgery: Thorax</h3> edited by W. P. Cleland, ed 2; 426 pp, with illus, $31, Philadelphia: J. B. Lippincott Co., 1968. There is no longer a dearth of atlases available for surgical education. The vacuum, once only partially filled by one or two satisfactory texts, now no longer exists. There are excellent presentations of standard operative techniques in general abdominal and thoracic and cardiovascular procedures. Any emerging text at this time must, therefore, compete in fairly sophisticated company. These two volumes from part of a large series of books on operative surgery, are designed to describe techniques in surgery of the eyes, ears, nose, and throat, general abdominal surgery, the hand, head and neck, neurosurgery, obstetrics and gynecology, orthopedics, and, finally, vascular surgery. The volumes are obtainable as a set or individually and must be judged on their individual merits. The first volume devotes itself to general considerations in surgery