Presence Of Intra-abdominal Abscess Research Articles

P0111 Patient reported outcome measures (PROM) in patients scheduled to undergo bowel resection for Crohn’s disease

Abstract Background Indication for surgery in Crohn’s disease patients is a matter of ongoing debate. Increasing number of available medical treatments can lead to significant postponement of surgery in many patients. Later first abdominal surgery for Crohn’s disease is commonly seen as significant achievement of modern biological treatment. However, later surgery is not necessarily a success since it might only prolong unnecessary suffering. Thus, it is of a paramount importance to understand whether patients are “losing” or “winning” time by avoiding abdominal surgery. Patient reported outcome measurement – various indices, scores and Quality-of-Life measurement tools – are used to assess the degree of suffering and to calculate the treatment success. In present prospective study, we assessed the value of commonly used PROM tools to characterize disease severity in patients scheduled for bowel resection for Crohn’s disease. Methods Consecutive patients scheduled for bowel resection were assessed preoperatively using CDAI (Crohn’s disease activity index), IBD-DI (IBD Disability index) and the IBDQ (IBD questionnaire to assess quality of life). Also, patients were asked to rate their global health (GH) from 1 (unbearable) to 10 (perfectly good). Worse scoring was expected to be found in patients with disease complications which are frequent in surgical population: severe anemia (HB <10g/dl) weight loss of >10%, penetrating disease, intraabdominal abscess and emergency hospitalization before surgery. Results 109 patients were assessed. Conclusion PROM’s alone are not sufficient to guide the decision toward or against the potential surgery since “good” scores still miss some significant disease complications. Also, PROM’s are dynamic tools with scores differing significantly over time. Indication for surgery should be rather guided by expected risks and prognosis than by mere “disease activity”. Table 1 illustrates preoperative results of PROM’s assessment. An incongruence of all scores can be observed. While 34% of patients have a quiescent disease according to the CDAI, only 13.5 % according to IBD-Q. Table 2 demonstrates great inconsistency between the tools regarding their ability to predict severe disease (as illustrated by emergency hospitalization, significant weight loss, presence of intraabdominal abscess and penetrating disease). Only severe anemia led to significant worsening in all calculated tools.

P489 Surgery for enterocutaneous fistula: the strongest predictor of postoperative mortality in Crohn’s disease patients

Abstract Background To access the risk of bowel resection in Crohn’s disease patients with enterocutaneous fistulae. Methods Consecutive patients undergoing intestinal resections for Crohn’ disease between 1992 and 2021 were included in the present prospective observational study. Exclusion criteria were: a) abdominoperineal resections for perianal disease, b) surgery for colorectal cancer complicating Crohn’s disease, c) abdominal surgery without intestinal resection (e.g. stoma formation or closure, mere adhesiolysis etc. Enterocutaneous fistulae occurring after previous bowel resection were named “postresection fistulae”, all other – “non-postresection fistulae”. Results 750 patients were included. At all, 70 patients (9%) underwent intestinal resections due to enterocutaneous fistulae. The frequency of surgery for enterocutaneous fistula decreased significantly during the last decade of the study (1992-2000: 13% of surgeries, 2001-2010: 12% of surgeries, 2011-2021: 6% of surgeries; p=0.05). The postoperative intraabdominal septic complication rate was 15% (n=111), six patients (0.8%) died. The mortality rate was 7% (5 of 79%) in patients with enterocutaneous fistulae. All latter death occurred only in patients with postresection fistulae. By multivariate analysis, surgery for enterocutaneous fistula (Hazard ratio 27.4, 95% CI: 2.9 – 255.6; p=0.004), age of 50 years and older (Hazard ratio 13.2; 95% CI: 2.0 – 87.7; p=0.008) and presence of intraabdominal abscess (Hazard ratio 11.8; 95% CI: 1.2 – 116.5; p=0.035) were associated with an increased risk of postoperative death. Age over 50 years was associated with an increased risk of death in patients with enterocutaneous fistulae (mortality rate 20% vs. 3.6%, Hazard ratio 16.61; 95% CI: 1.28 – 216.07; p=0.032). Conclusion Surgery for enteroctunaeous fistulae still poses significant risks, specially, when they occurred after bowel resection and in older patients.

P538 Implementation of Kono-S anastomosis as a new standard of surgical care

Abstract Background The Kono-S ileocolic anastomosis is thought to reduce the risk of clinical and surgical recurrence in Crohn’s disease patients. The Kono-S anastomosis was established as a new standard of care at our institution in 2018, however, it was not performed in all patients. The present study describes the learning curve and reasons for hesitation to use the new technique. Methods Consecutive patients undergoing bowel resection with formation of ileocolic anastomosis since starting to use Kono-S technique were included in the present retrospective analysis. Intraabdominal septic complications (IASC) were peritonitis, anastomotic leak, intraabdominal fistula and abscess. Results Since starting to use Kono-S anastomosis, 90 patients underwent ileocolic resection (45M, 45F). However, during this period, conventional side-to-side ileocolic anastomosis was still performed in 26 patients (29%). Kono-S anastomosis was performed in 46% of cases during the first 6 months, in 76% during the next 6 months and in 82% of cases after the first year since implementation (p=0.005). There was no difference in postoperative IASC rate between patients with or without Kono-S anastomosis (2% vs. 4%, p=0.5). Also, postoperative overall complication rate, incidence of postoperative small bowel obstruction and length of postoperative hospital stay did not differ between groups. There were no anastomotic leaks. By the multivariate analysis, the presence of intraabdominal abscess or fistula (Hazard ratio 0.25, p=0.037) was the main reason to perform the conventional hand S/S anastomosis instead of new technique. Conclusion Some hesitation to use Kono-S anastomosis could be observed after the implementation of the new standard of care, especially during the first six months and in patients presenting with more complex intraabdominal findings. However, the learning curve has no impact on postoperative morbidity.

Efficacy of endoscopic management for anastomotic leakage after gastrectomy in patients with gastric cancer

BackgroundAnastomotic leakage (AL) after gastrectomy in gastric cancer patients is associated with high mortality rates. Various endoscopic procedures are available to manage this postoperative complication. The aim of study was to evaluate the outcome of two endoscopic modalities, clippings and stents, for the treatment of AL.Patients and methodsThere were 4916 gastric cancer patients who underwent gastrectomy between December 2007 and January 2016 at the National Cancer Center, Korea. A total of 115 patients (2.3%) developed AL. Of these, 85 patients (1.7%) received endoscopic therapy for AL and were included in this retrospective study. The endpoints were the complete leakage closure rates and risk factors associated with failure of endoscopic therapy.ResultsOf the 85 patients, 62 received endoscopic clippings (with or without detachable snares), and 23 received a stent insertion. Overall, the complete leakage closure rate was 80%, and no significant difference was found between the clipping and stent groups (79.0% vs. 82.6%, respectively; P = 0.89). The complete leakage closure rate was significantly lower in the duodenal and jejunal stump sites (60%) than esophageal sites (86.1%) and gastric sites (94.1%; P = 0.026). The multivariate analysis showed that stump leakage sites (adjusted odds ratio [aOR], 4.51; P = 0.031) and the presence of intra-abdominal abscess (aOR, 4.92; P = -0.025) were associated with unsuccessful leakage closures.ConclusionsEndoscopic therapy using clippings or stents is an effective method for the postoperative management of AL in gastric cancer patients. This therapy can be considered a primary treatment option due to its demonstrated efficacy, safety, and minimally invasive nature.

The effect of peritoneal lavage with a mixture of lincomycin–gentamicin on postoperative infection in cases of colorectal cancer surgery

Objective The aim of this work was to evaluate the effect of the use of antibiotic solution formed of lincomycin and gentamycin in normal saline in decreasing the risk for postoperative infection in cases of colorectal cancer. Background Infection after colon cancer operations is still the most common and the most serious complication, with an incidence of more than 30%. Patients and methods This study was carried out on 40 randomly allocated patients with resectable colon and rectal cancer. Group 1 included patients who underwent intra-abdominal lavage with normal saline, followed by a second lavage with a gentamicin–lincomycin solution, and group 2 included those who underwent lavage with normal saline. Results There was a significant difference between groups as regards the presence of postoperative wound sepsis. Isolated organisms were mainly gram negative in both groups. In group 1, the isolated organism was Pseudomonas. In group 2, three cases were diagnosed with Escherichia coli and two cases for each of Pseudomonas, Klebsiella, and Enterobacter. Intraoperative abscess was diagnosed in three cases, two in group 2 and the remaining one in group 1. There was no significant difference between groups as regards the presence of intra-abdominal abscess. Conclusion Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infection. A normal saline lavage did not significantly reduce the number of positive cultures, in contrast to an antibiotic one (gentamicin–lincoamycin), which resulted in negative cultures in 90% of the cases.

A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis.

Our objective was to perform a meta-analysis on RCTs that compared outcomes in children with perforated appendicitis (PA) who underwent either early appendectomy (EA) or interval appendectomy (IA). We also sought to determine if the presence of an intra-abdominal abscess (IAA) at admission impacted treatment strategy and outcomes. We identified two RCTs comparing EA versus IA in children with PA. A meta-analysis was performed using regression models and the overall adverse event rate was analyzed. The treatment effect variation depending on the presence of IAA at admission was also evaluated. EA significantly reduced the odds of an adverse event (OR 0.28, 95% CI 0.1-0.77) and an unplanned readmission (OR 0.08, 95% CI 0.01-0.67), as well as the total charges (79% of the IA, 95% CI 63-100) for those who did not have an IAA at admission. In children with an IAA, there was no difference between EA and IA. However, heterogeneity of treatment effect was present regarding IAA at presentation. While EA appears to improve outcomes in patients without an abscess, the published data support no significant difference in outcomes between EA and IA in patients with an abscess.

Assessment of intraoperative tube thoracostomy after diaphragmatic resection as part of debulking surgery for primary advanced-stage Müllerian cancer

ObjectiveThe present study assessed the use of an intraoperative tube thoracostomy for patients with primary advanced-stage ovarian, fallopian tube, or peritoneal cancer who underwent a diaphragmatic resection as part of debulking surgery and to define which patients are more likely to benefit from an intraoperative tube thoracostomy. MethodsAll consecutive patients with stage IIIC–IV Müllerian cancer who underwent diaphragmatic resection at our institution between April 2008 and March 2013 were retrospectively reviewed. When a full-thickness resection of the diaphragm was performed and the thoracic cavity was opened, a chest tube was routinely placed during surgery. Patient-, disease-, and surgery-related data were collected from the patients' medical records. The data were evaluated with particular attention directed at pleural effusion after diaphragmatic resection. ResultsA total of 37 patients were included in this study. No complications associated with the intraoperative tube thoracostomy procedures occurred. An infection of the thoracic cavity occurred in one patient, following the presence of intra-abdominal abscess. The total volume of pleural drainage ranged from 88 to 2826mL (median, 965mL). The estimated blood loss, intraoperative blood transfusion, and area of the diaphragmatic opening were significantly associated with the total volume of pleural drainage in univariate analyses. In a multivariate analysis, the estimated blood loss was the only factor to be significantly associated with the total volume of pleural drainage. ConclusionsA prophylactic tube thoracostomy might be considered if the volume of the estimated blood loss is higher than usual.

Prospective observational study of the frequency and features of intra-abdominal abscesses in patients with melioidosis in northeast Thailand

SummaryRetrospective case series from Thailand have reported the presence of intra-abdominal abscesses in around half of patients with melioidosis, a much higher rate than our clinical experience would suggest. We performed a prospective, observational study of 230 adult patients with culture-confirmed melioidosis in which all patients underwent abdominal ultrasound. One or more abscesses were detected in the liver and/or spleen in 77 (33%) cases. These were often multiple (70%, 31/44 in hepatic abscesses and 88%, 50/57 in splenic abscesses) and clinically silent (27% of cases with abscesses presenting with abdominal pain). The mortality rate at 4 weeks post-discharge was lower in patients who were abscess-positive vs abscess-negative (10%, 8/77 vs 20%, 31/153).

Effects of the intraperitoneal lornoxicam on the formation of intraperitoneal adhesions in rat peritonitis model

To investigate the effects of intraperitoneally administered lornoxicam on adhesion formation, bursting pressure, tissue antioxidant levels, morbidity and mortality after ileocolic anastomosis in a rat bacterial peritonitis model. Thirty-six rats were divided into three random groups. Bacterial peritonitis was induced by performing a cecal ligation and puncture, then the cecal was resected and ileocolic anastomosis was performed. Rats of groups 1, 2 and 3 were given 2 mL normal saline, 2 mL lornoxicam, and nothing, respectively. All groups were killed at day 14. Adhesions were scored, and the presence of intra-abdominal abscesses and fistulas were noted. Anastomotic healing was assessed by bursting pressure. Tissue antioxidant levels were tested from left abdominal walls. One day after cecal ligation and puncture, microbiological examination showed polymicrobial bacterial peritonitis. The rats treated with lornoxicam had significantly lower adhesion scores than did the saline and nothing treated rats (P = 0.007). Bursting pressures of groups were unaffected by the treatment. Tissue antioxidant levels of groups were affected by the treatment. Morbidity and mortality were similar in all groups. The present study demonstrated that a single intraperitoneal instillation of lornoxicam in buffer solution at the end of the surgery reduces adhesion formation in rats bacterial peritonitis model. It was also determined that lornoxicam had no negative effect on the healing of intestinal anastomosis, abscess and anastomotic leakage. Use of lornoxicam in peritonitis was effective in decreasing the oxidative stress of tissue during peritonitis.

Emergent Right Hemicolectomies

Emergent right hemicolectomies have historically been associated with surprisingly high morbidity and mortality rates. A retrospective review of emergent right hemicolectomies over a 7-year period was performed to assess current morbidity and mortality. Emergent right hemicolectomy was defined as a procedure performed for an acute abdomen with no formal preoperative cleansing of the colon. Demographic data, diagnostic evaluation, length of stay and outcomes were evaluated. Over the study period, 122 emergent right hemicolectomies were performed on both general surgery and trauma patients. The average patient was 52.9 +/- 18.5 years old, and the majority of patients (66.4%) were male. The indications for the procedures performed were bowel perforation (51), hemorrhage (25), cancer (16), benign obstruction (14), phlegmon (8), ischemia (6), or other (2). Resection with primary anastomosis was performed in 98 patients, 16 had an end ileostomy, and 8 underwent damage control procedures in which gastrointestinal continuity was not reestablished at the time of the original operation. Postoperative complications developed in 48 patients (39.3%). The majority of the complications (83.3%) were related to infection including intra-abdominal abscess (21 patients), sepsis (16), and wound infection (5). Other complications included anastomotic leak (5), wound dehiscence (3), stoma-related (3) and postoperative bowel obstruction (2). The patients who developed complications did not differ from those who had an uneventful postoperative course in terms of age, indication for procedure, or presence of intraabdominal abscess or gross contamination at the time of the original procedure. The overall mortality rate was 13 per cent. Patients who died were older than those who lived (63 +/- 19 vs 52 +/- 18; P = 0.03) and were significantly more likely to have evidence of shock on presentation (P = 0.0013). Emergent right hemicolectomies continue to be associated with high morbidity and mortality rates. The most common complications are related to infection. Age and manifestations of shock at the time of admission are strong predictors of mortality.

Evaluation of the Learning Curve in Laparoscopic Colorectal Surgery

To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

Predictors of Outcome for Children with Perforated Appendicitis Initially Treated with Non-Operative Management

Initial non-operative therapy for children with perforated appendicitis has become increasingly popular with the advent of powerful broad-spectrum antibiotics. However, there is no consensus regarding which patients may be managed effectively with this strategy. We reviewed all children with perforated appendicitis who were treated initially with non-operative therapy to determine those characteristics that may predict a successful outcome. We reviewed the medical records of children admitted to our hospital between January 1, 2000 and May 1, 2003 with the diagnosis of perforated appendicitis. Only those who were treated initially with a single broad-spectrum antibiotic (piperacillin-tazobactam), with the intention of performing an interval appendectomy, were included in this study. Patients were divided into two groups based on whether they were managed successfully with non-operative therapy: Responders and non-responders. Non-responders were defined as patients who either did not improve with antibiotic therapy or who required appendectomy prior to their electively scheduled time (six weeks). Demographic data, duration and type of presenting symptoms, initial white blood cell count (WBC), percent bands, percent neutrophils (PMNs), computed tomography (CT) interpretation, and interventions/operations were abstracted. Categorical data were compared using Chi-square analysis or the Fisher exact test; continuous variables were compared using the Student t-test and the Mann-Whitney U-test. Overall, 26% (19/73) of patients treated initially non-operatively required appendectomy prior to the electively scheduled date. There was no difference between responders (n = 54) and non-responders (n = 19) with respect to age, gender, initial WBC, percent bands, percent PMNs, or duration and type of presenting symptoms. However, responders were more likely to have a phlegmon on CT scan compared to non-responders (11/54 vs. 0/19, p = 0.03). Non-responders were twice as likely to undergo drainage of an abscess by interventional radiology (10/19 vs. 13/54, p = 0.02) compared to responders. Among all patients who required percutaneous drainage, the failure rate of non-operative management was 43% (10/23). Children with perforated appendicitis can be managed effectively with nonoperative therapy, even in the presence of intra-abdominal abscesses. However, the need for abscess drainage increases the failure rate, perhaps due to inadequate source control. Those patients with a phlegmon on CT scan as opposed to an abscess, are most likely to respond to non-operative management. Initial non-operative therapy of perforated appendicitis in children is appropriate under certain clinical circumstances, especially when the body itself or interventional radiology can achieve adequate source control.

The efficacy of fibrin sealant in prevention of anastomotic leak after laparoscopic gastric bypass 1,2

Anastomotic leak after laparoscopic gastric bypass (GBP) can result in significant morbidity, mortality, and consumption of healthcare resources. Fibrin sealant has been used clinically in the prevention of leak; however, its efficacy has not been clearly demonstrated. The aims of this study were to (1) develop an iatrogenic leak model in swine, (2) examine the efficacy of fibrin sealant in sealing iatrogenic anastomotic leak, and (3) review our experience with the use of fibrin sealant in 66 patients who underwent laparoscopic GBP. This study was performed in three phases. In phase 1, laparoscopic gastrojejunostomy was performed in adult swine with iatrogenic disruption of the anastomotic staple line. The size of disruption was sequentially increased (6- to 12-F opening) until a leak model was developed. In phase 2, 16 animals underwent laparoscopic gastrojejunostomy with a 12-F disruption of the anastomosis; 10 animals (study group) had fibrin sealant (Tisseel VH) applied on the disrupted anastomosis and 6 animals (control group) did not receive fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed and were examined for sealing of the anastomotic disruption and the presence of intraabdominal abscess. In phase 3, the outcome of 66 consecutive patients who underwent laparoscopic GBP with fibrin sealant applied at the gastrojejunostomy was reviewed. In phase 1, an anastomotic leak model was developed with a 12-F disruption of the staple line. In phase 2, two control animals required early sacrifice for bile peritonitis; three control animals had intraabdominal abscess discovered at sacrifice and one animal did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice and none of these animals had evidence of intraabdominal abscess or persistent leak. Therefore, 83% of animals in the control group developed either leak or abscess compared to 0% in the study group (P < 0.01, Fisher's exact test). Clinically, no leak or intraabdominal abscess developed in 66 patients who underwent laparoscopic GBP with the use of fibrin sealant. An anastomotic leak model was developed in swine with disruption of the stapled gastrojejunostomy to a 12-F opening. The use of fibrin sealant significantly reduces leak and abscess complication. Our results support the tissue sealing property of fibrin sealant and its use on high-risk gastrointestinal anastomosis.

Acute Left Colonic Diverticulitis: Can CT Findings Be Used to Predict Recurrence?

We explored CT and demographic predictors for unfavorable outcome of nonoperative treatment in patients with a first event of left colonic diverticulitis. We retrospectively analyzed the medical files and CT scans of 312 consecutive patients who were diagnosed as having diverticulitis on an admission CT report or who had a final diagnosis of left colonic diverticulitis. Patients who did not undergo nonoperative treatment or were lost to follow-up (n = 144) were excluded from the study. Admission CT scans of 168 consecutive patients with a diagnosis of left colonic diverticulitis who underwent nonoperative treatment and had an 18-month follow-up were reassessed by three radiologists unaware of the clinical findings. Nonoperative treatment was defined as an attempt to treat the patient with only antibiotics without scheduling them for elective (delayed) surgery. Unfavorable outcome was defined as a failure of nonoperative treatment 18 months after admission that required either surgery or rehospitalization for antibiotic treatment. The risk of unfavorable outcome was modeled using logistic regression as a function of sex, age, and CT criteria including the maximum number of diverticula per 10 cm of colon; the presence of intraabdominal abscess or extraintestinal gas bubbles (< 5 mm diameter) or gas pockets (>or=5 mm); the length and location of the abnormal colonic segment; the maximum thickness of the colonic wall; the presence of associated free intraperitoneal fluid; and the extent of fatty infiltration. Among these 168 patients, 115 (68%) had an uneventful outcome, but nonoperative treatment failed in 53 (32%). The presence of an abscess (n = 19) or extraintestinal gas pocket (n = 14) were the only CT findings significantly associated with failure of nonoperative treatment. Adjusted odds ratios (95% confidence interval) for failure were 6.18 (1.76-21.68) when an abscess was diagnosed and 4.26 (1.04-17.57) when pockets of free air were observed. Sex and age were not significantly associated with unfavorable outcome of nonoperative treatment. Abscess and pockets of extraintestinal gas 5 mm in diameter or larger correlated with unfavorable outcome of nonoperative treatment. None of the other criteria evaluated were predictive of failure of nonoperative treatment, including bubbles of extraintestinal gas smaller than 5 mm in diameter.

The efficacy of fibrin sealant in prevention of gastrointestinal anastomotic leak

Introduction: Anastomotic leak, although low in frequency (1–2%), is a dreaded complication after Roux-en-Y gastric bypass (GBP). Clinical uses of fibrin sealant for prevention of gastrointestinal (GI) leak have been reported; however, its efficacy has not been demonstrated. The aims of this study were to 1) develop an anastomotic leak animal model, 2) examine the efficacy of the tissue sealing property of fibrin sealant, and 3) review our experience in the use of fibrin sealant in 42 patients who underwent laparoscopic GBP. Methods: This study was performed in three phases. In phase 1, laparoscopic GI anastomosis was performed in adult swine with disruption of the staple-line starting at a 6F opening and sequentially increased in size until a leak model was developed. A leak model was developed at a 12F opening. In phase 2, ten animals (study group) underwent laparoscopic gastrojejunostomy with a 12F disruption of the anastomosis and received 2-mL of fibrin sealant (Tisseel, Baxter Healthcare Corp) applied on the disrupted area. The control animals (n = 6) did not receive the fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed. The primary endpoint was sealing of the disrupted anastomosis at sacrifice and secondary endpoint was evaluation for the presence of intraabdominal abscess. In phase 3, fibrin sealant was used clinically in 42 laparoscopic GBP patients. Results: In phase 2, persistent anastomotic leak was identified in 2 of 6 control animals (both required early sacrifice due to peritonitis). Three of 6 control animals had intraabdominal abscess discovered at sacrifice on postoperative day 5 without persistent leak and 1 animal in the control group did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice. None of the animals had evidence of intraabdominal abscess or persistent leak at sacrifice. Leak or abscess occurred in 83% of control animals compared to 0% in the study animals (p < 0.01, Fischer’s Exact test). Clinically, there was no leak or intraabdominal abscess in the 42 patients who underwent laparoscopic GBP. Conclusions: The use of fibrin sealant in an animal leak model significantly reduces leak and abscess complication. Our results support the efficacy of tissue sealing property of fibrin sealant and its use on high-risk GI anastomosis.

Prevention of intraperitoneal adhesion formation using beta-glucan after ileocolic anastomosis in a rat bacterial peritonitis model

Background To investigate the effects of beta-glucan on intraabdominal abscess and adhesion formation after ileocolic anastomosis in a rat bacterial peritonitis model. Methods Sixty male Wistar rats were used in this study. Bacterial peritonitis was induced by performing a cecal ligation and puncture (CLP). On the first day, abdomen was reopened and peritoneal fluid samples were taken for microbiological examination. Thereafter, cecum was resected and ileocolic anastomosis was made. Group 1 rats were given 1 mL of normal saline as a placebo. Group 2 and group 3 rats were given β-D-glucan 2 mg/kg by intramuscularly; 1 mg of β-1,3-D-glucanase was administered to group 3 rats just after the use of β-D-glucan. Half of each group were killed at day 7 and at day 21, respectively. Adhesions were scored and the presence of intraabdominal abscesses was noted. Results One day after CLP, microbiological examination showed polymicrobial bacterial peritonitis. Five (8%) of the 60 animals died owing to sepsis. One week after CLP, in two rats in each group developed abscess formation. Three weeks after CLP, abscess formation was observed in only one rat in each group. The rats treated with the beta-glucan had significantly lower adhesion scores than did the saline-treated rats ( P = 0.008 at one week; P = 0.001 at 3 weeks). Administration of beta-glucanase inhibited beta-glucan activity and resulted in more adhesions ( P = 0.022 at 1 week; P = 0.006 at 3 weeks). Conclusions Although the use of beta-glucan after ileocolic anastomosis in rats with experimentally developed intraabdominal sepsis does not have any significantly effect on mortality and abscess formation, beta-glucan is capable of reducing the frequency of adhesion. This effect of beta-glucan has been prevented with beta-glucanase