Presence Of Peritoneal Adhesions Research Articles

A Prospective Cohort Analysis of the Prevalence and Predictive Factors of Delayed Discharge After Laparoscopic Cholecystectomy in Italy: The DeDiLaCo Study.

The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC. This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units. A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24h; 2414 patients, 73.9%) and the Delayed group (>24h; 850 patients, 26.1%). At the multivariate analysis, ASA III class (P<0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60min (P<0.0001), drain placement (P<0.0001), pain (P=0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours. The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications

ObjectiveTo investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications. Study designA retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988–2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable. ResultsDuring the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04−1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (β=-0.055, P < 0.001). ConclusionAdhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

Peritoneal adhesions are an independent risk factor for peri- and post-partum infectious morbidity

ObjectiveTo investigate whether the presence of peritoneal adhesions during a second cesarean delivery resulting from the first cesarean delivery, are associated with peri- and post-partum infectious morbidity. Study DesignA retrospective cohort study was undertaken, comparing maternal peri- and immediate post-partum infectious morbidity during the second cesarean delivery, between women with and without adhesions resulting from the first cesarean delivery. All women over 18 years old at their second cesarean delivery, with a singleton pregnancy between the years 1988–2016 were included in the analysis. Patients with previously diagnosed adhesions during the first cesarean delivery, a history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies, and births of newborns with known chromosomal or structural abnormalities were excluded from the analysis, resulting in a study population of 7925 women. Infectious morbidity was defined as a composite of chorioamnionitis, post-partum fever, urinary tract infection and surgical wound infection or disruption. In order to identify factors that are independently associated with infectious morbidity, multivariate logistic regression analyses were constructed to control for potential confounders. ResultsDuring the study period, 32.6% (n = 2581) women were diagnosed with adhesions at the second cesarean delivery. Second cesarean deliveries complicated with adhesions were characterized by higher rates of peri- and post-partum maternal infectious morbidity (6.5% vs. 9%, p < 0.001). Our study population comprises two ethnic groups- Jewish (54.3%) and Bedouin Arabs (45.7%). We have tested interactions with adhesions of all predictor variables in the model. Since we found a strong interaction between adhesions and ethnicity, stratified data are presented. Infectious morbidity was significantly associated with the presence of peritoneal adhesions only among Jewish women (adjusted OR 2.09, PV < 0.001, 95% CI 1.56–2.80), adjusting for potential confounding variables and significant interactions. ConclusionCesarean delivery complicated with adhesions attributable to a previous cesarean delivery, increase the risk for peri- and immediate post-partum infectious morbidity among Jewish women.

Infection during Natural Orifice Transluminal Endoscopic Surgery Peritoneoscopy: A Randomized Comparative Study in a Survival Porcine Model

Background Infection in natural orifice transluminal endoscopic surgery (NOTES) remains controversial. Objective To estimate the frequency of infection during NOTES peritoneoscopy with different routes of access and to compare with laparoscopy. Design Prospective randomized controlled study (Canadian Classification type I). Methods Forty female pigs were randomly assigned to 3 NOTES (transgastric, transrectal, and transvaginal) and laparoscopic groups. Antiseptic technique was used for NOTES, whereas laparoscopy was performed in a sterile environment. Preoperative and postoperative intravenous antibiotics were administered. Closure of the transluminal access site was performed in all animals. Peritoneal fluid was collected for culture at the end of surgery and at necropsy at day 14. Results Thirty-nine peritoneoscopies were successfully completed. Necropsy confirmed complete healing of NOTES incisions, but 2 animals in the laparoscopy group had small abscesses in the abdominal incisions. There were no statistical differences in the presence of peritoneal adhesions. Positive culture results were seen in all groups at the end of the procedure and in all animals at necropsy, but this did not lead to clinical signs of gross infection. The most common organisms that colonized the peritoneum were gram-positive cocci and gram-negative bacilli from the normal swine gastrointestinal flora. Limitations Animal model and small sample size. Conclusions In these small series of animals and with the careful lavage and preparation used, NOTES appeared to be comparable to laparoscopy in terms of peritoneal contamination and clinical infection. Despite the adherence to a strict antiseptic protocol, peritoneal contamination occurs but does not lead to septic complications in the swine.

Port-sites excision for gallbladder cancer incidentally found after laparoscopic cholecystectomy

Port-site recurrence represents a severe complication in the case of incidental gallbladder cancer (ICG) discovered after laparoscopic cholecystectomy, and is reported to occur in 17% of cases. For this reason port-sites excision is an essential surgical step during the second operation, which includes liver resection (segments 4b and 5) and lymph node dissection (hepatic pedicle and retroduodeno-pancreatic region). In this article we describe a simple technique to obtain a radical port-site excision with the aim to standardize this surgical step and to perform it in a radical way. Port-sites excision is the accurate and complete excision of the parietal channel created by the trocar during the previous cholecystectomy. This channel is often Z-shaped. In the second operation, the presence of peritoneal adhesions helps to identify exactly the previous site of entry of the trocar in the peritoneal cavity. Trocar reinsertion through the abdominal wall along the correctly identified original path allows the excision of a perfect cylinder of abdominal wall including all of the layers from the skin to the peritoneum.

Laparoscopic resection for rectal cancer in patients with previous abdominal surgery: A comparative study

Objective: In laparoscopic colorectal procedures, the presence of peritoneal adhesions caused by previous surgery is one of the most common reasons for conversion and is often associated with increased postoperative morbidity. However, improvements in laparoscopic technique and instruments might, to some extent, help to overcome the adverse effects of peritoneal adhesions. Therefore, the present study was designed to compare and evaluate laparoscopic rectal cancer excision in patients who had had and who had not had previous abdominal surgery. Methods: The present study was a non‐randomized comparison of patients who have had and have not had previous abdominal surgery. Data were extracted from a prospective cohort of patients who had undergone laparoscopic anterior resection for rectal cancer in one particular unit between January 1996 and May 2000. For the purpose of standardization, data on laparoscopic low anterior resection and laparoscopic abdomino‐perineal resection were not used for analysis. The measured outcomes included operation time, blood loss and length of hospital stay as well as complications and conversions.Results: Of the 91 patients recruited for analysis, 26 patients had had previous abdominal surgery (study group), whereas 65 patients had not had previous abdominal surgery (control group). The two groups had a similar age and gender distribution as well as tumour staging. The median operating times of the study group and control group (115 vs 123 min, P = 0.34), their blood loss (122 vs 144 mL, P = 0.30) and lengths of hospital stay (10 vs 11 days, P = 0.66) were similar. The complication rates (23 vs 23%, P = 0.79) and conversion rates (15.4 vs 7.7%, P = 0.55) were also similar between the two groups. Conclusion: Laparoscopic resection for rectal cancer in patients who have had previous abdominal surgery is technically safe and produces similar results to those who have not had previous abdominal surgery.

Apendicectomia pelas técnicas de ligadura simples e de sepultamento sem ligadura do coto apendicular: estudo comparativo em coelhos

OBJETIVO: Comparar as técnicas operatórias de ligadura simples (A) e de sepultamento sem ligadura do coto apendicular (B). MÉTODO: Foram utilizados 36 coelhos da linhagem Nova Zelândia, machos, distribuídos aleatoriamente em dois grupos de 18, divididos respectivamente em subgrupos de seis animais cada um e praticada a eutanásia decorrido o tempo pós-operatório de sete, 14 e 21 dias. Foram avaliados macroscopicamente conforme a ferida operatória estivesse limpa, tivessem abscesso ou deiscência e a cavidade abdominal pela presença de aderências peritoneais. Foi feita avaliação histológica pela presença ou ausência dos seguintes parâmetros: infiltrado inflamatório agudo e crônico, fibrose, granuloma de corpo estranho, necrose e integridade da camada mucosa. RESULTADOS: Nos achados macroscópicos não foram observadas diferenças significantes no sétimo, 14º e 21º P.O. quanto à presença de abscesso e deiscência da ferida operatória entre os grupos A e B; o mesmo ocorreu quanto à presença de aderências peritoneais entre alças intestinais. Nos achados microscópicos houve diferença significante no 21º P.O. quanto ao infiltrado inflamatório agudo maior no grupo B, e à integridade da camada mucosa, maior no A. Na contagem de fibras colágenas houve diferença significante no 21º P.O., maior no grupo B. CONCLUSÃO: Do ponto de vista histológico a técnica de ligadura simples é superior à de sepultamento sem ligadura do coto apendicular.

Port dynamics during laparoscopic accessing

Objective: To determine tissue dynamics at port site during visual peritoneal entry using the Endoscopic Threaded Imaging Port.Method: Retrospective video review of 123 consecutive laparoscopic port insertions using a trocarless visual access cannula during open and closed laparoscopic port creation. Observations were recorded on a standard form and the results analyzed.Results: In preinsufflated closed laparoscopic entry, the CO2 distended abdomen transilluminated easily and looked grayish-blue in color when adhesions were absent. In presence of peritoneal adhesions, most were linear omental adhesions, and safe visual entry could be negotiated. During open laparoscopy, the nonadherent bowel or omentum could be observed to move with the patient’s respiratory movements prior to peritoneal entry. Once the peritoneal membrane is breached, the “presenting part” will balloon into the cannula if the tissues are not adherent and mobile and when the CO2 stopcock of the visual cannula is kept open. Peritoneal tenting is minimal at umbilical entry but could be generous at lower abdominal insertions unless the cannula is kept perpendicular to the skin surface during insertion.Conclusions: Interactive visual insertion of laparoscopic ports may infer added safety to the port insertion process and helps surgeons appreciate port dynamics and understand port competence.

Peritoneal fluid cytokine and eicosanoid levels and their relation to the incidence of peritoneal adhesion.

To determine the peritoneal fluid content of several cytokines and eicosanoids with inflammatory, anti-inflammatory, anti-fibrotic, and fibrotic activities, and to assess the relationship of these levels with the incidence of peritoneal adhesions. Peritoneal fluids were collected from 30 subjects with adhesions (n = 22) or with normal pelvic anatomy (n = 8), and the level of interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha), interleukin-10 (IL-10), interferon gamma (IFN-gamma), transforming growth factor beta-1 (TGF-beta 1), granulocyte macrophage-colony stimulating factor (GM-CSF), prostaglandin E2 (PGE2), leukotriene B4 (LTB4), and thromboxane B2 (TXB2) were determined by enzyme-linked immunosorbent assay (ELISA) and radioreceptor assay. The peritoneal fluid content of these factors varied considerably, with low levels of IL-1 beta, TNF-alpha, IL-10, IFN-gamma, and GM-CSF. Only IFN-gamma levels were significantly lower in subjects with adhesions compared with the normal group (P < .05). The levels of total (latent + active) and active TGF-beta 1 were higher than those of other cytokines assayed and were significantly higher in subjects with adhesions compared with the normal group (P < .05). The peritoneal fluid content of PGE2, TXB2, and LTB4 was significantly higher than that of the cytokines and was higher, but not significantly so, in subjects with adhesions compared with normal subjects (P = .06). Although the effect of length of time since the adhesions were formed is not known, the results indicate that peritoneal fluid content of these cytokines and eicosanoids, with the exception of IFN-gamma and TGF-beta 1, does not correlate with the presence of peritoneal adhesions.