Biomedical subjects
Publications and source records attributed to T Bisgaard.
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OBJECTIVE: The influence of surgery on release of soluble vascular endothelial growth factor (sVEGF) and the soluble inhibitory receptor (sVEGFR1) is unknown. The effect of major and minor surgery on variations in sVEGF and sVEGFR1 concentrations in vivo was studied, and on bacterial antigen-induced release of sVEGF and sVEGFR1 from whole blood in vitro. MATERIAL AND METHODS: Sixty-one patients with abdominal diseases undergoing five different surgical procedures were included in the study. Blood samples were drawn from patients before and after the operation. White blood cells and platelets were counted, and plasma sVEGF and sVEGFR1 were determined. Whole blood from each blood sample was stimulated in vitro with bacteria-derived antigens (lipopolysaccharides or protein A) and sVEGF and sVEGFR1 levels were subsequently determined in the supernatants. RESULTS: Neither sVEGF nor sVEGFR1 concentrations in plasma changed during surgery. In vitro stimulation of blood samples with bacteria-derived antigens resulted in a significant increase in sVEGF (p < 0.0001) and a less pronounced but still significant increase in sVEGFR1 (p < 0.01). Bacterial antigen-induced release of sVEGF correlated significantly with neutrophil cell counts (0.53 < r < 0.78; p < 0.0001). Bacterial antigen-induced sVEGFR1 release did not correlate with cell counts. CONCLUSIONS: Plasma sVEGF and sVEGFR1 concentrations did not change during surgery. In vitro bacterial stimulation led to increased release of sVEGF, which was not compensated for by an equivalent increase in sVEGFR1. There was a positive impact of major abdominal surgery on release of sVEGF. The bacterial antigen-induced changes in sVEGF may be related to the number of circulating neutrophils.
BACKGROUND AND OBJECTIVES: In patients with breast cancer, planning of the surgical strategy may rely on preoperative tumour size. The optimal method for assessment of small tumours has not been established. We compared findings from preoperative mammography and ultrasonography with histopathological tumour size in patients treated with breast-conserving surgery. MATERIAL AND METHODS: The study was retrospective and the setting a single institution clinic with free referral of patients. The patients were examined before the operation with mammography, ultrasonography, and findings were compared with postoperative histopathological tumour size. RESULTS: The study included 131 patients (median age was 59) years with grade I, II, and III cancers in 47, 71 and in 13 patients, respectively. The medium histological tumour size was 14 mm, range 4-45 mm. A wide 95% confidence interval between histopathological tumour size and preoperative mammography (standard deviation 4.8 mm) and ultrasonography (standard deviation 4.8 mm) was found. The combination of mammography and ultrasonography did not improve the results (standard deviation 4.3 mm). Preoperative mammography tended to over estimate the tumour size compared with histological tumour size whereas preoperative ultrasonography tended to underestimate the tumour size. CONCLUSION: In this retrospective study with preoperative evaluation of small breast cancers by mammography and ultrasonography, wide 95% confidence intervals for the methods were found and they should therefore be used with caution in the planning of the surgical strategy.
BACKGROUND: Preoperative oral carbohydrate can attenuate postoperative insulin resistance and catabolism, and may have the potential to improve postoperative recovery. There are no data from randomized studies on postoperative clinical outcome after specific surgical procedures. This study evaluated the clinical effects of a preoperative carbohydrate beverage in patients undergoing laparoscopic cholecystectomy. METHODS: Ninety-four patients undergoing laparoscopic cholecystectomy were included in a randomized clinical trial. Patients were randomized to receive 800 ml of an iso-osmolar 12.5 per cent carbohydrate-rich beverage the evening before operation (100 g carbohydrate) and another 400 ml (50 g carbohydrate) 2 h before initiation of anaesthesia, or the same volume of a placebo beverage. The primary endpoint was general well-being the day after operation. Patients were evaluated from 5 days before to 5 days after operation. Daily scores of general well-being, fatigue, appetite and pain, computerized measurements of physical activity and sleep (actigraphy), and subjective sleep quality were recorded. Nausea and vomiting were assessed twice within the first 24 h after surgery. RESULTS: Data from 86 patients were available for statistical analysis, 43 in each treatment group. No significant intergroup differences in general well-being or any other outcome variable were found. CONCLUSION: A preoperative carbohydrate beverage did not improve clinical outcome after laparoscopic cholecystectomy.
BACKGROUND: The aim of this study was to define factors that limit a short period of convalescence and to characterize the pain experienced after laparoscopic fundoplication. METHODS: This prospective study included 60 consecutive patients who underwent uncomplicated laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. Patients were recommended to convalesce for 2 days after operation. Duration of convalescence, dysphagia, fatigue, nausea, vomiting and different pain components were registered daily during the first week and on days 10 and 30 after fundoplication. RESULTS: Thirty-nine patients took a median of 13 (range 3-41) days off work and 60 stayed away from recreational activity for a median of 4 (range 1-22) days. Pain, fatigue and plans made before operation were the main contributors to prolonged convalescence. Some 30-40 per cent of the patients reported moderate or severe dysphagia during the study period. Fatigue scores were significantly increased for 6 days after surgery (P < 0 . 001). Visceral pain dominated over incisional and shoulder pain throughout the study. At day 30, 17 per cent of the patients reported moderate or severe visceral pain. CONCLUSION: Pain and dysphagia are significant problems after uncomplicated total laparoscopic fundoplication. The time taken off work and away from recreational activity exceeded the recommended 2 days of convalescence, justifying further efforts to optimize early clinical outcome after total laparoscopic fundoplication.
BACKGROUND: Multi-modal rehabilitation programmes may improve early postoperative body composition, pulmonary function, exercise capacity, and reduce hospital stay. So far, no data are available on convalescence after discharge. AIM: The objectives were to compare convalescence data (fatigue, sleep, time to resume normal activities, and functional capabilities) and need for nursing care and contact to general practitioner with fast-track multi-modal rehabilitation compared with conventional care after colonic surgery. METHODS: Non-randomised, prospective controlled study in 30 consecutive patients undergoing fast-track rehabilitation with continuous epidural analgesia, enforced oral nutrition, mobilisation, planned early discharge, and 30 consecutive patients undergoing conventional care. Patients were interviewed preoperatively and 14 and 30 days postoperatively. RESULTS: Median hospital stay was 2 vs. 8 days in the fast-track vs. conventional care group, respectively (p < 0.01). Fourteen days postoperatively, total and mid-day sleep were increased in the conventional care group when compared with the fast-track group (p < 0.01). Fatigue was increased significantly at 14 days (p < 0.05) and throughout the study period compared with the fast-track group (p < 0.01). Similarly, ability to walking stairs, cooking, house keeping, shopping and walking outdoor was significantly less reduced at 14 days in the fast-track group, who also regained leisure activities earlier (p < 0.05). There was no significant difference between groups at 30 days or between need for nursing care and visits to general practitioners. Readmission for surgery-related events occurred more frequently (5 vs. 1 patient) in the fast-track group. CONCLUSION: Fast-track rehabilitation with early discharge after colonic surgery results in earlier resumption of normal activities with reduced fatigue and need for sleep postoperatively compared to conventional care, and without increased need for nursing care or visits to general practitioners. However, readmissions may occur more frequently.
BACKGROUND: Downsizing the port incisions may reduce pain after laparoscopic cholecystectomy. METHODS: In a double-blind controlled study, 60 patients were randomized to undergo either microlaparoscopic cholecystectomy using one 10-mm and three 3.5-mm trocars (3.5-mm LC) or traditional laparoscopic cholecystectomy using two 10-mm and two 5-mm trocars (LC). Incisional pain at each port incision and overall pain were recorded for 1 week after the operation. Fatigue, nausea and vomiting, pulmonary function, and cosmetic results were also measured. RESULTS: Data from 52 patients were analyzed; eight patients were excluded from the study for various reasons. One patient was converted from 3.5-mm LC to LC due to technical problems with the 3.5-mm optic. In the 3.5-mm LC group (n = 25), incisional pain was significantly decreased in the 1st postoperative week as compared with the LC group (n = 27) (p <0.01). In both groups, pain scores at the supraumbilical 10-mm port were significantly higher compared with other port sites (p <0.05). The cosmetic results were significantly better in the 3.5-mm LC group (p <0.01). There were no significant differences in any of the other variables. CONCLUSION: The use of 3.5-mm trocars is feasible in LC, and it both reduces incisional pain and improves the cosmetic result.
BACKGROUND AND OBJECTIVES: Normally, the gallbladder is sent routinely for histological examination after cholecystectomy. From a cost-benefit point of view this may not be optimal. METHODS: Computerised records were used to identify patients with gallbladder carcinoma over a 20-year period, from 1979 to 1999, and these patient records were evaluated manually. RESULTS: The estimated cost for one histological examination was $37. During the period, 4,614 cholecystectomies were performed and 33 patients had gallbladder carcinoma. In 29 of the 33 patients, there was evident preoperative and/or peroperative suspicion of cancer, but no such suspicion in four patients. These four patients had other peroperative macroscopic abnormal findings, besides gallbladder stones. CONCLUSION: This retrospective series indicates that in the case of normal preoperative and/or peroperative macroscopic conditions (except for gallbladder stones) there is no need for histological examination of the gallbladder.
Use of electrocautery for laparoscopic surgery in patients with implanted pacemakers can create serious pace dysfunction. In these patients, the innovation of ultrasonic coagulation shears has provided the potential for safe routine laparoscopic cholecystectomy. We present a case where laparoscopic cholecystectomy was performed with the ultrasonic dissecting hook. The operation was converted to laparotomy due to unclear anatomy with further dissection using the ultrasonic hook. The intra- and postoperative courses were uneventful with no cardiac arrhythmias. More attention should be drawn towards this new surgical device so that patients with pacemakers may undergo routine laparoscopic surgery.
HYPOTHESIS: Detailed information on duration and limiting factors for convalescence after uncomplicated laparoscopic cholecystectomy is lacking. Duration of convalescence may be associated with patients' expectations, given recommendations, and postoperative complaints such as pain and fatigue. DESIGN: Prospective, descriptive study. SETTING: A university hospital. PATIENTS: Two hundred consecutive patients who underwent uncomplicated elective laparoscopic cholecystectomy. INTERVENTION: For sedentary, light, or moderate workload or main recreational activity, we recommended 2 days of postoperative convalescence; for strenuous workload or recreational activity, we recommended 1 week. MAIN OUTCOME MEASURES: Duration and reasons for absence from work. RESULTS: Convalescence from work (n = 85) and recreational activity (n = 198) was 6 days (range, 0-28 days) and 2 days (range, 0-24 days), respectively, in patients recommended for 2 days' convalescence. In patients recommended for 1 week of convalescence, convalescence from work (n = 25) was 10 days (range, 0-52 days), and convalescence from main recreational activity (n = 2), 8 days (range, 5-11 days). Among 87 patients who resumed work or activity later than recommended, pain was a contributory cause in 41 patients, fatigue in 35 patients, and convalescent period falling on a weekend in 26 patients, while 29 patients had arranged vacation or sick leave preoperatively. Preoperative expectation of convalescence and pain were independent contributory factors (P<.01) for convalescence from work for longer than 2 days in patients recommended for 2 days' convalescence. CONCLUSIONS: The period of convalescence after uncomplicated laparoscopic cholecystectomy is about 1 week from work and 2 days from recreational activity when 2 days of convalescence is recommended. Improved pain relief and patient information may further reduce convalescence.
Pain and speed of convalescence are the two main problems after uncomplicated laparoscopic cholecystectomy. We therefore identified interventional and descriptive studies in electronic databases and supplemented them with manual searches. Pain and interventional analgesic studies were analysed with reference to the effects on specific pain components after laparoscopic cholecystectomy. Convalescence and factors associated with early recovery were also analysed. Pain after cholecystectomy is most intense for the first 2-3 days with a high interindividual variability and dominated by incisional pain rather than other pain components. Early pain after cholecystectomy is reduced by minimising residual pneumoperitoneum and by giving incisional local anaesthetics, epidural analgesia, and non-steroidal anti-inflammatory drugs. There are inconclusive data about type and pressure of pneumoperitoneum, the use of intraperitoneal local anaesthetics, and the type of general anaesthesia. Pain and medico-cultural traditions are the main factors responsible for prolonged convalescence after laparoscopic cholecystectomy. To minimise pain and the duration of convalescence, we recommend multi-modal analgesic treatment in combination with short, standardised instructions to resume work and normal activity.
BACKGROUND: Laparoscopic cholecystectomy (LC) is traditionally performed with two 10-mm and two 5-mm trocars. The effect of smaller port incisions on pain has not been established in controlled studies. METHODS: In a double-blind controlled study, patients were randomized to LC or cholecystectomy with three 2-mm trocars and one 10-mm trocar (micro-LC). All patients received a multimodal analgesic regimen, including incisional local anesthetics at the beginning of surgery, NSAID, and paracetamol. Pain was registered preoperatively, for the first 3 h postoperatively, and daily for the 1st week. RESULTS: The study was discontinued after inclusion of 26 patients because five of the 13 patients (38%) randomized to micro-LC were converted to LC. In the remaining 21 patients, overall pain and incisional pain intensity during the first 3 h postoperatively increased in the LC group (n = 13) compared with preoperative pain levels (p<0.01), whereas pain did not increase in the micro-LC group (n = 8). CONCLUSIONS: Micro-LC in combination with a prophylactic multimodal analgesic regimen reduced postoperative pain for the first 3 h postoperatively. However, the micro-LC led to an unacceptable rate of conversion to LC (38%). The micro-LC instruments therefore need further technical development before this surgical technique can be used on a routine basis for laparoscopic cholecystectomy.
OBJECTIVE: To evaluate the effect of supplemental oxygen on postoperative cardiovascular response to submaximal exercise. DESIGN: Randomised, controlled study. SETTING: University hospital, Denmark. SUBJECTS: 16 patients having major abdominal operations. INTERVENTIONS: A submaximal exercise test (heart rate up to 120 min(-1)) done twice on the third day after operation. Patients were given either 100% oxygen (4 L min(-1)) or air (21% oxygen, 4 L min(-1)) 30 minutes before and during the test in randomised order. During the tests they were monitored with a Holter tape recorder and a pulse oximeter. MAIN OUTCOME MEASURES: Heart rate during exercise. RESULTS: At similar workloads there were significantly lower heart rates (median decrease 3 min(-1)) during exercise tests with oxygen compared with air (p < 0.05). Holter monitoring showed signs of myocardial ischaemia in 6 patients in relation to exercise testing, 4 of them related to both tests, 2 of them only when breathing air. Signs of myocardial ischaemia disappeared when the exercise ended. CONCLUSION: During the late postoperative period supplementary oxygen reduced heart rate in response to exercise to the same degree as observed previously in non-surgical patients and surgical patients not taking exercise. These findings do not suggest that decreased peripheral tissue oxygenation is responsible for the impaired cardiovascular response to exercise in postoperative patients.
Suspecting that paracrine inhibition might influence neuronal regulation of the endocrine L cells, we studied the role of somatostatin (SS) in the regulation of the secretion of the proglucagon-derived hormones glucagon-like peptide-1 and -2 (GLP-1 and GLP-2). This was examined using the isolated perfused porcine ileum stimulated with acetylcholine (ACh, 10(-6) M), neuromedin C (NC, 10(-8) M), and electrical nerve stimulation (NS) with or without alpha-adrenergic blockade (phentolamine 10(-5) M), and perfusion with a high-affinity monoclonal antibody against SS. ACh and NC significantly increased GLP secretion, whereas NS had little effect. SS immunoneutralization increased GLP secretion eight- to ninefold but had little influence on the GLP responses to ACh, NC, and NS. Basal SS secretion (mainly SS28) was unaffected by NS alone. Phentolamine + NS and NC abstract strongly stimulated release mainly of SS14, whereas ACh had little effect. Infused intravascularly, SS14 weakly and SS28 strongly inhibited GLP secretion. We conclude that GLP secretion is tonically inhibited by a local release of SS28 from epithelial paracrine cells, whereas SS14, supposedly derived from enteric neurons, only weakly influences GLP secretion.
Conversion of laparoscopic cholecystectomy to laparotomy may increase postoperative complications and convalescence and should therefore be avoided when possible. The authors present three technical tips that may prevent unnecessary conversion to open procedure (suspension sutures in the gallbladder, use of the Endo Paddle Retract (United States Surgical Corp., Norwalk, CT, USA) to depress abdominal viscera, and subtotal cholecystectomy). These methods may be used in situations in which there is no operative risk for complications, such as bile duct injury, but technical aspects of the operation normally would have resulted in conversion to laparotomy.
Seven healthy volunteers were intubated with two double lumen nasogastric tubes, one in the stomach, the other in the duodenum. This system allows simultaneous sampling of gastric juice and separate intraduodenal perfusion with a dietary fat (fish oil, 1269 kJ). Gastrin-17 was infused i.v. at a rate of 40 pmol/kg/h throughout the study. Gastric lipase was measured at 15-min intervals as activity (tributyrin) and as immunoreactivity (ELISA). Infusion of gastrin-17 resulted in a stable increase in the plasma concentration from a basal concentration of 8.3 +/- 0.8 pmol/l to 41.4 +/- 4.2 pmol/l. Perfusion with fat reduced gastric lipase activity from 24.2 +/- 5.3 to 7.2 +/- 2.5 kU/l (P < 0.05), and immunoreactivity from 0.7 +/- 0.1 to 0.42 +/- 0.1 mg/l (P < 0.05). After termination of fat perfusion, gastric lipase secretion increased again, though not reaching preinhibitory concentrations. During the intraduodenal perfusion with fat the plasma concentrations of glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK) increased from 6.9 +/- 0.5 to 15.1 +/- 1.5 pmol/l (P < 0.05) and from 1.2 +/- 0.4 to 3.8 +/- 0.9 pmol/l (P < 0.05). This study reveals a negative effect of fat in the duodenum on gastric lipase secretion. This effect may be mediated by GLP-1 and/or CCK.
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OBJECTIVE: Assessment of early postoperative activity is important in the documentation of improvements of peri-operative care. This study was designed to validate computerized activity-based monitoring of physical activity and sleep (actigraphy) in patients after abdominal surgery. METHODS: The study included twelve hospitalized patients after major abdominal surgery studied on day 2 to 4 after operation and twelve unhospitalized healthy volunteers. Measurements were performed for 24 consecutive hours. The actigraphy measurements were compared with self-reported activity- and sleep registration. The actigraphy output was obtained by the zero-crossing mode (ZCM) and time-above-threshold mode (TATM). RESULTS: The overall results showed comparable mean agreement between actigraphy and self-reported activity registrations for patients of 80% (SD 12%) and volunteers of 84% (SD 6%) (p = 0.15). In both study groups, all correlation coefficients between actigraphy measurements and self-reported activity data were statistically significant (r, values for patients 0.4 to 0.8 and volunteers 0.6 to 0.9). A higher mean agreement between automated actigraphy sleep detection and self-reported sleep registration were found in the volunteers (85%, SD 15%) compared with the patients (77%, SD 11%) (p < 0.05). The mean activity value awake was higher in the volunteers than in the patients (p < 0.05). CONCLUSION: Computerized activity monitoring by actigraphy is a reliable and easy method for monitoring physical activity and sleep-wake cycles after major abdominal surgery.