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PubMed1992

Meal-stimulated canine jejunal ionic absorption. Effect of direct jejunal meal delivery and premeal intravenous hydration.

The ingestion of a meal stimulates water and ion absorption from the small intestine. The administration of nutrient substances directly to the small bowel can cause dumping symptoms, with intraluminal fluid accumulation and relative systemic hypovolemia. This study compared the effect of oral versus direct jejunal meal delivery on jejunal water and ion absorption, with and without premeal intravenous saline infusion. Jejunal absorption studies (N = 40) were performed on dogs with 25 cm proximal jejunal Thiry-Vella fistulas and feeding jejunostomies. Luminal perfusion with [14C]PEG was used to calculate fluxes of water and electrolytes. Five groups were randomly studied: (1) intravenous 0.9% saline alone, (2) oral meal alone, (3) intravenous 0.9% saline plus oral meal, (4) jejunal meal alone, and (5) intravenous 0.9% saline plus jejunal meal. Hydration status was assessed hourly by measurement of hematocrit. Water and electrolyte absorption was significantly stimulated by both oral and jejunal meal delivery (P less than 0.01). Intravenous saline hydration significantly reduced the hematocrit (P less than 0.05) but did not alter the proabsorptive response to an oral or jejunal meal. In conclusion, a postprandial signal for proximal jejunal water and electrolyte absorption was stimulated equally by orally or jejunally administered nutrients and was not affected by premeal hydration. These data support the hypothesis that the proabsorptive signal that stimulates water and ion absorption is an enteroenteric phenomenon originating from the small intestine, without implicating pathophysiologic events such as hypovolemia or dumping.

Animals↗

PubMed1984

Characteristics of secretin-stimulated pancreatic secretion in dogs.

The effect of the periodic interdigestive activity of the gut on secretin-stimulated pancreatic secretion was studied in eight conscious dogs each with a Thomas duodenal fistula, a gastric fistula and a Heidenhain pouch. Pancreatic water and bicarbonate responses to a small dose of secretin were greatly augmented in phase with the spontaneous periodic activity of the gut. This augmentation was closely related to pancreatic protein secretion. As the dose of secretin was increased the interval between peaks was prolonged, the peaks became less sharp, the nadirs were raised, and finally the periodic activity was no longer seen. Bilateral cervical vagal blockade with local anaesthetics reduced the secretin-stimulated bicarbonate secretion by 50% but the augmentation at the peak was not abolished. Atropine abolished the periodic augmentation completely and reduced the bicarbonate response by 80%. The peak response of volume and bicarbonate to secretin obeyed Michaelis-Menten kinetics. The nadir secretin dose response, however, was a sigmoid curve with a Hill coefficient larger than one. The action of atropine or hexamethonium was to shift the peak response kinetics to the nadir kinetics. It is concluded that the pancreatic response to secretin is greatly modulated by the spontaneous periodic activity of nerves.

Animals↗

PubMed2001

Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae.

OBJECTIVE: To evaluate surgical options of treatment in combined tracheo-esophageal injuries and their sequelae and elaborate new ones. METHODS: The overlooked diagnosis of combined tracheo-esophageal injury would lead to severe stenosis of the esophagus and trachea with tracheo-esophageal fistula. This condition requires a complex surgical intervention to be performed with non-standard procedure in every single case. Forty patients with combined tracheo-esophageal injuries were treated in our institution. Nine patients were urgently operated while others were transferred to us from other hospitals with chronic sequelae of the initial trauma. RESULTS: In the majority of cases the cause of the injury was penetrating (17 patients) or iatrogenic (13 patients) trauma followed by blunt neck and chest trauma (six patients) and caustic burn (four patients). Three patients had total cut off of the esophagus and trachea, which were repaired with end-to-end anastomoses. Another six patients had tracheal and esophageal disruptions within one-half to three-quarters of circumference. In these cases both the trachea and esophagus were mobilized within wall laceration and sutured by interrupted Vicryl 4/0. One of them died due to pre-existing disease. Thirty-one patients with sequelae of the trauma were also operated on. In spite of the complexity and extent of the tracheo-esophageal stenosis and fistula the surgical treatment was aimed to one-stage reconstruction of both the esophagus and trachea. For this purpose we performed an originally developed surgical intervention, which was to be modified in accordance with patients diagnosis. The main point of the procedure is that after mobilization of the trachea and esophagus we resect an involved part of the trachea, but preserve a pedicled flap fashioned from the tracheal membrane. Then we remove the mucosa from the flap, resect an involved esophageal wall, repair esophageal mucosa and replace the defect of the muscular layer of the esophagus with the tracheal flap. Then a tracheal or laryngo-tracheal anastomosis is established. There were no postoperative mortality and complications among patients with the sequelae. CONCLUSION: Combined tracheo-esophageal injury requires the precise preoperative diagnosis and well organized plan of surgical treatment, which may be unique for every single patient. The main purpose of the treatment is to restore the continuity of both the esophagus and trachea in one-stage intervention.

Adolescent↗

PubMed1990

[X-ray computed tomography and percutaneous drainage change the indications for reoperation after digestive surgery].

In order to assess the major clinical biological and radiological signs of an intra-abdominal abscess following digestive surgery as well as the place of automatic reoperation, this retrospective study analysed 79 patients requiring intensive therapy for such a complication since 1982. Surgery consisted in oesophagectomy (n = 38), hepatectomy or cholecystectomy (n = 12), pancreatic surgery (n = 17) and colectomy (n = 12). A postoperative abdominal abscess was recognized in 75 patients consisting in intrathoracic or intra-abdominal oesophageal fistulas (n = 31), pancreatic abscesses and fistulas (n = 17), peri- or intrahepatic abscesses (n = 11), colonic fistulas (n = 12) and acalculous cholecystitis. With regard to the intensity of symptomatology the patients have been allocated into 2 groups. In group I, including 12 patients, the infectious syndrome occurred early (3 first postoperative days), was severe and associated with positive blood cultures in 60% of cases. The patients were reoperated without previous CT-scanography. Four died postoperatively. In group II, including 67 patients, the symptomatology was more discrete. CT-scanography was highly beneficial, with discovery of an abscess in 90% of cases. In 20 patients, the abscess has been punctured and drained successfully by percutaneous route. In 6 patients with negative CT-scanography, an automatic reoperation resulted in the discovery of an abscess in 2 cases. Five out of 6 of these patients died postoperatively. It is concluded that in case of intraabdominal complication following digestive surgery: a) in case of early and severe symptomatology, a rapid reoperation is mandatory; b) CT-scanography has a high diagnostic value for abscess recognition in patients with discrete and delayed symptomatology; c) nearly one third of the abscesses can be treated successfully by percutaneous drainage; d) the value of automatic reoperations remains unsubstantiated.

Abdomen↗

PubMedDate not supplied

Continuous high-energy low-flow-rate enteral support: a panoramic review of 1000 cases.

One thousand intensive care digestive surgical cases are reviewed concerning continuous low-flow-rate enteral support (CLFRES), using Nutripompe: 607 males and 393 females, average age 51 years. The average duration of CLFRES is 21.5 days +/- 13, range 4 to 180 days. CLFRES was used postoperatively in 76 per cent, preoperatively in 10 per cent, and pre- and postoperatively in 14 per cent of cases, respectively. The enteral support route was 63 per cent nasogastric, 20 per cent gastrostomy and 17 per cent jejunostomy. Five hundred and ten patients required extensive digestive surgery with temporary exclusions. More than 100 patients with either temporary enterostomies or enterocutaneous fistulas have had continuous reinstillation of digestive chyme (CRDC) associated with their intensive care unit treatment management. CRDC in the lower end of an enterostomy has shown a specific retrograde inhibitory effect on the upper digestive secretions, particularly on the intestinal secretions during pathologies associated with one or several interruptions of the continuity of the gastrointestinal tract. This technique and its physiological implications were discussed. The principal pathologies in this important study group are: severe digestive fistulas, 24 per cent; acute diffuse peritonitis, 18 per cent; acute enterocolitis, 14 per cent; digestive tumours, 35 per cent; and acute necrotizing haemorrhagic pancreatitis, 9 per cent. A comparative analysis of nutritional energy nitrogen requirement was presented in view of the cancer, the septic, and the non-cancer non-septic patient groups. Enteral support nutritional solutions were primarily mixed non-degraded food, 70 per cent, and semi-elemental diets, 30 per cent. Certain pathology groups required variations in protein and lipid percentage. An up-to-date evaluation of nutritive formulas based on small peptides in normal and small bowel postoperative patients was discussed. Four CLFRES administration programmes were discussed: normal gastrointestinal tract, 38 per cent; abnormal gastrointestinal tract, 44 per cent; pancreatitis, 11 per cent; short bowel, 7 per cent. Nutrition evolution parameters (clinical), were: weight gain curve (minimum 10 days), local regional healing, biological positive changes in protein metabolism, nitrogen balance, lipid metabolism and glucose regulation. Impact on complications such as thrombosis, embolism and haemorrhage were discussed. Clinical and biological results using CLFRES were most satisfactory in more than 90 per cent of patients.

Adolescent↗

PubMed2006

Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery.

BACKGROUND: This study examined the feasibility of using Polyflex stents in the treatment of enteric leaks after various bariatric operations. Chronic and acute leaks were treated. METHODS: We performed a retrospective case series review. Four patients received 6 Polyflex stents to treat complications of bariatric surgery. Two presented with early sepsis before stenting. One presented with abdominal pain. One presented with a chronic persistent fistula with an associated abscess. Stenting was performed under endoscopy with fluoroscopic guidance. The stents were left in place for 6 weeks. RESULTS: All patients tolerated a clear liquid diet within 24 hours of stenting and were able to be advanced to a pureed diet. All patients improved clinically after stenting. Three patients with acute leaks sealed their leaks after stent placement. One patient with a chronic leak persisted and required operative closure after a second stent was placed and failed. All patients experienced short-term nausea, as well as early satiety that lasted the duration of the stenting. One patient experienced hypersialisis while the stent was in place. Two stents migrated, although this had no effect on leak closure. One patient had an anastomotic stenosis successfully treated with a second stent. CONCLUSIONS: Polyflex stents are useful in bypassing acute upper intestinal leaks after various bariatric operations. They provide a temporary bridge for wound healing with continued oral intake. Stenting provides a minimally invasive option in the management of acute leaks and, in our experience, had no serious associated morbidity.

Adult↗

PubMed1991

The gastrointestinal tract in Down syndrome.

Down Syndrome is recognized as one of the most common predisposing conditions for a group of serious gastrointestinal (GI) anomalies. Tracheo-esophageal fistula, duodenal obstruction with or without pyloric stenosis, annular pancreas, imperforate anus and Hirschsprung's disease are the most prevalent lesions. Understanding of the morphogenetic mechanisms responsible for this range of abnormalities is far from clear, as none of the lesions is specific to the trisomic state and the underlying defects (i.e., failure of foregut canalization, failure of neural crest cell migration into the myenteric and submucosal plexuses or malformation of the anterior abdominal wall, etc) are encountered in unaffected infants. Segregation analysis of inheritance patterns points to multi-factorial traits and random genetic action provide appropriate models (to a certain extent) for describing the observations. Furthermore, intestinal anomalies can be found in many other genetic disorders, with recent evidence suggesting the presence of GI developmental regulatory genes on chromosome 13q. A possible common pathway to the observed anomalies might be enhanced epithelial adhesiveness, as demonstrated in vitro experiments with fibroblasts. Molecular genetic techniques applied to the smallest human autosome could provide the needed insight into the ultimate mechanisms determining morphogenesis. The development of a murine model is a promising tool for the successful approach to these extraordinarily complex questions.

Digestive System↗

PubMed1982

Portal and cephalic venous gastrin after peptone infusion in the alert dog.

A model was designed to permit sampling of portal venous blood in nonanesthetized dogs. Five mongrel dogs were prepared with indwelling portal venous catheters and gastric fistulas. After a minimum recovery period of 7 days, a 10 percent peptone meal was infused into the stomach. Portal and peripheral venous sera were obtained in the basal state and at various time points after intragastric peptone infusion. Serum gastrin concentrations were later measured by radioimmunoassay. Mean basal gastrin from portal and peripheral venous sera were 17 +/- 5 and 13 +/- 2 pg/ml, respectively. After peptone infusion, a biphasic gastrin response was observed. The first peak in portal venous serum occurred at 2 minutes, increasing to 49 +/- 20 pg/ml, while in the peripheral venous serum, the initial peak occurred at 4 minutes to 33 +/- 4 pg/ml. The second peak component occurred at 30 minutes in both circulations, increasing to 35 +/- 14 pg/ml in portal venous serum and to 29 +/- 8 pg/ml in peripheral venous serum. The results of this study (1) demonstrate that the release of gastrin after a peptone meal in the dog is prompt and biphasic, and (2) provide an effective method for obtaining simultaneous portal and peripheral venous blood for measurement of gastrointestinal peptides in alert, nonanesthesized dogs.

Animals↗

PubMedDate not supplied

Factors affecting surgical risk in elderly patients with inflammatory bowel disease.

The operative treatment of elderly patients with inflammatory bowel disease (IBD) has often been avoided in favor of medical management because of a perceived increase in surgical risk. This study sought to define the following in the elderly IBD patient population: (1) the risk of surgical management and (2) those factors affecting risk. Thirty patients with IBD, aged 60 years or more, who were surgically managed by a single surgeon over a 10-year period, were retrospectively matched to 75 patients with IBD who were less than 60 years of age; patients were matched according to sex, date of surgery, and type of surgery performed. Regression analysis using generalized estimating equation methodology to account for the matched clusters of patients was performed to evaluate the effect of age group on the complication rate, operating room time, and length of hospital stay. Presence of comorbid conditions, surgical indications, prior surgery for IBD, and the use of immunosuppressive medications were studied in multivariate models, adjusting for age group. By means of univariate analysis, the odds of complications in elderly IBD patients were shown to be statistically higher than the odds seen in younger patients (47% vs. 20%, P = 0.01). Also observed in the elderly group were a longer length of hospital stay (11.5 days vs. 7.1 days, P = 0.001) and longer operating room time (249 minutes vs. 212 minutes, P = 0.02). Multivariate analysis revealed that the effect of age remained statistically significant, even when adjusted for potential confounding variables such as comorbidity, medications, date of diagnosis of IBD, and indications for surgery. The complication outcome was significantly associated with the surgical indication, with obstruction, fistula, and bleeding having increased odds of complications as compared with other indications (odds ratio = 1.7 vs. 4.2 vs. 7.2, respectively, P = 0.02). The length of hospital stay similarly was significantly associated with the surgical indication (fistula, 10.5 days vs. bleeding, 9.8 days vs. obstruction, 7.4 days vs. other, 9.3 days; P = 0.04) and a history of prior surgery. A significant interaction for length of hospital stay was present between age group and prior surgery status (with prior surgery: old, 18 days vs. young, 6.4 days, P = 0.0001; without prior surgery: old, 9.5 days vs. young 7.3 days, P = 0.10). Elderly patients with IBD have an increased rate of postoperative complications along with an increased length of hospital stay and increased operating room time. This effect of age persists when adjusted for comorbidity and immunosuppressive therapy. Complications are most dependent on surgical indications, with obstruction being the least and bleeding the worst predictive factors. The longest hospital stay is associated with patients who require surgery for fistulous disease and patients who have undergone previous surgery. The fact that the higher complication rate seen in older patients with IBD is associated with disease-defined surgical indications suggests that IBD in elderly patients may be more aggressive than what is observed in younger individuals.

Adolescent↗

PubMed2000

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients.

INTRODUCTION: Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. METHODS: This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. RESULTS COMPLICATIONS: Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). FOLLOW-UP: During the follow-up period of 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B, 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squeeze pressure did not change. CONCLUSION: In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailment of oncologic standards. A protective stoma for three months is advantageous.

Aged↗

PubMed1992

Abdominal chemo- and mechanosensitivity in ruminants and its role in the control of food intake.

Ruminant animals have evolved a large and complex set of stomachs which allow fermentation of fibrous food by symbiotic micro-organisms. These stomachs are well innervated and generate signals which are thought to be important in the control of voluntary food intake. Tension receptors in the muscular wall of the rumen and reticulum are slowly adapting and provide a measure of distension while epithelial receptors are rapidly adapting and provide information on the fibrousness of the digesta; they are involved in the control of stomach motility and voluntary food intake in order to prevent excessive distension. The epithelial receptors are also sensitive to the chemical nature of the digesta, particularly acidity. There are mechano- and chemoreceptors in the abomasum (true stomach) and duodenum and chemoreceptors in the liver, all of which have been implicated in the control of intake. It is relatively easy to prepare and maintain ruminants with a rumen fistula and many studies have shown the effects of such manipulations as distension of balloons in the rumen on voluntary intake. With fibrous, slowly digested feeds intake is primarily limited by rumen distension. With more rapidly digested feeds, however, the products of digestion play an important role in controlling intake. Short-chain fatty acids are the main products of fermentation and infusion of their salts into the rumen depresses food intake to a much greater extent than infusion into the general circulation. Acetate or propionate given into the rumen are more effective, mole for mole, than butyrate but must be given at rates exceeding the natural rate of production in order to have a significant effect. It has been suggested that much of the effect of sodium acetate is via the increase in the osmolality of rumen fluid but there is considerable uncertainty as to the physiological significance of osmotic effects, especially when animals have free access to water and can prevent excessive increases in tonicity by increasing their water intake. Other constituents of rumen fluid have been implicated in the control of food intake, particularly lactic acid and nitrogenous compounds, especially as these can be found in fermented feeds such as silage. The omasum controls the flow of digesta to the abomasum; it is therefore well placed to control rumen fill and thus intake but there has been little study in this area and this is also true for the abomasum.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed1975

Congenital malformations in twins: epidemiologic survey.

Among 1195 twins born in the Collaborative Perinatal Project, for whom information was available, 219 (18.33%) were found to have malformations, 179 (14.98%) single and 40 (3.35%) multiple. The frequency of malformations and malformed individuals was significantly higher in twins than in singletons from the same population but the difference was entirely contributed by MZ twins. This held true for both major and minor malformations. There was no significant difference in the frequency of multiple malformations. Negro twins were more frequently malformed than white, and male twins were more frequently malformed than female. Twins had a significant, more than two-fold, increase of cardiovascular and alimentary tract malformations, and smaller increases of central nervous system, musculoskeletal, ear, and respiratory malformations over singletons. Significantly increased among specific malformations were macrocephaly, encephalocele, cleft lip and palate, anomalies of the diaphragm, cardiac septal defects, tracheoesophageal fistula, malformations of the alimentary tract, inguinal and umbilical hernias, and cystic kidney. A significant increase of malformations in twins over singletons occurred only in live births who survived to one year. There was a small but not significant increase of malformations in twin fetal deaths and deaths beyond the neonatal period; but among neonatal deaths, twins were less frequently malformed than singletons. Monoamniotic twins had higher mortality, more complications of delivery, and significantly more congenital malformations than diamniotic twins. One of the 9 pairs of MA twins in the study was a conjoined thoracopagus twin pair with multiple cardiovascular, alimentary, and other malformations. The case is interesting because of the medical history of the mother before and during pregnancy, and its possible bearing on the cause of MZ twinning and of congenital malformations. There was no difference in the frequency of malformations among first- and second-born twins. Concordance rates were significantly higher among MZ than among DZ twins for any malformation as well as for the categories of major, minor, single and multiple malformations. In the majority of cases, the twins were concordant for the same malformation. Concordance rates of MZ twins were consistently higher than those of DZ for all systems, but the difference was significant only for the musculoskeletal system, comprising mostly clubfoot. Because of the small numbers involved, the results of the concordance analysis should be interpreted with caution.

Amnion↗

PubMed2004

Indications and results of side-to-side isoperistaltic strictureplasty in Crohn's disease.

PURPOSE: Strictureplasty has commonly been used for short stenotic tracts, but it has rarely been applied to stenoses longer than 10 cm. Michelassi proposed a side-to-side isoperistaltic strictureplasty for single or multiple strictures that affected long bowel tracts. The experience and results obtained to date with this type of strictureplasty are limited. We therefore decided to review the cases in which we performed this procedure. METHODS: Thirty-one patients, aged 21 to 66 years, underwent this operation between August 1996 and October 2002. Indications for surgery included subocclusion in 22 patients, malnutrition in 9 patients, and fistula or abscess in 6 patients. Two side-to-side isoperistaltic strictureplasties have been performed in jejunum, 6 in jejunum-ileum, 16 in the proximal ileum, 1 in terminal ileum, and 6 in the ileo-cecal tract. RESULTS: The average length of side-to-side isoperistaltic strictureplasty as 32.1 cm (range, 10-54 cm). Sixteen patients also underwent concomitant bowel resection and 17 patients have received additional strictureplasty. There was no perioperative mortality, nor were there any postoperative complications requiring reoperation. In all patients intestinal occlusion and malnutrition were resolved. Decrease of activity indices was observed in 62.3 percent of patients within 6 months after surgery. At an average follow-up of 26.4 months, six patients required reoperation, but in only one of them did the recurrence involve a previous strictureplasty site. In that case the side-to-side isoperistaltic strictureplasty was soft and was without signs of inflammation or stenosis. CONCLUSIONS: Side-to-side isoperistaltic strictureplasty seems to provide a technical solution leading to improvement when long intestinal inflamed tract are treated. Longer follow-up and larger experience is needed to validate this observation.

Adult↗

PubMed2003

Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients.

HYPOTHESIS: Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications. DESIGN: A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). SETTING: Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). PATIENTS: From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery. MAIN OUTCOME MEASURES: The dependent variables studied included surgical site infection (SSI) (divided into parietal and deep infectious complications with or without fistulas) and global infectious complications (SSI and extraparietal and abdominal infectious complications). RESULTS: The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age (60-74 years, OR, 1.64; >or=75 years, OR, 1.45); being underweight (OR, 1.51); having cirrhosis (OR, 2.45), having a vertical abdominal incision (OR, 1.66); having a suture placed or an anastomis of the bowel (OR, 1.48) in the digestive tract; having a prolonged operative time (61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72); and being categorized as having a class 4 surgical site (ie, obese patients or having a risk factor of a healing defect) (OR, 1.66). Ceftriaxone sodium therapy was identified as a protective factor (OR, 0.43). In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis (OR, 4.75), having a suture placed or an anastomosis of the bowel (OR, 1.82) in the digestive tract, having postoperative abdominal drainage (OR, 2.15), undergoing a surgical procedure for the treatment of cancer (OR, 1.74), and receiving curative anticoagulant therapy (OR, 3.33) postoperatively. CONCLUSIONS: Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.

Adult↗

PubMed2000

Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial.

OBJECTIVE: To determine the suitability of a single-layer continuous technique for intestinal anastomosis in a surgical training program. SUMMARY BACKGROUND DATA: Several recent reports have advocated the use of a continuous single-layer technique for intestinal anastomosis. Purported advantages include shorter time for construction, lower cost, and perhaps a lower rate of anastomotic leakage. The authors hypothesized that the single-layer continuous anastomosis could be safely introduced into a surgical training program and that it could be performed in less time and at a lower cost than the two-layer interrupted anastomosis. METHODS: The study was conducted during a 3-year period ending September 1999. All adult patients requiring intestinal anastomosis were considered eligible. Patients who required anastomosis to the stomach, duodenum, and rectum were excluded. Patients were also excluded if the surgeon did not believe either technique could be used. Patients were randomly assigned to one- or two-layer techniques. Single-layer anastomoses were performed with a continuous 3-0 polypropylene suture. Two-layer anastomoses were constructed using interrupted 3-0 silk Lembert sutures for the outer layer and a continuous 3-0 polyglycolic acid suture for the inner layer. The time for anastomosis began with the placement of the first stitch and ended when the last stitch was cut. Anastomotic leak was defined as radiographic demonstration of a fistula or nonabsorbable material draining from a wound after oral administration, or visible disruption of the suture line during reexploration. RESULTS: Sixty-five single-layer and 67 two-layer anastomoses were performed. The groups were evenly matched according to age, sex, diagnosis, and location of the anastomosis. Two leaks (3.1%) occurred in the single-layer group and one (1.5%) in the two-layer group. Two abscesses (3.0%) occurred in each group. A mean of 20.8 minutes was required to construct a single-layer anastomosis versus 30.7 minutes for the two-layer technique. Mean length of stay was 7.9 days for single-layer patients and 9.9 days for two-layer patients; this difference did not quite reach statistical significance. Cost of materials was $4.61 for the single-layer technique and $35.38 for the two-layer method. CONCLUSIONS: A single-layer continuous anastomosis can be constructed in significantly less time and with a similar rate of complications compared with the two-layer technique. It also costs less than any other method and can be incorporated into a surgical training program without a significant increase in complications.

Anastomosis, Surgical↗

PubMed2001

Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer.

BACKGROUND: The purpose of this study was to determine the morbidity and survival associated with bowel resection at the time of primary cytoreductive surgery for ovarian cancer. STUDY DESIGN: We reviewed all patients undergoing bowel resection by gynecologic oncology faculty at the time of primary cytoreduction for advanced epithelial ovarian cancer diagnosed between 1983 and 1995. RESULTS: There were 105 patients meeting the above criteria. The median age was 65 years (range 34 to 85 years). There were 76 stage III and 25 stage IV cancers. The primary indication for bowel resection was tumor debulking in 92% of the patients. Seventy patients had segmental resection of the colon only, and 22 patients underwent resections that included the large and small bowels. Mean operating time was 260 minutes and mean estimated blood loss was 1,447 mL. Thirty-three (31%) patients were optimally cytoreduced to less than 1 cm residual disease. Ten patients experienced major complications directly related to bowel resection, including bowel fistula (4 patients), early postoperative bowel obstruction (5 patients), and stomal hernia (1 patient). Other morbidity included ileus for more than 10 days (18 patients), cardiac complications (17 patients), pneumonia (8 patients), sepsis (5 patients), and thromboembolism (4 patients). Six patients died and five patients required reexploration within 30 days of operation. Patients with preoperative bowel obstruction and suboptimal residual disease were more likely to have postoperative morbidity. Median survival in the optimally debulked patients was 35 months compared with 18 months in patients suboptimally cytoreduced (p = 0.006). Multivariate analysis demonstrated that optimal debulking (p = 0.009) and platinum chemotherapy (p = 0.00006) were independently associated with improved survival. Age, International Federation of Gynecologia Oncologists stage, American Society of Anesthesiologists class, and paclitaxel chemotherapy did not influence survival. CONCLUSIONS: In patients undergoing bowel resection at the time of primary cytoreduction for ovarian cancer, optimal cytoreduction to less than 1 cm residual disease results in improved survival. Morbidity is common but is comparable to other published series of ovarian cancer patients undergoing primary cytoreductive surgery without bowel resection. Additionally, patients with preoperative bowel obstruction and suboptimal residual disease are more likely to have serious morbidity.

Adult↗

PubMedDate not supplied

Congenital anomalies of the upper gastrointestinal tract.

A wide spectrum of congenital anomalies may affect the upper gastrointestinal tract, including anomalies of the esophagus (e.g., atresia, fistulas, webs, duplications, vascular rings), stomach (e.g., congenital gastric outlet obstruction, duplications), and duodenum (e.g., atresia, annular pancreas, duplications, malrotation). The evaluation of affected patients can require multiple imaging modalities for diagnosis and surgical planning. Radiography is often diagnostic and specific and can usually provide important clues to help determine the optimal diagnostic procedure. Neonates with complete gastric or upper intestinal obstruction do not usually require further radiologic evaluation after radiography: Barium studies are usually contraindicated, and complementary procedures (e.g., ultrasound [US], computed tomography [CT]) are not usually helpful and may even delay surgery, resulting in death. Nevertheless, US has become important in the evaluation of the pediatric gastrointestinal tract and is being used in an increasing number of applications. CT and magnetic resonance imaging are unsuitable for general screening but provide superb anatomic detail and added diagnostic specificity. They are especially useful in demonstrating esophageal duplications and vascular rings as well as associated abnormalities. However, the decision to perform a given imaging examination should be considered carefully to avoid inconvenience or unnecessary radiation exposure to the patient or delays in surgical correction. Quality control programs should be in place to ensure safe, effective radiologic practice through use of up-to-date equipment and good imaging technique.

Diagnostic Imaging↗

PubMedDate not supplied

Balloon dilatation of intrahepatic duct and biliary-enteric anastomosis strictures. Long term results.

From June 1984 to December 1986, 13 patients with 15 benign bile duct strictures were treated by Gruntzig balloon dilatation via the T-tube fistula or transhepatic route. The patients were 7 men and 6 women; ages ranged from 24 to 63 years old. The site of strictures were hepatojejunostomy in six, right intrahepatic duct in 4, left intrahepatic duct in 4 and one choledochoduodenostomy. Eleven out of 13 patients with bile duct strictures had intrahepatic stones. Ninety-three percent (14/15) of the strictures were successfully dilated by the Gruntzig balloon catheter. After the biliary stent was inserted for 2 to 6 months, follow-up cholangiogram or choledochoscopy revealed good patency of the biliary tree. Ninety-one percent (10/11) of the intrahepatic stones were removed completely by choledochoscopy. No major complication was found during balloon dilatation, except tolerable wound pain. Five patients (45%) developed symptoms during the follow-up period of 5 to 7 1/2 years. Two patients complained of right upper quadrant (RUQ) pain and 3 patients developed acute cholangitis which was treated by percutaneous biliary drainage again or laparotomy. Balloon dilatation for biliary-enteric anastomosis and intrahepatic duct strictures is a non-surgical, simple and effective procedure, but the incidence of restenosis rate is high and up to 45% within a long-term follow-up period of 5 to 7 1/2 years.

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