Effect of a Forced-Air Warming Blanket on Different Parts of the Body on Core Temperature of Patients Undergoing Elective Open Abdominal Surgery: A Randomized Controlled Single-Blind Trial.

PURPOSE: This study aimed to determine the effect of a forced-air warming blanket placed on different body parts on the core temperature of patients undergoing elective open abdominal surgery. DESIGN: Prospective, single-center, randomized, controlled, single-blind trial. METHODS: A total of 537 patients who underwent open abdominal surgery were randomized into groups A, B, and C and provided with different forced-air warming blankets. Group A was given an upper body blanket, group B a lower body blanket, and group C an underbody blanket. The incidence of intraoperative hypothermia, the time maintaining the core temperature over 36 â„ƒ before hypothermia, the duration of hypothermia, the rewarming rate, and relevant complications were compared among three groups. FINDINGS: Intraoperative hypothermia occurred in 51.4% of patients in group B, 37.6% of patients in group A, and 34.1% of patients in group C (P = .002). Maintaining the core temperature above 36 â„ƒ was longer before hypothermia in groups A and C (log-rank P = .006). In groups A and C, the duration of hypothermia was shorter, the rewarming rate was higher, and the incidence of shivering and postoperative nausea and vomiting were lower, compared to group B. CONCLUSIONS: In patients undergoing elective open abdominal surgery, a forced-air warming blanket on the upper body part or underbody area decreased intraoperative hypothermia, prolonged the time to maintain the core temperature above 36 â„ƒ before hypothermia, and could better prevent further hypothermia when the core temperature had decreased below 36 â„ƒ. In addition, it was significantly superior in reducing shivering and postoperative nausea and vomiting in the postanesthesia care unit.

Neuraxial Anesthesia for Combined Left Nephrectomy and Left Hemicolectomy in a One-Lung Patient.

Monopulmonary patients undergoing major abdominal surgery represent a high-risk population. While general anesthesia is typically the standard approach, mechanical ventilation can cause significant complications, particularly in patients with pre-existing lung conditions. Tailored anesthesia strategies are essential to mitigate these risks and preserve respiratory function. We present the case of a 71-year-old female with a history of prior right pneumonectomy for lung cancer. She was scheduled for combined left nephrectomy and left hemicolectomy laparotomic surgery because of extended colon cancer. The patient was prepared according to the local Enhanced Recovery After Surgery (ERAS) protocol and underwent thoracic neuraxial anesthesia with sedation maintaining spontaneous breathing, so avoiding general anesthesia and mechanical ventilation. Anesthesia in the surgical field was effective, and no respiratory problems occurred intraoperatively. The patient's rapid recovery and early discharge underscore the success of our "tailored anesthesia strategy." Our experience highlights the feasibility and benefits of tailored anesthesia in monopulmonary patients undergoing major abdominal surgery. By avoiding general anesthesia and mechanical ventilation, we mitigated risks and optimized patient outcomes, emphasizing the importance of individualized approaches in high-risk surgical populations.

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review.

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

The impact of anemia and blood transfusion on mortality after open abdominal surgery in the elderly.

BACKGROUND: Major abdominal surgery is associated with considerable mortality in the elderly. Anemia has been linked to increased mortality in other types of surgery, such as hip and cardiac surgery. This study aimed to assess the impact of preoperative anemia on mortality in the elderly undergoing major abdominal surgery, and how allogeneic red cell blood transfusion influences mortality in these patients. MATERIALS AND METHODS: We conducted a single-center, register-based retrospective study on patients, who were aged beyond 60 years and underwent one of 81 open abdominal surgical procedures. Patients operated on during the period from January 1, 2000, to May 31, 2013, were consecutively identified in the Danish National Patient Registry. Plasma hemoglobin was measured within 30 days prior to surgery and the primary endpoint was 30-day postoperative mortality. Information about patient transfusions from the hospital blood bank was available from 1998 to 2010. RESULTS: A total of 3199 patients were included of whom 85% underwent emergency surgery. The total mortality after 30 days was 20%. The median preoperative hemoglobin value of survivors was 7.7 mmol/L vs 6.9 mmol/L in those who died. The difference in hemoglobin values, between those who survived or died, decreased from the pre- to the post-operative phase. The 30-day postoperative mortality was 28%, 20%, and 12% in patients with a preoperative hemoglobin level in the lower, median, and upper quartile respectively. Transfusion therapy was associated with higher postoperative mortality, except in patients with very low hemoglobin values. CONCLUSION: Preoperative anemia has a clear association with surgically related mortality. The distribution of hemoglobin values in patients with a fatal outcome differs significantly from that of survivors. Red cell transfusion is associated with increased mortality, except in patients with very low hemoglobin values which supports recent guidelines suggesting a restrictive transfusion strategy.

Volume Incentive Spirometry Reduces Pulmonary Complications in Patients After Open Abdominal Surgery: A Randomized Clinical Trial.

Objective: To compare the effect of diaphragmatic breathing and volume incentive spirometry (VIS) on hemodynamics, pulmonary function, and blood gas in patients following open abdominal surgery under general anesthesia. Methods: A total of 58 patients who received open abdominal surgery were randomly assigned to the control group (n=29) undergoing diaphragmatic breathing exercises and the VIS group (n=29) undergoing VIS exercises. All the participants performed the six-minute walk test (6MWT) preoperatively to evaluate their functional capacity. Hemodynamic indexes, pulmonary function tests, and blood gas indexes were recorded before surgery and on the 1st, 3rd, and 5th postoperative day. Results: The functional capacity was not significantly different between the two groups during the preoperative period (P >0.05). At 3 days and 5 days postoperatively, patients in the VIS group had a significantly higher SpO2 than that in the control group (P <0.05). Pulmonary function test values were reduced in both two groups postoperatively when compared to the preoperative values but improved for three and five days afterward (P <0.05). Of note, the significantly elevated levels of peak expiratory flow (PEF), forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio were observed on the 1st, 3rd, and 5th postoperative days in the VIS group compared with those in the control group (P <0.05). Besides, bass excess (BE), and pH values were significantly higher in the VIS group on the 1st postoperative day than those in the control group (P <0.05). Conclusion: Diaphragmatic breathing and VIS could improve postoperative pulmonary function, but VIS exercise might be a better option for improving hemodynamics, pulmonary function, and blood gas for patients after open abdominal surgery, hence lowering the incidence of postoperative pulmonary complications.

Restrictive blood transfusion and 1-year mortality in patients undergoing open abdominal surgery: A retrospective propensity score-matched cohort study.

BACKGROUND: The importance of patient blood management is increasingly recognized in surgery patients. This study aimed to examine the effect of perioperative restrictive blood transfusion on 1-year mortality and blood transfusion rate in open abdominal surgery. METHODS: We retrospectively studied 452 consecutive patients who underwent open abdominal surgery before (liberal group: 233 patients) and after (restrictive group: 219 patients) implementing intraoperative restrictive transfusion of red blood cell. The trigger levels of hemoglobin were less than 9-10 g/dL in the liberal group and less than 7-8 g/dL in the restrictive group. All-cause mortality at 1-year as the primary outcome and the transfusion rate of any allogeneic blood products as secondary outcome were compared between the liberal group and the restrictive group by the propensity-score matching. RESULTS: Among a total of 452 patients (69 ± 11 yr., 70.5 % men), overall mortality at 1 year was 8.4 % and the proportion of patients who received any allogeneic blood products was 19.6 %. Compared with 155 propensity-score matched patients of the liberal group, 155 matched patients of the restrictive group had significantly lower 1-year mortality (4 [2.5 %] versus 18 [11.6 %], p = 0.003, percent absolute risk reduction [%ARR]; 9.0, 95 % confidential interval [CI], 3.1-14.7) and had significantly lower proportion of patients who received any allogeneic blood products (21 [13.5 %] versus 41 [26.4 %], p = 0.006, %ARR; 12.9, 95 % CI, 3.9-21.5). CONCLUSIONS: The results of this study indicate that intraoperative restrictive blood transfusion reduces 1-year mortality and the transfusion rate of allogeneic blood products.

Development and validation of a risk score for predicting postoperative delirium after major abdominal surgery by incorporating preoperative risk factors and surgical Apgar score.

STUDY OBJECTIVE: To develop and validate a simple delirium-predicting scoring system in patients undergoing major abdominal surgery by incorporating preoperative risk factors and intraoperative surgical Apgar score (SAS). DESIGN: Observational retrospective cohort study. SETTING: A tertiary general hospital in China. PATIENTS: 1055 patients who received major abdominal surgery from January 2015 to December 2019. MEASUREMENTS: We collected data on preoperative and intraoperative variables, and postoperative delirium. A risk scoring system for postoperative delirium in patients after major open abdominal surgery was developed and validated based on traditional logistic regression model. The elastic net algorithm was further developed and evaluated. MAIN RESULTS: The incidence of postoperative delirium was 17.8% (188/1055) in these patients. They were randomly divided into the development (n = 713) and validation (n = 342) cohorts. Both the logistic regression model and the elastic net regression model identified that advanced age, arrythmia, hypoalbuminemia, coagulation dysfunction, mental illness or cognitive impairments and low surgical Apgar score are related with increased risk of postoperative delirium. The elastic net algorithm has an area under the receiver operating characteristic curve (AUROC) of 0.842 and 0.822 in the development and validation cohorts, respectively. A prognostic score was calculated using the following formula: Prognostic score = Age classification (0 to 3 points) + arrythmia + 2 * hypoalbuminemia + 2 * coagulation dysfunction + 4 * mental illness or cognitive impairments + (10-surgical Apgar score). The 22-point risk scoring system had good discrimination and calibration with an AUROC of 0.823 and 0.834, and a non-significant Hosmer-Lemeshow test P = 0.317 and P = 0.853 in the development and validation cohorts, respectively. The bootstrapping internal verification method (R = 1000) yielded a C-index of 0.822 (95% CI: 0.759-0.857). CONCLUSION: The prognostic scoring system, which used both preoperative risk factors and surgical Apgar score, serves as a good first step toward a clinically useful predictive model for postoperative delirium in patients undergoing major open abdominal surgery.

Preexisting right ventricular systolic dysfunction in high-risk patients undergoing non.emergent open abdominal surgery: A retrospective cohort study.

Background: The prognostic value of right ventricular systolic dysfunction in high-risk patients undergoing non-emergent open abdominal surgery is unknown. Here, we aim to evaluate whether presence of preexisting right ventricular systolic dysfunction in this surgical cohort is independently associated with higher incidence of postoperative major adverse cardiac events and all-cause in-hospital mortality. Methods: This is a single-centered retrospective study. Patients identified as American Society Anesthesiology Classification III and IV who had a preoperative echocardiogram within 1 year of undergoing non-emergent open abdominal surgery between January 2010 and May 2017 were included in the study. Incidence of postoperative major cardiac adverse events and all-cause in-hospital mortality were collected. Multivariable logistic regression was performed in a step-wise manner to identify independent association between preexisting right ventricular systolic dysfunction with outcomes of interest. Results: Preexisting right ventricular systolic dysfunction was not associated with postoperative major adverse cardiac events (P = 0.26). However, there was a strong association between preexisting right ventricular systolic dysfunction and all-cause in-hospital mortality (P = 0.00094). After multivariate analysis, preexisting right ventricular systolic dysfunction continued to be an independent risk factor for all-cause in-hospital mortality with an odds ratio of 18.9 (95' CI: 1.8-201.7; P = 0.015). Conclusion: In this retrospective study of high-risk patients undergoing non-emergent open abdominal surgery, preexisting right ventricular systolic dysfunction was found to have a strong association with all-cause in-hospital mortality.

Subcuticular Sutures versus Staples in Reducing Surgical Site Infections after Open Abdominal Digestive Surgery: A System Review and Meta-Analysis of Randomized Controlled Trials.

Background: Wound complications, primarily surgical site infections (SSIs), impose heavy a heavy burden on public health. This study aimed to compare the difference in the abilities of subcuticular sutures and staples to prevent SSIs after open abdominal surgery on the digestive system. Methods: A comprehensive search in Ovid-MEDLINE, Embase, Web of Science, and Cochrane Library (Central Register of Controlled Trials) was performed in January 2021. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PICOS (population, intervention, control, outcome, study type) model was applied to guide study selection and data extraction. Results: Six studies including 3,863 participants were included. According to analysis of SSI incidence, there was no obvious difference between the incidence of SSI when subcuticular sutures and staples were used (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.61-1.08; p = 0.15). In the subsequent subgroup analysis of different operation procedures, the pooled results also failed to show significance for upper gastrointestinal surgery (OR, 1.09; 95% CI, 0.63-1.9; p = 0.75), lower gastrointestinal surgery (OR, 0.77; 95% CI, 0.56-1.05; p = 0.1), or hepatobiliary-pancreatic surgery (pooled OR, 0.72; 95% CI, 0.34-1.54; p = 0.4). Conclusions: Subcuticular sutures and staples did not show differences in their ability to prevent SSI incidence after open abdominal operation. These results require further verification by large-scale, high-quality randomized controlled trials.

Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice.

BACKGROUND: Open abdominal surgery is associated with high rates of wound complications . Surgical site infection (SSI) is associated with prolonged length of stay, delayed treatment and high rates of readmission (1, 3, 4). Negative pressure wound therapy over closed incisions (ciNPWT) is a novel approach to prevention of SSI. We reviewed the outcomes of studies comparing ciNPWT and standard therapy in open abdominal wounds to assess the efficacy of the current evidence base. AIM: To assess the effect of negative pressure wound therapy used over closed incisions in open abdominal surgery. METHODS: Search of relevant terms was conducted on PubMed, Scopus and Cochrane to identify studies published between Jan 2006-Feb 2019. Studies were chosen based on specific inclusion criteria. Articles were screened to assess demographics, study design and outcomes. RESULTS: Seven retrospective and six prospective randomised controlled trials were identified for inclusion, totalling 3048 participants. 967 received ciNPWT and 2081 received standard treatment. Studies assessed a mix of surgeries (colorectal n = 6, pancreaticoduodenectomy n = 1, gynaecologic n = 1, acute care surgery n = 1, mixed open n = 2). ciNPWT was statistically significant in reducing SSI in 9 of 13 studies. CONCLUSION: ciNPWT in open abdominal surgery has demonstrated promising results for reducing SSI rate in some trials however, patient selection remains unclear. Recent randomized controlled trials have failed to demonstrate benefit overall with use of ciNPWT in open abdominal surgery. Further multicentre prospective trials are needed for cost-benefit analysis and appropriate patient-selection.

Laparoscopic vs. Open Abdominal Radical Hysterectomy for Cervical Cancer: A Single-Institution, Propensity Score Matching Study in China.

Study Objective: To compare the surgical and oncologic outcomes between open abdomen radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH) for cervical cancer. Methods: Retrospective observational study with propensity score matching was used to ensure balanced groups for ARH and LRH. One-hundred-and-ninety-eight women with cervical cancer, 99 treated using ARH and 99 using LRH, between January 2012 and December 2014. Outcomes included disease-free survival (DFS), overall survival (OS), intra-operative factors, post-operator recovery, urinary retention, and adverse events. Moreover, the inverse probability of the treatment weighting (IPTW) method was also used. Main Results: Compared with ARH, LRH was associated with a lower volume of blood loss (P < 0.001) and transfusion rate (P < 0.001), with a broader resection of the parametrium (P < 0.001). Post-operatively, the time to first flatus was shorter for LRH than ARH (P < 0.001) but the rate of urinary retention was higher for LRH (22.2%) than ARH (8.1%; P = 0.009). DFS and OS were similar between groups. By IPTW, laparoscopy was also not associated with poorer survival in terms of DFS (HR 1.52, CI 0.799-2.891, P = 0.202) or OS (HR 0.942, HR 0.425-2.09, P = 0.883). Conclusion: Compared with ARH, LRH provided better intra-operative and post-operative outcomes, with no significant difference in oncologic outcomes and survival. Urinary retention remains a clinical issue to improve with LRH. The technology of LRH has been improved in China to address the inconsistent results of oncologic outcomes in previous studies. Whether these improvements could be effective needs to be investigated in the future.

Recomendaciones en la analgesia para cirugía abdominal abierta / Recommendations in analgesia for open abdominal surgery

Resumen: La analgesia postoperatoria es uno de los componentes básicos en la recuperación funcional tras una intervención quirúrgica. El bloqueo de los estímulos nociceptivos contribuye a disminuir la respuesta al estrés quirúrgico, acelerando la rehabilitación y disminuyendo la incidencia de dolor crónico postoperatorio. Al bloquear las vías de conducción del dolor se limita la respuesta neuroendocrina, metabólica, inflamatoria e inmunitaria al estrés quirúrgico. La analgesia epidural sigue siendo el estándar de referencia en la cirugía abierta abdominal, en cuanto a la calidad de la analgesia dinámica y a la disminución de los tiempos de extubación, de ventilación mecánica y de las complicaciones respiratorias, con el potencial de reducir las tasas de eventos adversos relacionados (dolor no controlado, bloqueo motor y retención urinaria). La analgesia multimodal, basada en un concepto amplio de combinación de analgésicos, fármacos coadyuvantes y técnicas analgésicas, se presenta como una alternativa segura y eficaz (para ver el artículo completo visite http://www.painoutmexico.com).

Abstract: Postoperative analgesia is one of the basic components in functional recovery after surgical intervention. The blocking of nociceptive stimulus contributes to decrease the response to surgical stress, accelerating rehabilitation and decreasing the incidence of chronic postoperative pain. By blocking the pain conduction pathways, the neuroendocrine, metabolic, inflammatory and immune response to surgical stress is limited. Epidural analgesia continues to be the reference standard in open abdominal surgery, in terms of the quality of dynamic analgesia and the reduction of extubation times, mechanical ventilation and respiratory complications, with the potential to reduce the rates of related adverse events (uncontrolled pain, motor blockage and urinary retention). Multimodal analgesia, based on a broad concept of combination of analgesics, adjuvant drugs and analgesic techniques, is presented as a safe and effective alternative (full version visithttp://www.painoutmexico.com ) .

Distal acupoint stimulation versus peri-incisional stimulation for postoperative pain in open abdominal surgery: a systematic review and implications for clinical practice.

BACKGROUND: Acute postoperative pain remains a major clinical problem that affects patient recovery. Distal acupoint and peri-incisional stimulation are both used for relieving acute postoperative pain in hospital. Our objective was to assess and compare the effects of distal and peri-incisional stimulation on postoperative pain in open abdominal surgery. METHODS: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Chinese databases CNKI and Wanfangdata were searched to identify eligible randomized controlled trials. Intensity of postoperative pain, opioid consumption and related data were extracted and analyzed using a random effects model. Risk of bias was assessed. Subgroup analyses were conducted when data were enough. RESULTS: Thirty-five trials were included, in which 17 trials studied distal stimulation, another 17 trials studied peri-incisional stimulation and one studied the combination of the two approaches. No studies that directly compared the two approaches were identified. Subgroup analysis showed that both distal and peri-incisional stimulation significantly alleviated postoperative resting and movement pain from 4 h to 48 h after surgery by 6 to 25 mm on a 100 mm visual analogue scale. Peri-incisional stimulation showed a better reduction in postoperative opioid consumption. No studies compared the effects of the combined peri-incisional and distal stimulation with either mode alone. Overall the quality of evidence was moderate due to a lack of blinding in some studies, and unclear risk of allocation concealment. CONCLUSION: Both distal and peri-incisional modes of stimulation were effective in reducing postoperative pain. Whether a combined peri-incisional stimulation and distal acupuncture has superior results requires further studies.

Colon Myoelectric Activity Measured After Open Abdominal Surgery with a Noninvasive Wireless Patch System Predicts Time to First Flatus.

BACKGROUND: Passage of flatus after abdominal surgery signals resolution of physiological postoperative ileus (POI) and often, particularly after complex open surgeries, serves as the trigger to initiate oral feeding. To date, there is no objective tool that can predict time to flatus allowing for timely feeding and optimizing recovery. In an open, prospective study, we examine the use of a noninvasive wireless patch system that measures electrical activity from gastrointestinal smooth muscles in predicting time to first flatus. METHODS: Eighteen patients who underwent open abdominal surgery at El Camino Hospital, Mountain View, CA, were consented and studied. Immediately following surgery, wireless patches were placed on the patients' anterior abdomen. Colonic frequency peaks in the spectra were identified in select time intervals and the area under the curve of each peak times its duration was summed to calculate cumulative myoelectrical activity. RESULTS: Patients with early flatus had stronger early colonic activity than patients with late flatus. At 36 h post-surgery, a linear fit of time to flatus vs cumulative colonic myoelectrical activity predicted first flatus as much as 5 days (± 22 h) before occurrence. CONCLUSIONS: In this open, prospective pilot study, noninvasive measurement of colon activity after open abdominal surgery was feasible and predictive of time to first flatus. Interventions such as feeding can potentially be optimized based on this prediction, potentially improving outcomes, decreasing length of stay, and lowering costs.

Neopterin and mini-mental state examination scores, two independent risk factors for postoperative delirium in elderly patients with open abdominal surgery.

BACKGROUND: Postoperative delirium is described as one of the most common complications for elderly patients with unknown pathophysiological pathways. In this present study, we analyzed the clinical and biochemical parameters in elderly patients with or without a delirium after open abdominal surgery to investigate the possible predicative factors for a delirium. MATERIALS AND METHODS: Patients aged ≥60 years scheduled to undergo elective gastrointestinal tumor resection via laparotomy from July 2012 to June 2015 were enrolled in this study. Demographic and clinical data, characteristics of the surgical and anesthetic procedure, biochemical parameters were compared between patients with or without a delirium. Multivariate logistic regression testing was used for the evaluation of independent risk factors for postoperative delirium. RESULTS: Overall, 112 participants were enrolled in this study, 49 of which were diagnosed with postoperative delirium. Patients with a delirium had an older age (P = 0.013) and a lower Mini-Mental State Examination (MMSE) score (P < 0.01) compared with those patients who had no delirium. The duration of surgery and anesthesia, the levels of neopterin, C-reactive protein, interleukin-6, insulin-like growth factor-1 in patients with a delirium were significantly higher than those without a delirium (P < 0.05). Independent risk factors in the logistic regression for postoperative delirium were the levels of neopterin and MMSE scores. CONCLUSIONS: Our present study suggested the potential roles of neopterin and MMSE scores in the pathophysiology and prediction of delirium in elderly patients after open abdominal surgery.

Randomized Comparison of Subcuticular Sutures Versus Staples for Skin Closure After Open Abdominal Surgery: a Multicenter Open-Label Randomized Controlled Trial.

BACKGROUND: The incisional surgical site infection (SSI) is an extremely common complication following open abdominal surgery and imposes a considerable treatment and cost burden. METHOD: We conducted a multicenter open-label randomized controlled trial at three Tokyo Metropolitan medical institutions. We enrolled adult patients who underwent either an elective or an emergency open laparotomy. Eligible patients were allocated preoperatively to undergo wound closure with either subcuticular sutures or staples. A central Web-based randomization tool was used to assign participants randomly by a permuted block sequence with a 1:1 allocation ratio and a block size of 4 before mass closure to each group. The primary endpoint was the occurrence of a superficial SSI within 30 days after surgery in accordance with the Centers for Disease Control and Prevention criteria. This trial was registered with UMIN-CTR as UMIN 000004836 ( http://www.umin.ac.jp/ctr ). RESULTS: Between September 1, 2010 and August 31, 2015, 401 patients were enrolled and randomly assigned to either group. One hundred and ninety-nine patients were allocated to the subcuticular suture and 202 patients to the staple groups (hereafter the "suture" and "staple" group, respectively). Three hundred and ninety-nine were eligible for the primary endpoint. Superficial SSIs occurred in 25 of 198 suture patients and in 27 of 201 staple patients. Overall, the rate of superficial SSIs did not differ significantly between the suture and staple groups. CONCLUSION: Subcuticular sutures did not increase the occurrence of superficial SSIs following open laparotomies mainly consisting of clean-contaminated surgical procedures. The applicability of the wound closure material and method is likely to depend on individual circumstances of the patient and surgical procedure.

Alvimopan combined with enhanced recovery strategy for managing postoperative ileus after open abdominal surgery: a systematic review and meta-analysis.

BACKGROUND: To assess the efficacy and safety of alvimopan in conjunction with enhanced recovery strategy, compared with this strategy alone, in management of postoperative ileus in patients undergoing open abdominal surgery. METHODS: Electronic databases were comprehensively searched for relevant randomized controlled trials. We were interested in doses of 6 and 12 mg. The efficacy end points included the time to recovery of full gastrointestinal (GI) function (a composite end point measured by the time to first toleration of solid food [SF] and the time to first passage of stool, GI-2), the recovery of upper (SF) or the lower (the time to first bowel movement, BM) GI function, and the length of hospital stay (the time to discharge order written). Safety end points included GI-related, non-GI-related, and serious adverse events. These parameters were all analyzed by RevMan 5.3 software. RESULTS: Nine randomized controlled trials involving 4075 patients were enrolled in this study. The pooled results showed that alvimopan significantly decreased the time to GI-2 recovery (6 mg, hazard ratio [HR] = 1.45, P < 0.00001; 12 mg, HR = 1.59, P < 0.00001), BM (6 mg, HR = 1.54, P < 0.00001; 12 mg, HR = 1.74, P = 0.0002), and the time to discharge order written (6 mg, HR = 1.37, P < 0.00001; 12 mg, HR = 1.34, P < 0.00001) compared with the placebo group. However, SF was significantly reduced in 6 mg group (HR = 1.23, P = 0.008) rather than 12 mg group (HR = 1.14, 95% confidence interval 1.00, 1.30, P = 0.04). The incidence of some GI-related and serious adverse events were significantly lower in the alvimopan group than the placebo group, and the dose of 12 mg was superior to 6 mg in this regard. CONCLUSIONS: Alvimopan can accelerate recovery of GI function (especially for the lower GI tract), shorten the length of hospital stay, and reduce postoperative ileus-related morbidity without compromising opioid analgesia in an enhanced recovery setting.

High-fat enteral nutrition reduces intestinal mucosal barrier damage after peritoneal air exposure.

BACKGROUND: Peritoneal air exposure is needed in open abdominal surgery, but long-time exposure could induce intestinal mucosal barrier dysfunction followed by many postoperative complications. High-fat enteral nutrition can ameliorate intestinal injury and improve intestinal function in many gastrointestinal diseases. In the present study, we investigated the effect of high-fat enteral nutrition on intestinal mucosal barrier after peritoneal air exposure and the underlying mechanism. METHODS: Male adult rats were administrated saline, low-fat or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Rats undergoing anesthesia without laparotomy received saline as control. Twenty four hours after surgery, samples were collected to assess intestinal mucosal barrier changes in serum D-lactate levels, intestinal permeability, intestinal tight junction protein ZO-1 and occludin levels, and intestinal histopathology. The levels of malondialdehyde and the activity of superoxide dismutase in the ileum tissue were also measured to assess the status of intestinal oxidative stress. RESULTS: High-fat enteral nutrition significantly decreased the serum D-lactate level and increased the intestinal tight junction protein ZO-1 level when compared to the group treated with low-fat enteral nutrition (P < 0.05). Meanwhile, histopathologic findings showed that the intestinal mucosal injury assessed by the Chiu's score and the intestinal epithelial tight junction were also improved much more in the high-fat enteral nutrition-treated group (P < 0.05). In addition, the intestinal malondialdehyde level was lower, and the intestinal superoxide dismutase activity was higher in the high-fat enteral nutrition-treated group than that in the low-fat enteral nutrition-treated group (P < 0.05). CONCLUSIONS: These results suggest that high-fat enteral nutrition could reduce intestinal mucosal barrier damage after peritoneal air exposure, and the underlying mechanism may be associated with its antioxidative action. Perioperative administration of high-fat enteral nutrition may be a promising intervention to preserve intestinal mucosal barrier function in open abdominal surgery.