Evaluation of a fast-track programme for patients undergoing liver resection.

BACKGROUND: Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast-track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection. METHODS: This was a prospective study involving the first 100 consecutive patients who followed fast-track principles for liver resection. Catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. Discharge criteria were: pain sufficiently controlled by oral analgesics alone, patient comfortable with discharge and no untreated complications. RESULTS: Median length of stay (LOS) for all patients was 5 days, with 2 days after laparoscopic versus 5 days following open resection (P < 0·001). Median LOS after minor open resections (fewer than 3 segments) was 5 days versus 6 days for major resections (3 or more segments) (P < 0·001). Simple right or left hemihepatectomies had a median LOS of 5 days. The readmission rate was 6·0 per cent and 30-day mortality was zero. CONCLUSION: Fast-track principles for perioperative care were introduced successfully and are safe after liver resection. Routine discharge 2 days after laparoscopic resection and 4-5 days after open liver resection may be feasible.

Intraoperative hemodynamic monitoring during liver transplantation: goals and devices.

With the introduction of orthotopic liver transplantation (OLT) almost 40 years ago, changes in the cardiovascular system that manifest during the different phases of the operation combined, sometimes with massive hemorrhage in likely critically ill patients have been a challenge. Here hemodynamic monitoring of the patients during OLT is addressed with focus on maintaining the patients' central blood volume (CBV) and methods and devices that can serve that purpose are listed. It is considered that a stable CBV maintains cerebral blood flow and oxygenation and thereby the well-being of the patient, while even a small reduction in blood pressure affects cerebral blood flow and oxygenation if it reflects a reduced CBV and thereby cardiac output. In that regard it is accepted that for the patient going through OLT cardiac output (~8 L/min-1) and also venous oxygen saturation (~85%) are larger than for other categories of patients when a flow related parameter (cardiac stroke volume, cardiac output or (mixed) venous oxygen saturation) does not respond to a fluid challenge, i.e. the patient is "normovolaemic". Also the administration strategy for liver transplantation is considered with emphasis on haemostatic control resuscitation, i.e. balanced administration of red blood cells, plasma and platelets to massively bleeding patients.

[Perineal hernia after rectal extirpation]. / Perinealt hernie efter rectumeksstirpation.

Perineal hernia after abdominoperineal extirpation of the rectum is a rare condition. The most common symptom is perinea/discomfort and bulging. This condition most often develops within a year after extirpation of the rectum. In order to prevent perineal hernia great effort should be taken when closing the peritoneum and the muscular layer towards the pelvic cave. Several repair operations have been proposed in the literature. The authors recommend a transabdominal approach, possibly with interposition of a synthetic mesh. If the perineal skin is damaged, a combined approach with both transabdominal and perineal access should be used.

[A single physician or a group of specialists in the surgical ward. I: Impact on quality of the care provided by specialists]. / Samme versus forskellige speciallaeger på stuegang. I: Indvirkning på kvaliteten af det laegefaglige arbejde.

The impact on quality of ward care provided by surgeons within two continuity schedules was assessed by explicit and implicit audit. In one schedule one surgeon provided care and in another a staff of surgeons provided care. The study included 214 consecutive inpatients. The study demonstrated that quality of ward care was unaffected by continuity schedule. In the single surgeon continuity schedule, however, nearly twice as many discharge letters were posted within four days (p < 0.001). Likewise, twice as many contained information that the patients had been informed about the diagnosis (p < 0.05). In both continuity schedules about 20% of the patients received inadequate care. Analysis of this finding demonstrated that more patients had been subject to inadequate follow-up in the single surgeon continuity schedule, whereas more patients had been subject to inadequate postoperative observation in the staff continuity schedule. In both schedules an equal number of patients had been subject to incomplete diagnoses and inadequate medical care.

[3-layer anastomoses after resection of colorectal cancer. A prospective study of 1015 anastomoses]. / Trelagede anastomoser efter resektion af kolorektal cancer. En prospektiv undersøgelse of 1.015 anastomoser.

This study included patients who underwent elective curative resection of adenocarcinoma of the large bowel with primary suture of the anastomosis. The overall incidence of clinical anastomotic leakage was 5%. The incidence of anastomotic leakage was significantly higher in men than in women after low anterior resection. The three-layer anastomosis has no advantage in large bowel surgery when compared with data from other sutured anastomoses reported in the literature.

[The effect of suxamethonium on intracranial pressure]. / Suxamethons virkning på det intrakraniale tryk.

The literature concerning the effect of suxamethonium on intracranial pressure in animals and in humans is presented. The studies have not provided firm indications that suxamethonium per se increases the intracranial pressure. Patients with increased intracranial pressure who are to receive suxamethonium should first be deeply anaesthetized and given a defasciculating dose of a non-depolarizing blocker.

[Hartmann's procedure in the treatment of acute obstructive left-sided colonic cancer]. / Hartmann's procedure til behandling af akut obstruerende venstresidig coloncancer.

This retrospective study included all patients over a five-year period who underwent the Hartmann's procedure because of a malignant left-sided large bowel obstruction. Twenty-nine patients were treated with this procedure. The cumulative operative mortality was 14%, and the five-year survival was 31%. Intestinal continuity was restored in seven patients (24%). There were no anastomotic leakages. The treatment resulted in a permanent colostomy in 62% of the patients. The Hartmann's procedure can be employed as a treatment of malignant left-sided large bowel obstruction, but will cause a high frequency of permanent colostomy.

Trends in monitoring patients with aneurysmal subarachnoid haemorrhage.

After aneurysmal subarachnoid haemorrhage (SAH), the clinical outcome depends upon the primary haemorrhage and a number of secondary insults in the acute post-haemorrhagic period. Some secondary insults are potentially preventable but prevention requires prompt recognition of cerebral or systemic complications. Currently, several neuro-monitoring techniques are available; this review describes the most frequently used techniques and discusses indications for their use, and their value in diagnosis and prognosis. None of the techniques, when considered in isolation, has proved sufficient after SAH. Furthermore, the use of multi-modality monitoring is hampered by a lack of clinical studies that identify combinations of specific techniques in terms of clinical information and reliability. However, ischaemia at the tissue level can be detected by intracerebral microdialysis technique. Used together with the conventional monitoring systems, for example intracranial pressure measurements, transcranial Doppler ultrasound and modern neuro-imaging, direct assessment of biochemical markers by intracerebral microdialysis is promising in the advancement of neurointensive care of patients with SAH. A successfully implemented monitoring system provides answers but it also raises valuable new questions challenging our current understanding of the brain injury after SAH.

Colonic necrosis or fistula following pancreatitis or gastric surgery.

Eight cases of extensive colonic necrosis or colonic fistula secondary to gastric surgery or surgical drainage of necrotic pancreatitis were seen over a 2-year period. Four of the patients died, and all the survivors had fistula only. Diagnosis of such lesions is often difficult, and fistulography is recommended when a pancreatic abscess is drained. Resection of the gut is not mandatory in cases of fistula.

The clinical significance of salivary amylase in duodenal aspirates in evaluation of exocrine pancreas function.

Salivary and pancreatic amylases in duodenal aspirates were quantitated in 419 consecutive tests performed on 378 patients suspected of having insufficiency of the exocrine pancreatic function. Salivary amylase was detected in samples from 31% of the tests. However, the amount of salivary amylase was sufficient to cause a misinterpretation in 13 tests only. Five of these tests originated from patients with a history of surgery for peptic ulcer disease. This group of patients tended to have large amounts of salivary amylase in the duodenal aspirates. In the unoperated patients (n = 336) 200 tests yielded values for the total amylase concentration above the lower level of the reference interval, and only in 8 of these tests (4%) did correction for salivary amylase change the results to values below the reference interval. It it concluded that quantitation of isoamylase activity in duodenal samples is unlikely to be of significant value in patients without a history of surgery for peptic ulcer disease.

Postvagotomy diarrhoea and dumping treated with reconstruction of the pylorus.

The results of reconstruction of the pylorus in 12 patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty are reported. Eight patients, primarily operated on with a truncal vagotomy and pyloroplasty, all indicated frequent diarrhoea as their principal symptom. After the reconstruction operation the stools were normalized in five, and the frequency of diarrhoea was reduced considerably in two patients. Three of four patients who had had a selective vagotomy and pyloroplasty complained of severe dumping after all kinds of food; after the reconstruction these symptoms were milder and provoked by sweets and milk only. The fourth patient with heavy diarrhoea as the principal symptom had postoperatively a slight reduction of the frequency. The operation is easy to perform, and no complication was encountered. The pathogenesis of the symptoms is discussed, and it is recommended that patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty undergo a reconstruction of the pylorus.

Prevalence of esophageal Candida colonization in a Danish population: special reference to esophageal symptoms, benign esophageal disorders, and pulmonary disease.

A population sample selected at random after stratification for the presence of pulmonary disease was screened for benign esophageal disease; 175 subjects agreed to participate in the invasive investigation, 86 without pulmonary disease and 89 with chronic obstructive pulmonary disease (COPD). Of these, 169 underwent endoscopy of the upper gastrointestinal tract, 164 had mucosal brushings for the presence of Candida albicans in the esophagus, 169 had esophageal pressure measurements, and 113 had 12-h pH measurements. One hundred fourteen subjects with benign esophageal disease were found. The prevalence of C. albicans in the esophagus (greater than or equal to 50 colonies) in subjects with and without COPD was 12.3% and 25.1%, respectively. C. albicans occurred equally in subjects with and without esophageal symptoms. There was no relation between the presence of C. albicans and benign esophageal disease and no significant clinical correlation between esophageal plaques and colony counts of C. albicans.

Gastroscopic and pharmacokinetic evaluation of a new pivmecillinam tablet.

Three different pivmecillinam preparations, a conventional 200 mg tablet (P tablet) and two new formulations containing respectively pivmecillinam 200 mg and 400 mg plus Avicel (microcrystalline cellulose) as a disintegrator (PA tablet), were compared in vitro and in a gastroscopic study in 8 healthy volunteers. Disintegration of the PA tablet was significantly more rapid both in vitro and in the stomach. Following disintegration, the content of the PA tablet was spread over a larger area of the gastric mucosa (1088 mm2) than was observed with the P tablets (408 mm2). Three of the 8 volunteers taking the P tablet developed hyperaemia, interstitial bleeding or erosions of the mucosa of the stomach. No such reactions were seen with the PA tablets. Serum concentrations of mecillinam following ingestion of pivmecillinam tablets were determined in three groups of subjects; fasting volunteers, both supine and ambulant, and in ambulant subjects who took the preparation with a light meal. There was a tendency for the new PA tablets to produce a higher peak serum level as well as greater bioavailability of mecillinam. Administration of the PA tablets with a meal significantly increased the peak serum level and total bioavailability of the drug. On the basis of our observations we recommend adoption of the new PA tablet, because of its quick passage through the oesophagus and its more rapid and complete disintegration in the stomach.