Standardised pomegranate peel extract lavage prevents postoperative peritoneal adhesion by regulating TGF-ß and VEGF levels.

Peritoneal adhesion represents a severe complication following surgery. Punica granatum (pomegranate) possesses several anti-oxidative and anti-inflammatory properties. Pomegranate peel extract (PPEx) can alleviate the production of various inflammatory factors and cytokines. Thus, we sought to evaluate the anti-adhesion effects of pomegranate in rats. Thirty male Wistar rats (6-week-old, 220 ± 20 g) were divided into five groups (n = 6): normal group without any surgical procedures, control group, and experimental groups receiving 2 ml of 1%, 2%, and 4% w/v PPEx, respectively. Peritoneal adhesions were examined macroscopically. Furthermore, we evaluated inflammatory cytokines levels [interleukin 6 (IL-6), and tumour necrosis factor-α (TNF-α)], growth factors [transforming growth factor- ß1 (TGF-ß1), and vascular endothelial growth factor (VEGF)], and oxidative stress parameters [nitric oxide metabolites (NO), and malondialdehyde (MDA), and glutathione (GSH)] using biochemical methods. Our results showed that the adhesion score and IL-6, TNF-α, TGF-ß1, VEGF, NO, and MDA levels were increased in the control group. In contrast, the GSH level was diminished in the control group compared with the normal group (P < 0.001). PPEx (1 and 2% w/v) markedly reduced all measured parameters compared with the control group (P < 0.001-0.05). PPEx may reduce peritoneal adhesion by alleviating adhesion formation, IL-6, TNF-α, TGF-ß1, VEGF, NO, and MDA, and stimulating anti-oxidative factors. Therefore, PPEx may be considered an appropriate candidate for the treatment of postoperative peritoneal adhesion.

[Integrated approach to correction enteral insufficiency in early postoperative period].

AIM: The purpose of the research was to study the effectiveness of enteral insufficiency correction at an acute peritonitis by applying minimally invasive techniques, electrical stimulation and rehabilitation of the bowel and abdominal intestine using Remaxol drug. MATERIAL AND METHODS: The analysis of the results of clinical and laboratory examination and treatment of 110 patients with acute diffuse peritonitis. In the comparison group (62 patients) in the early postoperative period applied standardized treatment, including software reorganization of the abdominal cavity, in the study group (48 patients) -- a comprehensive treatment that includes software laparoscopic sanation abdominal electrical stimulation of the duodenum, and intra-abdominal (single dose, 200 ml), and intracolonic (200 ml, 2 times daily) administration Remaxol. It was noted a significant improvement in treatment outcomes, including reduced mortality by 2.3 times, the shortening of hospital stay by 1.3 times. RESULTS: The major component of the positive effect of the developed scheme of therapy is its ability to promptly arrest the effects of enteral insufficiency, maintain the functional status of the liver. The relatively rapid recovery of motor and intestinal barrier function leads to a lowering of enteral insufficiency syndrome, which along with increased liver detoxification ability underlies the significant reduction of endogenous intoxication in three days. An important contribution to the effectiveness of the treatment makes intra and intracolonic administration Remaxol. The drug, possessing antioxidant, antihypoxic, hepatoprotective effects, contributes to the relatively rapid improvement of the barrier function of the peritoneum and intestines, detoxification ability of the liver recovery that significantly contributes to the relief of endogenous intoxication.

Efficacy and safety of strong acid electrolyzed water for peritoneal lavage to prevent surgical site infection in patients with perforated appendicitis.

PURPOSE: Our previous experimental study of perforated peritonitis in rats proved that peritoneal lavage with strong acid electrolyzed water (SAEW) has no adverse effects, reduces the bacteria count in the ascitic fluid more effectively than saline, and increases the survival rate significantly. Thus, we conducted a randomized controlled study, applying SAEW in the treatment of perforated appendicitis in children. METHODS: Forty-four patients, aged 3-14 years, were randomly divided into two groups: Group S (n = 20), in which the peritoneal cavity was lavaged with 100 ml/kg saline and the wound was washed out with 200 ml saline; and Group E (n = 24), in which the peritoneal cavity was lavaged with 100 ml/kg SAEW and the wound was washed out with 200 ml SAEW. RESULTS: No adverse effect of SAEW was observed in Group E. There was no difference in the bacterial evanescence ratio of ascitic fluid after lavage between Groups S and E (11.1 and 15.8%, respectively). A residual abscess developed in one patient from each group (5.0 and 4.2%, respectively). The incidence of surgical site infection (SSI) was significantly lower in Group E than in Group S (0 and 20%, respectively; P < 0.05). There was no difference in the duration of pyrexia, positive C-reactive protein, leukocytosis, or hospital stay between the groups. CONCLUSION: Peritoneal lavage and wound washing with SAEW have no adverse effects and are effective for preventing SSI.

[Opportunities of intraoperative hyperthermic perfusion application in treatment of peritoneal carcinomatosis].

Normothermic intraperitoneal perfusion (IPEP) and hyperthermic intraperitoneal perfusion (HIPEP) were performed in 44 Wistar female rats with transplanted ascites tumor of the ovary. Opportunities of intraoperative hyperthermic perfusion application in treatment of peritoneal carcinomatosis. Antineoplastic affects were evaluated according to increase of animals' survival. IPEP and HIPEP increase median survival time by 78% (p=0.307) and 150% (p=0.005) respectively in comparison with conventional intraperitoneal introduction of physiological solution. Thus HIPEP has statistically more significant antineoplastic affect in vase of peritoneal carcinomatosis.

[Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal and appendiceal origin].

BACKGROUND: We report our initial experience combining cytoreductive surgery (CRS) plus intraperitoneal chemotherapy with hyperthermia (HIPEC) in a selected group of patients presenting with disseminated peritoneal carcinomatosis (PC) of colorectaL or appendiceaL origin at a single tertiary referral institution. METHODS: The study included patients who underwent CRS with HIPEC at the Sheba Medical Center between April 2009 and December 2011. The HIPEC technique was administered with the open Coliseum technique reaching a steady state of mitomycin-C delivery at 410 C for perfusion duration of 90 minutes. RESULTS: AnaLysis included 45 patients (18 males) incorporating 42 cases of primary colorectal cancer (CRC) or appendiceal cancer and 3 cases of pseudomyxoma peritonei. Thirty-seven patients (82%) underwent CC-0 resections with a median overall hospital stay of 8 days (range 5-43). There was one perioperative death at 90 days. The perioperative complication rate was 31.1%. The median follow-up was 12 months (range 2-36) during which 13 patients died. Among the CRC and appendiceal cancer group the median overall survival was 20.2 months and the median progression free survival was 16.4 months (Kaplan-Meier analysis). During follow-up, 23 patients experienced disease progression. CONCLUSION: The selective use of cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for patients with peritoneal carcinomatosis from colorectal or appendiceal origin is safe with acceptable morbidity and low mortality.

[Effect of combined and local cytokine- and ozone therapy on the indices of lipid peroxidation, endogenous intoxication and ferroproteins in diffuse peritonitis].

The article analyzes the results of effect of combined and local cytokine- and ozone therapy on the indices of lipid peroxidation, endogenous intoxication and ferroproteins in 111 patients with diffuse peritonitis. It was shown, that combined sequential local and systemic cytokine and ozone therapy allows correcting the expression of endogenous intoxication and lipid peroxidation in diffuse peritonitis. This method suppresses an inflammation in the abdominal cavity. At the same time, it accelerates the elimination of intestine atony and thereby potentiates the possibilities of traditional methods of treatment.

Therapeutic peritoneal lavage with warm saline solution as an option for a critical hypothermic trauma patient.

INTRODUCTION: In this paper, we present the case of a 63-year-old woman, who was found in her flat lying unconscious on the floor for an unknown time. At the time of admission, her core temperature was 24 °C and ventricular fibrillation was detected on the electrocardiogram (ECG). Because of the unstable conditions, the persistent nonperfusing cardiac rhythm and the dramatically inhibited coagulation cascade, a peritoneal lavage connected to a rapid infuser was performed for rewarming, instead of using a transportable heart-lung machine and a haemodialysis device. After a prolonged cardiopulmonary resuscitation (CPR), the patient could be transferred to the intensive care unit (ICU) in a stable condition. After 40 days in the ICU, recovery was fast, and another month of treatment later, she could be discharged back home without any discomfort. CONCLUSION: This report illustrates the successful use of the peritoneal lavage for rewarming a severely hypothermic patient without any extracorporeal rewarming device. Furthermore, it can be used in nearly every hospital if the necessary equipment is affordable. It is demonstrated that this technique is able to provide good outcomes for all victims of accidental hypothermia.

[Hypothermal sanation in acute peritonitis].

Comparative analysis of treatment of 78 patients, suffering an acute peritonitis, was conducted for studying of practical significance of hypertonic peritoneal-enteric sanation (PES). In 40 patients (control group) the conventional methods of treatment were used and in 38 (the main group)--the treatment was conducted on the PES background. Such clinical indices, as the patient state, body temperature, respiration rate, pulse and intestinal peristalsis, while the PES application, have had normalized earlier. As well the raising of the survival capacity of an organism, suffering critical state, was noted. Relaparotomy was conducted in 17.5% of patients control group and in 7.9% of the main; the complications rate had constituted accordingly 27.5 and 15.7%, mortality - 22.5 and 15.8%, the stationary treatment duration--(17.2 +/- 1.02) and (12.4 +/- 0.7) days. Due to its simplicity the method may be applied in every clinic, not depending on its equipment.

Surgical treatment for peritoneal carcinomatosis from gastric cancer.

This review describes the latest surgical treatments for peritoneal carcinomatosis (PC) arising from gastric cancer. Systemic chemotherapy is less effective against PC because of the existence of the blood-peritoneal barrier. Accordingly, perioperative intraperitoneal chemotherapy plus cytoreductive surgery (CRS) is a new trend of multidisciplinary therapy for PC. Intraperitoneally administered drugs penetrate directly into the peritoneal dissemination, resulting in the high loco-regional intensity of drugs. A new bidirectional chemotherapy called neoadjuvant intraperitoneal/systemic chemotherapy (NIPS) has been developed. After NIPS, the disappearance of PFCCs has been reported, and the incidence of complete cytoreduction has increased accordingly. Complete cytoreduction, a low peritoneal carcinomatosis index, and negative PFCCs are significant favorable prognostic factors. Hyperthermic intraperitoneal chemotherapy (HIPEC) after CRS is associated with improved survival with an acceptable postoperative mortality and morbidity. Early postoperative intraperitoneal chemotherapy (EPIC) has also contributed to improving survival after CRS.

Effects of peritoneal lavage with lidocaine on survival of rats with fecal peritonitis.

PURPOSE: To study the effects of peritoneal lavage with a 2% lidocaine solution, on the survival of the rats submitted to peritonitis caused by their own feces. METHODS: Forty-eight Wistar rats, weighting between 300 g and 330 g (mean, 311,45 +/-9,67 g), were submitted to laparotomy 6 hours following induction of fecal peritonitis. Animals were randomly divided into four groups of 12 each as follows: 1- Control, no therapy; 2- Drying of the abdominal cavity; 3- Peritoneal lavage with saline and drying; 4- Peritoneal lavage with a 2% lidocaine solution and drying. Animals that died were submitted to necropsy and the time of their death recorded; survivors were killed on the post-operation 11th day and necropsied. RESULTS: Death occurred within 52 h in all animals of group 1; within 126 h in 100% of those of group 2; within 50 h in 50% of those of group 3. All animals of group 4 survived. Survival on the 11 th day was higher in groups 3 and 4 than in groups 1 and 2 (p<0.001), and higher in group 4 than in group 3 (p<0.01). CONCLUSION: Peritoneal lavage with a 2% lidocaine saline solution without adrenaline, prevented the mortality of all animals with fecal peritonitis.

Effects of peritoneal lavage with lidocaine on survival of rats with fecal peritonitis

PURPOSE: To study the effects of peritoneal lavage with a 2 percent lidocaine solution, on the survival of the rats submitted to peritonitis caused by their own feces. METHODS: Forty-eight Wistar rats, weighting between 300g and 330g (mean, 311,45 ±9,67g), were submitted to laparotomy 6 hours following induction of fecal peritonitis. Animals were randomly divided into four groups of 12 each as follows: 1- Control, no therapy; 2- Drying of the abdominal cavity; 3- Peritoneal lavage with saline and drying; 4- Peritoneal lavage with a 2 percent lidocaine solution and drying. Animals that died were submitted to necropsy and the time of their death recorded; survivors were killed on the post-operation 11th day and necropsied. RESULTS: Death occurred within 52 h in all animals of group 1; within 126 h in 100 percent of those of group 2; within 50 h in 50 percent of those of group 3. All animals of group 4 survived. Survival on the 11 th day was higher in groups 3 and 4 than in groups 1 and 2 (p<0.001), and higher in group 4 than in group 3 (p<0.01). CONCLUSION: Peritoneal lavage with a 2 percent lidocaine saline solution without adrenaline, prevented the mortality of all animals with fecal peritonitis .

OBJETIVO: Estudar o efeito da lavagem peritoneal com solução de lidocaína a 2 por cento na sobrevida de ratos com peritonite fecal por fezes autógenas. MÉTODOS: Foram utilizados 48 ratos Wistar, pesando entre 300g e 330g (M.A 311,45 ±9,67) submetidos à laparotomia 6 horas após a indução de peritonite, distribuídos aleatoriamente em 4 grupos: 1- (n=12) Controle, nenhum tratamento; 2- (n=12) Enxugamento da cavidade abdominal; 3- (n=12) Lavagem da cavidade abdominal com 3 ml de solução salina 0,9 por cento e enxugamento ; 4- (n=12) Lavagem da cavidade abdominal com 30 mg/Kg( ± 0,5 mL) de lidocaína 2 por cento ,sem adrenalina, e 2,5ml de solução salina 0,9 por cento e enxugamento. Os animais que faleceram foram necropsiados e o horário do óbito anotado. Os sobreviventes foram mortos no 11º dia de pós-operatório e realizou-se a necropsia. RESULTADOS: Houve 100 por cento de mortalidade nos animais do grupo 1, em 52 horas; 100 por cento nos animais do grupo 2, em 126 horas e 50 por cento nos animais do grupo 3 em 50 horas. Os animais do grupo 4 sobreviveram. A sobrevida, no 11º dia de pós-operatório, foi maior nos grupos 3 e 4 em relação aos grupos 1 e 2 ( p< 0,001) e maior nos grupos 4 que no grupo 3(p<0,01). CONCLUSÃO: A lavagem peritoneal com lidocaína a 2 por cento sem adrenalina e diluida em 2,5 ml de solução salina, foi eficaz para evitar o óbito, por 11 dias(eutanásia) em 100 por cento dos animais com peritonite fecal.

[Efficacy of intraoperative hypotonic peritoneal chemo-hyperthermia combined with early postoperative intraperitoneal chemotherapy on gastric cancer].

BACKGROUND & OBJECTIVE: Abdominal recurrence from exfoliated cancer cells contributes a lot to treatment failure of advanced gastric cancer. Intraperitoneal chemotherapy, which has been proved effective in eliminating exfoliated cancer cells in abdominal cavity, is a hot topic on treatment of gastric cancer. This study was to explore application of combined therapy of intraoperative hypotonic peritoneal chemo-hyperthermia and early postoperative intraperitoneal chemotherapy to gastric cancer. METHODS: A total of 156 gastric cancer patients were randomized into 3 groups, and underwent the combined therapy (treatment group 1), intraoperative chemotherapy (treatment group 2), and peritoneal lavage with distilled water (control group), respectively. RESULTS: The 2-year survival rate of treatment group 1 was significantly higher than that of control group (88.4% vs. 65.2%, P < 0.05). The 3-year survival rate of treatment group 1 was significantly higher than those of treatment group 2, and control group (71.1% vs. 50.0%, and 45.6%, P < 0.05). Occurrence of liver metastasis was significantly lower in treatment groups 1 and 2 than in control group (7.7%, and 10.2% vs. 27.3%, P < 0.05). CONCLUSIONS: Combined therapy of intraoperative hypotonic chemo-hyperthermia and early postoperative intraperitoneal chemotherapy is effective for gastric cancer. Intraperitoneal chemotherapy can be used to prevent postoperative liver metastasis of gastric cancer.

Heat stroke : a review of cooling methods.

The prognosis of heat stroke in patients is directly related to the degree of hyperthermia and its duration. Therefore, the most important feature in the treatment of heat stroke is rapid cooling. Several cooling methods have been presented in the literature including immersion in water at different temperatures, evaporative cooling, ice pack application, pharmacological treatment and invasive techniques. This article describes the various cooling techniques in terms of efficacy, availability, adverse effects and mortality rate. Data suggest that cooling should be initiated immediately at time of collapse and should be based on feasible field measures including ice or tepid water (1-16 degrees C), which are readily available. In the emergency department, management should be matched to the patient's age and medical background and include immersion in ice water (1-5 degrees C) or evaporative cooling.

[The method of parietal-cavitary sanitation of intestines in complex treatment of acute diffuse peritonitis]. / Metod pristenochno-polostnoi sanatsii kishechnika v kompleksnom lechenii ostrogo rasprostranennogo peritonita.

Experimental investigations carried out in 154 white rats and 24 mongrel dogs have proved pathogenetical effectiveness and safety of using the method of parietal-cavitary sanitation of the intestine in treatment of acute experimental peritonitis. This method used in complex treatment in 28 patients with acute diffuse peritonitis allowed a 1.5-2 times quicker arrest of the syndrome of endogenous intoxication and liquidation of intestinal paresis. Infectious complications were 43% less frequent and the lethality indices were reduced by 9.5% as compared with the results obtained in the control group.

Distilled water peritoneal lavage after colorectal cancer surgery.

PURPOSE: Tumor cells exfoliated into the peritoneal cavity during colorectal cancer surgery are viable and tumorigenic and may contribute to peritoneal recurrence. Although commonly used, the tumoricidal effectiveness of antiseptics in peritoneal lavage is doubted because of their chemical alteration by peritoneal secretions. In contrast, osmotic lysis by incubation in distilled water may offer an effective tumoricidal activity. Data defining the susceptibility of colorectal carcinoma cells to osmotic lysis are lacking and hence there is no consensus on optimal lavage methodology. METHODS: We examined the cytocidal activity of water on colorectal cancer cell lines in culture and determined the effect of peritoneal secretions in vivo on the tumoricidal effectiveness of water. RESULTS: Incubation of cells in distilled water resulted in cell lysis, with 100 percent lysis achieved after 14 minutes of incubation. In vivo, contamination of lavage water by peritoneal secretions produced a resultant solution with an osmolality of 50 mM. Sequential lavages reduced this contamination, enabling a final resultant solution with an osmolality of 10 mM, which produced 100 percent cell lysis after 32 minutes of incubation. CONCLUSIONS: Current peritoneal lavage methodology is inadequate because complete cell lysis requires water incubation for longer time periods than is currently practiced. Solutions to this problem are discussed.

Application of cisplatin as intraoperative hyperthermic peritoneal lavage (IHPL) in patients with locally advanced gastric cancer: analysis of pharmacokinetics and of nephrotoxicity.

UNLABELLED: The purpose of this study was to assess the extent of the systemic absorption of cisplatin during intraoperative hyperthermic peritoneal lavage (IHPL) in patients with locally advanced gastric cancer. MATERIALS AND METHODS: The pharmacokinetics and nephrotoxicity of cisplatin were analyzed in patients receiving IHPL (8000 ml of Ringer's solution containing 150 mg/m2 cisplatin and 15 mg/m2 mitomycin C for one hour at 43.5 degrees C). Levels of ultrafiltrable platin were determined by flameless atomic absorption spectrometry. Nephrotoxicity was assessed by nephelometric analyses of urinary marker-proteins. The data were compared to respective analyses in patients receiving intravenous cisplatin. RESULTS: Twenty-four patients received five applications of cisplatin as IHPL (five patients) and 53 applications of intravenous cisplatin (21 patients). Platin levels within the lavage fluid declined monophasically (half-life, 0.48 +/- 10 hours; area under curve (AUC) 29,274 +/- 9075 ng/ml*h). The pharmacokinetic parameters calculated for IHPL vs. intravenous application of cisplatin were: maximum plasma levels 2392 +/- 407 vs. 1349 +/- 692 ng/ml; terminal half-lives 93 +/- 73 vs. 36 +/- 9 hours; AUC 9508 +/- 856 vs. 11,627 +/- 3372 ng/ml*h; total urinary excretion of platinum 24 +/- 6 vs. 49 +/- 13% of dose; renal clearance 127 +/- 34 vs. 145 +/- 35 ml/min. Pathologic urinary albumin excretion occurred on days 9 +/- 0 vs. 5 +/- 2 (maximum 232 +/- 179 vs. 20 +/- 20 mg/l). Plasma creatinine levels rose to 1.5 +/- 0.4 vs. 0.9 +/- 0.1 mg/dl on days 15 +/- 4 vs. 16 +/- 26. The degree of albuminuria was related to the clearance of platin from the lavage fluid (p = 0.048). CONCLUSION: A significant amount of intraperitoneally applied cisplatin is available systemically and probably adds to the nephrotoxicity of IHPL.

[Curative effect of radical gastrectomy combined with peritoneal lavage with thermal hypoosmotic solution in treatment of gastric cancer].

OBJECTIVE: To evaluate the curative effect and indications of radical gastrectomy combined with peritoneal lavage with thermal hypoosmotic solution, double distilled water (DDW) or DDW plus chlorhexidine acetate, in treatment of gastric cancer. METHODS: Five hundred cases of gastric cancer who underwent radical gastrectomy from January 1986 to December 1995 were divided into three groups: group A with 198 cases who underwent radical gastrectomy and peritoneal lavage for 10 minutes with 400 ml of DDW at 43 degrees C, group B, with 89 cases who underwent radical gastrectomy and peritoneal lavage for ten minutes with 4 000 ml of DDW plus 0.6 g chlorhexidine acetate, and group C, with 213 cases who underwent radical gastrectorny and peritoneal lavage for four minutes with 4 000 ml of normal saline at normal temperature as controls. RESULTS: The group A and group B (called lavage group as a whole) had almost the same curative effects. The one-year survival rates and three-year survival rates were similar among the cases in different stages in no matter what group. The five-year survival rate was 63.8% in the lavage group and 51.2% in the control group, most of the cases with a good effect being at the mid-stage (II and III A stages). CONCLUSION: Peritoneal lavage, helpful in killing the exfoliated cancer cells in peritoneal cavity of patients with gastric cancer at II and III A stages, should be conducted in the treatment of gastric cancer by radical gastrectomy before closing the abdomen.

Successful intraperitoneal hyperthermic chemoperfusion for the prevention of postoperative peritoneal recurrence in patients with advanced gastric carcinoma.

BACKGROUND: The majority of advanced gastric carcinoma patients with serosal invasion die of peritoneal recurrence, even when a curative gastrectomy is performed, because peritoneal recurrence occurs due to intraperitoneal free tumor cells that detach from the serosal-invaded focus. In an attempt to prevent peritoneal recurrence, intraperitoneal hyperthermic chemoperfusion (IHCP) treatment was combined with aggressive surgery. METHODS: Between March 1987 and December 1996, 141 gastric carcinoma patients with macroscopic serosal invasion were allocated randomly to 2 groups. Seventy-one patients underwent IHCP combined with surgery (IHCP group) and the remaining 70 patients underwent surgery alone (control group). IHCP was performed just after gastric resection and alimentary tract reconstruction under general anesthesia along with systemic hyperthermia. RESULTS: Postoperative complications were reported in 2 of the 71 patients in the IHCP group and in 2 of the 70 patients in the control group. The peritoneal recurrence rate in the IHCP group was significantly decreased (P = 0.0000847) compared with that in the control group. The 2-year, 4-year, and 8-year survival rates for the IHCP group were 88%, 76%, and 62%, respectively, whereas those for the control group were 77%, 58%, and 49%, respectively. The IHCP group thus reaped a significant survival benefit (P = 0.0362) compared with the control group. CONCLUSIONS: Although this study was conducted randomly for a small number of patients, compared with the control group, the IHCP group had a high survival rate and better prognosis.