Perigraft reaction and incorporation of porcine and bovine pericardial patches.

OBJECTIVES: Bovine and porcine pericardial patches are frequently used in cardiothoracic and vascular surgery. There are no guidelines recommending the usage of these patches for particular surgical approaches. However, these 2 materials supposedly possess different properties. The clinical advantage of porcine compared with bovine patches remains controversial. In this experimental study, we analysed the incorporation and vascularization of bovine and porcine pericardial patches during the initial phase after implantation. METHODS: Bovine and porcine pericardial patches were implanted into the dorsal skinfold chamber of C57BL/6 mice (n = 8 per group) to study vascularization and inflammation at the implantation site using repetitive intravital fluorescence microscopy over a 14-day period. At the end of the in vivo experiments, CD-31-positive cells were determined to evaluate the vascularization by immunohistochemistry. Furthermore, cell proliferation and apoptosis were analysed immunohistochemically. RESULTS: Implanted bovine patches exhibited an enhanced vascularization, as indicated by a significantly higher number of CD-31-positive cells and micro-vessels (23.2 ± 4.3 vs 16.5 ± 5.8 mm-2; P = 0.001). Furthermore, bovine patches showed a slightly but not significantly higher functional capillary density. Both patches induced a moderate leukocytic inflammatory host tissue response, and neither bovine nor porcine patches significantly affected apoptosis and cell proliferation at the implantation site. CONCLUSIONS: Bovine and porcine pericardial patches are similarly suitable for surgery. Bovine patches exhibited an improved vascularization during the first 14 days after implantation. This may result in a quicker and improved incorporation into the surrounding tissue compared with porcine pericardial patches.

Neither Isolated Hepatic Arterial Clamping nor Hepatic Arterial Ligation Induce Ischemic Type Biliary Lesions in Rats.

BACKGROUND Ischemic type biliary lesions (ITBL) is a troublesome complication after liver transplantation. Little is known about its pathogenesis and there is particularly little data about morphological alterations. Prolonged warm and cold ischemia time and reduced hepatic arterial perfusion are risk factors leading to ITBL. There are only a few animal models described in literature. Therefore, we examined the effects of 3 h of hepatic artery ischemia-reperfusion (3 h I/R) and hepatic arterial ligation (HAL), both combined with ligation of the peribiliary plexus (PBP). MATERIAL AND METHODS 3 h I/R was performed by clamping the hepatic artery with microvascular clamps for 3 h. HAL was performed by ligation of the hepatic artery. Both procedures were combined with stenting of the common bile duct with double ligation of the PBP. A sham group without clamping served as control. Serum activities of aspartate transaminase (AST) and alanine transaminase (ALT), direct and total bilirubin (DB/TB), and lactate dehydrogenase (LDH) were measured. Bile flow was analyzed and histological examinations of leukocyte infiltration (CAE), cell proliferation (PCNA), apoptotic cells (HE), and bile ducts morphology (CK7) were performed. Western blots of the vascular endothelial growth factor (VEGF) and caspase 3 were made to investigate vascular growth expression and apoptotic cell death. RESULTS 3 h I/R and HAL were associated with a significant hepatocellular injury and inflammation, shown through increased AST and ALT, leukocyte infiltration, and apoptotic cell death. An increase of bile ducts and a reduction of arteries/bile duct ratio after 30 days was observed in the 3 h I/R group and HAL, but no ITBL-typical bile duct necrosis, intrahepatic strictures, or dilatations of bile ducts occurred. CONCLUSIONS Morphological alterations in a rat animal model of 3 h I/R and HAL could be demonstrated. However, a model of intrahepatic biliary lesions could not be established through hepatic arterial ligation or through 3-h hepatic arterial ischemia and reperfusion.

Perigraft vascularization and incorporation of implanted Dacron prostheses are affected by rifampicin coating.

BACKGROUND: Prosthetic vascular grafts are increasingly implanted to replace damaged arteries. However, their microbial contamination is highly problematic and often results in devastating clinical complications. To reduce the risk of infection, Dacron grafts may be coated with rifampicin. In this experimental study we analyzed whether this coating affects the early tissue incorporation of the grafts. METHODS: Saline- and rifampicin-coated Dacron (Dacron-Rifamp) grafts were implanted into dorsal skinfold chambers of C57BL/6 mice (n = 8 per group) to study vascularization, inflammation, cell proliferation, and apoptosis at the implantation site using repetitive intravital fluorescence microscopy and immunohistochemistry over an observation period of 14 days. RESULTS: Implanted Dacron-Rifamp grafts exhibited a impaired vascularization, indicated by a significantly lower functional capillary density (85 ± 1 cm/cm2) compared with controls (113 ± 1 cm/cm2; P < .05). This was associated with a reduced number of Ki-67-positive proliferating cells (9.4% ± 1.1% vs 13.5 ± 0.4%; P < .05) and an increased number of cleaved caspase-3-positive apoptotic cells (2.7% ± 0.3% vs 1.3% ± 0.3%; P < .05) in the newly developing granulation tissue surrounding the implants. In addition, the neutrophilic (652 ± 84 mm2 vs 934 ± 117 mm2; P = .06), lymphatic (26 ± 6 mm2 vs 39 ± 9 mm2; P = .24) and macrophage response (177 ± 42 mm2 vs 233 ± 86 mm2; P = .57) was decreased by trend in the group with Dacron-Rifamp grafts. CONCLUSIONS: Our novel findings show that early perigraft vascularization and incorporation of implanted Dacron prostheses are affected by the rifampicin coating. Because rapid graft vascularization and incorporation are thought to reduce the risk of infection, the use of Dacron-Rifamp Dacron grafts for antibacterial prophylaxis should be reconsidered particularly in cases of elective arterial reconstruction in a noninfected environment.

Preconditioning by cilostazol protects against cold hepatic ischemia-reperfusion injury.

BACKGROUND: In liver transplantation, prolonged cold storage and post-transplant reperfusion are associated with endothelial inflammation, organ dysfunction, and graft failure. We herein studied whether cilostazol, a phosphodiesterase-3-inhibitor, attenuates post-ischemic liver injury after prolonged cold storage. MATERIAL AND METHODS: Sprague-Dawley rats were assigned to 5 groups (n=6 each): sham animals (cold storage time (CST): 1 h), vehicle-treated (NaCl 0.9%) controls (CST: 24 h), and animals receiving 0.1, 1.0, or 10.0 mg/kg body weight (BW) cilostazol pre-treatment (CST: 24 h). After organ explantation, all livers were stored at 4°C in HTK solution, followed by 60 min of reperfusion with 37°C Krebs Henseleit buffer in a non-recirculating ex situ system. Bile flow was measured to evaluate liver function. To analyze inflammation and morphology, liver tissue samples were taken and histology, immunohistochemistry, and Western blotting were conducted. RESULTS: In vehicle-treated controls, prolonged cold storage and warm reperfusion induced inflammation, organ dysfunction, and cell death. This was indicated by an increase of hepatocellular vacuolization, endothelial ICAM-1 expression, and apoptotic cell death compared to sham animals. Cilostazol pre-treatment protected against cold hepatic ischemia-reperfusion injury by preventing hepatocellular disintegration, ICAM-1-associated endothelial inflammation, and apoptotic death. CONCLUSIONS: Inhibition of PDE3 reduces endothelial cell activation and hepatocellular injury in cold ischemia/reperfusion of the liver.

Cilostazol improves hepatic blood perfusion, microcirculation, and liver regeneration after major hepatectomy in rats.

Major hepatectomy or small-for-size liver transplantation may result in postoperative liver failure. So far, no treatment is available to improve liver regeneration. Herein, we studied whether cilostazol, a selective phosphodiesterase III inhibitor, is capable of improving liver regeneration after major hepatectomy. Sprague-Dawley rats (n = 74) were treated with cilostazol (5 mg/kg daily) or a glucose solution and underwent either 70% liver resection or a sham operation. Before and after surgery, hepatic arterial and portal venous blood flow and hepatic microvascular perfusion were analyzed. Liver morphology, function, and regeneration were studied with histology, immunohistochemistry, western blotting, and bile excretion analysis. Cilostazol significantly increased hepatic blood flow and microcirculation before and after hepatectomy in comparison with sham-operated controls. This was associated with an elevation of hepatic vascular endothelial growth factor expression, an increase of hepatocellular proliferation, and an acceleration of liver regeneration. Furthermore, cilostazol protected the tissue of the remnant liver as indicated by an attenuation of hepatocellular disintegration. In conclusion, cilostazol increases hepatic blood perfusion, microcirculation, and liver regeneration after a major hepatectomy. Thus, cilostazol may represent a novel strategy to reduce the rate of liver failure after both extended hepatectomy and small-for-size liver transplantation.

Isoflurane does not protect from brain death-associated aggravation of cold hepatic ischemia-reperfusion injury.

BACKGROUND: Previous studies have shown that brain death aggravates cold ischemia-reperfusion injury in liver transplantation. Isoflurane, a volatile anesthetic, has been indicated to reduce warm hepatic ischemia-reperfusion injury. Herein, we studied in Sprague-Dawley rats whether isoflurane is capable of ameliorating brain death-associated aggravation of cold hepatic ischemia-reperfusion injury. MATERIAL AND METHODS: Brain-dead animals were treated for 30 min with isoflurane (MAC 1.5%; n=8). Animals without isoflurane treatment served as controls (n=8). Another 13 animals without induction of brain death served as sham controls. After a 4-h period portal venous blood perfusion, hepatic microcirculation and bile flow were determined. Livers were recovered and stored for 24 h in 4°C cold HTK solution, followed by reperfusion with 37°C Krebs-Henseleit-buffer for 60 min. Liver enzymes in the effluent and bile flow were analyzed. Hepatocellular morphology was determined by histology and immunohistochemistry. RESULTS: Brain death reduced portal venous blood perfusion and bile flow, induced heme oxygenase-1 (HO-1), and resulted in hepatocellular damage. Isoflurane treatment did not prevent the reduction of portal venous blood perfusion or bile flow or the induction of HO-1. Accordingly, isoflurane was not capable of reducing the hepatocellular injury. CONCLUSIONS: Isoflurane does not protect from brain death-associated aggravation of cold hepatic ischemia-reperfusion injury.

The phosphodiesterase 3 inhibitor cilostazol does not stimulate growth of colorectal liver metastases after major hepatectomy.

Liver failure after extended hepatectomy represents a major challenge in the surgery of hepatic colorectal metastasis. A previous study has indicated that inhibition of phosphodiesterase type 3 (PDE 3) stimulates liver regeneration. However, little is known whether PDE 3 inhibitors, such as cilostazol, also stimulate the growth of remnant metastases. Therefore, we herein studied the effect of cilostazol on engraftment, vascularization and growth of colorectal liver metastasis after major hepatectomy. WAG-rats underwent either major hepatectomy or sham operation. Metastases were induced by subcapsular implantation of 5 × 10(5) CC531-colorectal cancer cells. Animals were daily treated with cilostazol (5 mg/kg body weight) or glucose solution. Tumor growth was measured by high-resolution ultrasound at days 7 and 14. Tumor vascularization and tumor cell proliferation were determined by immunohistochemistry and western blotting. High-resolution ultrasound analysis in hepatectomized and non-hepatectomized animals showed that cilostazol does not stimulate tumor growth. Accordingly, the number of PCNA-positive tumor cells did not differ between cilostazol-treated animals and sham-treated controls. Interestingly, cilostazol reduced tumor vascularization in both hepatectomized and non-hepatectomized animals. This was indicated by a significantly lower number of platelet-endothelial cell adhesion molecule (PECAM-1)-positive cells in tumors of cilostazol-treated animals compared to sham-treated controls. The PDE 3 inhibitor cilostazol does not stimulate the growth of colorectal metastases during liver regeneration after major hepatectomy.

Percutaneous endovascular Y-stenting of a malignant superior vena cava and innominate vein obstruction.

Superior vena cava syndrome (SVCS) is considered one of the telltale signs of a terminal malignant process. We describe a successful endovascular desobliteration of a subtotal occluded SVC and the left innominate vein using a Y-stent technique in a 46-year-old female with a mediastinal nodal metastasis of a relapsing renal cell carcinoma. Complete clinical improvement in the symptoms within the first 24 hours of the procedure and no complication were observed. This report describes endovascular stenting of the SVC as a palliation therapy to overcome the severe clinical symptoms of SVCS besides surgical or chemotherapy in mediastinal malignancy masses.

Successful management of postoperative necrotizing pancreatitis after infrarenal abdominal aortic aneurysm repair.

We present a case of severe necrotizing pancreatitis that developed after elective repair of an abdominal aortic aneurysm. Surgeons are confronted in cases of postoperative acute pancreatitis with the dilemma of potential intraabdominal infection and the high risk of a subsequent infection of the retroperitoneal synthetic material. The therapeutic options range from a restrictive regime to radical necrosectomy and multivisceral resection.

Silver acetate coating promotes early vascularization of Dacron vascular grafts without inducing host tissue inflammation.

BACKGROUND: Silver acetate is frequently used as an antimicrobial coating of prosthetic vascular grafts. However, the effects of this coating on the early inflammatory and angiogenic host tissue response still remain elusive. Therefore, the aim of the present in vivo study was to analyze the biocompatibility and vascularization of silver acetate-coated and uncoated vascular grafts during the initial phase after implantation. METHODS: Two different prosthetic vascular grafts (ie, uncoated Dacron and silver acetate-coated Dacron Silver) were implanted into the dorsal skinfold chamber of C57BL/6 mice (n = 8 per group) to study angiogenesis and leukocytic inflammation at the implantation site by means of repetitive intravital fluorescence microscopy over a 14-day period. At the end of the in vivo experiments, collagen formation, apoptosis, and cell proliferation were analyzed in the newly developed granulation tissue surrounding the implants by histology and immunohistochemistry. RESULTS: During the initial 14 days after implantation, Dacron Silver exhibited an improved vascularization, as indicated by a significantly increased functional capillary density compared with Dacron. This was not associated with a stronger leukocytic inflammatory host tissue response to the implants. Moreover, silver acetate coating did not affect collagen formation, apoptosis, and cell proliferation at the implantation site. CONCLUSIONS: Silver acetate coating of prosthetic vascular grafts improves their early vascularization without inducing severe inflammatory side effects. Accordingly, this material modification crucially contributes to an improved incorporation of the implants into the host tissue, which may decrease the risk of vascular graft infection.

Multidrug donor preconditioning protects steatotic liver grafts against ischemia-reperfusion injury.

BACKGROUND: Graft dysfunction of steatotic livers (SL) still remains a major challenge in liver transplantation. Different mechanisms are thought to be involved in the impaired tolerance of SL to ischemia-reperfusion injury. Thus, different pharmacologic strategies may need to be combined to effectively protect SL and to reduce graft dysfunction after transplantation. Therefore, we analyzed the effectiveness of a multidrug donor preconditioning (MDDP) procedure to protect SL from cold ischemia-reperfusion injury. METHODS: Liver steatosis was induced by a high-carbohydrate, fat-free diet. A total of 24 Sprague-Dawley rats were divided into 3 groups (n = 8 each), including a control group with nonsteatotic livers (Con), a vehicle-treated SL group (SL-Con), and a SL group undergoing MDDP (SL-MDDP), including pentoxyphylline, glycine, deferoxamine, N-acetylcysteine, erythropoietin, melatonin, and simvastatin. MDDP was applied before liver perfusion with 4°C histidine-tryptophan-ketoglutarate (HTK) solution and organ harvest. After 24 hours of cold storage in HTK, postischemic reperfusion was performed in an isolated liver reperfusion model using 37°C Krebs-Henseleit bicarbonate buffer. RESULTS: After 60 minutes of reperfusion, SL showed a significant reduction of bile flow as well as a marked increase of liver enzyme levels and apoptotic cell death compared with Con. This was associated with an increased malondialdehyde formation, interleukin-1 production, and leukocytic tissue infiltration. MDDP completely abolished the inflammatory response and was capable of significantly reducing parenchymal dysfunction and injury. CONCLUSIONS: MDDP decreases SL injury after cold storage and reperfusion. The concept of MDDP as a simple and safe preoperative regime, thus may be of interest in clinical use, expanding the donor pool from marginal donors.

Delayed gastric emptying after pancreaticoduodenectomy: influence of the orthotopic technique of reconstruction and intestinal motilin receptor expression.

BACKGROUND: Delayed gastric emptying (DGE) is still a common postoperative complication after pancreaticoduodenectomy (PD). Because different reconstruction techniques after PD and the influence of motilin receptor expression are controversially discussed, the present study analyzed the influence of a total orthotopic reconstruction technique on DGE after PD. METHODS: Data from patients undergoing PD and reconstruction using a total orthotopic technique were reviewed, and correlations between DGE and clinico-pathological variables were analyzed. Motilin receptor expression was measured within the duodenum, jejunum, and terminal ileum. RESULTS: Three hundred seven patients received orthotopic reconstruction using a single jejunal loop. DGE grade B or C could be observed in 16.6% of the patients. DGE was significantly associated with the severity of a postoperative pancreatic fistula, the need for a reoperation, wound infections, and vascular complications. Furthermore, these parameters correlated significantly with the grade of DGE. The density of motilin receptor expression decreased significantly behind the duodenum in aboral direction. CONCLUSIONS: The orthotopic reconstruction after PD is the shortest distance without resection of a jejunal segment, preserves the greatest length of jejunum and thus the highest density of motilin receptors, and should therefore be recommended to reduce the incidence of DGE after PD.

Split-liver procedure and inflammatory response: improvement by pharmacological preconditioning.

BACKGROUND: Final outcome of split-liver (SL) transplantation is impaired due to an increased rate of vascular complications and primary non-function. Herein, we hypothesized that an in situ split-liver procedure induces an inflammatory response and a deterioration of graft quality. We further studied whether graft quality can be improved by pharmacologic preconditioning. MATERIAL AND METHODS: SL-procedure was performed in rats. One group (SL-HPP; n = 8) was pretreated according to a defined protocol [Homburg preconditioning protocol (HPP)], including pentoxyphylline, glycine, deferoxamine, N-acetylcysteine, erythropoietin, melatonin, and simvastatin. A second SL group (SL-Con; n = 8) received NaCl. Untreated non-SL served as controls (Sham; n = 8). Cytokines release, leukocyte invasion, endothelial activation and liver morphology were studied directly after liver harvest and after 8 h cold storage. Lung tissue was studied to determine remote injury. RESULTS: The SL-procedure induced an increase of TNF-α concentration, intercellular-adhesion-molecule 1 (ICAM-1) expression, leukocytic-tissue infiltration and vacuolization. This was associated with an increased number of apoptotic hepatocytes. HPP reduced TNF-α release, ICAM-1 expression, the number of infiltrated leukocytes, as well as hepatocellular vacuolization and apoptosis. In lung tissue, the SL-procedure caused an increased IL-1 and IL-6 concentration and leukocyte infiltration. CONCLUSIONS: HPP was capable of abrogating cytokine-mediated leukocytic response. Pharmacologic preconditioning of liver donors prevents the SL procedure-mediated inflammatory response, resulting in an improved graft quality.

Multidrug donor preconditioning prevents cold liver preservation and reperfusion injury.

PURPOSE: Primary graft dysfunction still represents a major challenge in liver transplantation. We herein studied in an isolated rat liver perfusion model whether a multidrug donor preconditioning (MDDP) can not only reduce but also completely prevent cold ischemia-reperfusion injury. METHODS: MDDP included curcumin, simvastatin, N-acetylcysteine, erythropoietin, pentoxyphylline, melatonin, glycine, and methylprednisolone. Postischemic reperfusion was performed after 24 h cold storage in histidine-tryptophan-ketoglutarate solution with 37°C Krebs Henseleit bicarbonate buffer. RESULTS: Cold hepatic ischemia-reperfusion resulted in a massive K(+) release, protein loss, and aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase elevation. This was associated with increased malondialdehyde formation, enhanced tumor necrosis factor-alpha and interleukin-6 production, pronounced leukocytic tissue infiltration, and apoptotic cell death. CONCLUSIONS: MDDP abolished the inflammation response and was capable of completely preventing the manifestation of parenchymal injury. Thus, MDDP potentiates the protective effects reported after single-drug donor preconditioning and may therefore be an interesting approach to improve the outcome in clinical liver transplantation.

Long term follow up for incisional hernia after severe secondary peritonitis-incidence and risk factors.

BACKGROUND: In patients with secondary peritonitis, infections of the abdominal cavity might render the abdominal wall susceptible to secondary complications such as incisional hernia (IH). METHODS: One hundred ninety-eight patients treated for secondary peritonitis underwent midline laparotomy. Ninety-two surviving patients accessible to clinical follow-up were examined for the occurrence of IH, and risk factors at the time of surgery or during follow-up were determined. RESULTS: During a median follow-up period of 6 years, 54.3% of the patients developed IHs. A high body mass index, coronary heart disease, intense blood loss, requirement for intraoperative or postoperative transfusions, and small bowel perforation as a source of peritonitis were associated with IH. CONCLUSIONS: IH occurs quite frequently after surgery for secondary peritonitis. Preexisting risk factors for IH and intraoperative blood loss or requirement for blood transfusions were correlated with the development of IH. Interestingly, surgical technique was not correlated with the development of IH in this series.

Impact of postoperative pancreatic fistula on surgical outcome--the need for a classification-driven risk management.

BACKGROUND: The International Study Group of Pancreatic Fistula (ISGPF) classification allows comparison of incidence and severity of postoperative pancreatic fistula (POPF). Its post hoc character, however, does not provide a guideline for the treatment of POPF in individual patient. We therefore studied the association of POPF type A-C on secondary surgical morbidity and mortality in patients undergoing pancreatic resection. PATIENTS AND METHODS: Between 3/2001-12/2007, 483 patients underwent pancreatic resections. POPF were classified according to the ISGPF classification. All patient data were entered in a clinical data management system prospectively. RESULTS: Patients who developed POPF had significantly more vascular but not other surgical complications than patients without POPF. Patients with POPF A had no vascular or surgical complications. Twenty one of the 29 patients with POPF C had surgical complications (17 vascular complications). Mortality attributed to surgical complications after POPF C was 5/29. A soft pancreatic consistency (OR 8.5; p < 0.008) and a high drain lipase activity on postoperative day 3 (OR 4.4; p = 0,065) were predictors for the development of POPF C. DISCUSSION: POPF C is associated with vascular complications like erosion bleeding and other surgical complications like delayed gastric emptying or pleural effusions. A soft pancreatic consistency and a high drain lipase activity on postoperative day 3 are early predictors for the development of POPF C.

Amiodarone pretreatment of organ donors exerts anti-oxidative protection but induces excretory dysfunction in liver preservation and reperfusion.

The continuous shortage of organs necessitates the use of marginal organs from donors with various diseases, including arrhythmia-associated cardiac failure. One of the most frequently used anti-arrhythmic drugs is amiodarone (AM), which is given in particular in emergency situations. Apart from its anti-arrhythmic actions, AM provides anti-oxidative properties in cardiomyocytes. Thus, we were interested in whether AM donor pretreatment affects the organ quality and function of livers procured for preservation and transplantation. Donor rats were pretreated with AM (5 mg/kg of body weight) 10 minutes before flush-out of the liver with a cold (4 degrees C) histidine-tryptophan-ketoglutarate solution (n = 8). Livers were then stored for 24 hours at 4 degrees C before ex situ reperfusion with a 37 degrees C Krebs-Henseleit solution for 60 minutes in a nonrecirculating system. At the end of reperfusion, tissue samples were taken for histology and Western blot analysis. Animals with vehicle only (0.9% NaCl) served as ischemia/reperfusion controls (n = 8). Additionally, livers of untreated animals (n = 8) not subjected to 24 hours of cold ischemia served as sham controls. AM pretreatment effectively attenuated lipid peroxidation, stress protein expression, and apoptotic cell death. This was indicated by an AM-mediated reduction of malondialdehyde, heme oxygenase-1, and caspase-3 activation. However, AM treatment also induced mitochondrial damage and hepatocellular excretory dysfunction, as indicated by a significantly increased glutamate dehydrogenase concentration in the effluate and decreased bile production. In conclusion, AM donor pretreatment exerts anti-oxidative actions in liver preservation and reperfusion. However, these protective AM actions are counteracted by an induction of mitochondrial damage and hepatocellular dysfunction. Accordingly, AM pretreatment of donors for anti-arrhythmic therapy should be performed with caution.

Antibacterial [corrected] coating of abdominal closure sutures and wound infection.

BACKGROUND: Poor wound healing and the development of infection in incisional wounds continue to be among the most common complications of open abdominal surgery. Various bacteria may contaminate not only the tissue in the operative wound, but also the actual suture material. To prevent the contamination of suture material in surgical wounds, triclosan-coated polyglactin 910 suture materials with antibacterial activity (Vicryl plus) was developed. The aim of this study was to ascertain if the use of Vicryl plus reduced the number of wound infections after midline laparotomy comparing to polydioxanon suture (PDS II). METHODS: We performed 2,088 operations in our department between October 2004 and September 2006 via midline incision. In the first time period (TP1), a PDS II loop suture was used. In the second time period (TP2), we used Vicryl plus. All variables were recorded prospectively in a database. The primary outcome was the number of wound infections. Risk factors for poor wound healing were collected prospectively to compare the 2 groups. RESULTS: Using a PDS loop suture for abdominal wall closure in TP1, 10.8% of patients with wound infections were detected. The number of patients with wound infections decreased in TP2 using Vicryl plus for abdominal wall closure to 4.9% (P < .001) despite no other changes in protocols of patient care. Other risk factors for the development of site infections were comparable in the 2 groups. CONCLUSION: The use of antibiotic-coated loop suture for abdominal wall closure can decrease the number wound infections after abdominal surgery.

Staged lavage versus single high-volume lavage in the treatment of feculent/purulent peritonitis: a matched pair analysis.

BACKGROUND: Spontaneous and iatrogenic secondary peritonitis remain to have a mortality of 10-30% and significant socioeconomic impact in survivors and especially non-survivors. Data on the most cost-effective treatment are lacking. We therefore studied outcome and resource utilization in a homogeneous cohort of patients with secondary fecal or purulent peritonitis undergoing surgery with source control and two different types of abdominal lavage. METHODS: Thirty-one consecutive patients with secondary feculent or purulent peritonitis of the lower gastrointestinal tract underwent a single high-volume lavage. That cohort was matched with 31 patients with the same source, extent, and quality of peritonitis treated by source control and staged lavage (intermittent lavage). RESULTS: Patients in both groups were comparable in gender distribution, age, comorbidity, source, extent, and severity of peritonitis with the history of intestinal perforation in the single high-volume lavage group being significantly higher than in the intermittent lavage group (2.0 +/- 1.7 vs. 1.1 +/- 0.8d; p = 0.008). Patients in the single high-volume lavage group had significantly less operations, thus requiring significantly less operation time (OR-time), intensive care unit (ICU)-requirement, ventilatory support, and inotropic support. CONCLUSION: Patients with secondary fecal or purulent peritonitis in at least two quadrants, undergoing a one step surgical repair including source control, primary anastomosis, and single high-volume lavage with more than 25 l have a comparable outcome to patients treated by staged lavage at significantly lower OR and ICU-utilization.

Surgery of liver metastasis in gynecological cancer - indication and results.

BACKGROUND: Liver surgery for patients with liver metastases from gynecological malignancies, an indicator of advanced cancer disease, has remained unclear in the literature. We therefore analyzed the potential survival benefit of patients with surgically resectable compared to unresectable liver metastases. PATIENTS AND METHODS: 43 patients who underwent surgery for liver metastases from gynecological cancers were included in our retrospective observational analysis. Overall survival was estimated according to the Kaplan-Meier method and compared with the log-rank test. RESULTS: Primary gynecological tumors were breast (n = 27), ovarian (n = 8), and uterine (n = 8) cancers. Solely exploratory laparotomy was performed in 13 patients who served as controls. Whereas the perioperative mortality was 0%, minor complications occurred in 18.7%. The overall survival of all patients undergoing liver resection was significantly higher (p < 0.05) than that of patients with unresectable metastases. Subgroup analyses showed that particularly patients with respectable liver metastases from breast cancer had a significantly higher (50%) 5-year survival compared to patients with only an exploratory laparotomy. CONCLUSION: In selected patients, liver resection of metastases from gynecological cancers can achieve a survival benefit similar to that of patients with colorectal cancer metastases.