Surgical site infection rate is lower in laparoscopic than open colorectal surgery.

OBJECTIVE: Few studies have investigated whether surgical site infection (SSI) incidence differs between laparoscopic colorectal surgery (LCS) and open colorectal surgery (OCS). This study investigated the SSI incidence using the validated UK SSI Surveillance Service (SSISS) criteria for diagnosing wound infections. METHOD: Prospective data collection recorded patients' demographics, operative details, antibiotic use, wound evaluation and microbiological wound culture results, for consecutive patients undergoing elective resectional LCS and OCS. Postdischarge surveillance consisted of patient questionnaires sent out at 30 days and the primary care communication. RESULTS: A total of 122 patients underwent colorectal resections over 1 year (LCS 43; OCS 79). Patients' demographics and operative case-mix were similar for both groups, including body mass index (BMI), diabetic and smoking status. Operative duration was longer in the LCS group compared with OCS group (P = 0.012, Mann-Whitney U-test), but hospital stay was shorter for LCS (P = 0.0001, Mann-Whitney U-test). The SSI rate was significantly lower in the LCS than OCS group (7%vs 25% respectively; P = 0.015, two-tailed Fisher's exact test). BMI > 30 and operation length > 4 h influenced the risk of SSI formation (P < 0.05, chi-squared test). One LCS patient required conversion to a limited laparotomy. CONCLUSIONS: Surgical site infection incidence is significantly lower following LCS when compared with OCS. Confounding factors in this study include patient selection for LCS and nonrandomization.

Parameters of the rectoanal inhibitory reflex in patients with idiopathic fecal incontinence and chronic constipation.

PURPOSE: The rectoanal inhibitory reflex is a response of the internal anal sphincter to rectal distention, reflecting the functional nature of the anal sampling mechanism of rectal discrimination. The aim of this study was to assess the parameters of the rectoanal inhibitory reflex in healthy volunteers and incontinent and symptomatically constipated patients. METHODS: The rectoanal inhibitory reflex was recorded in 42 patients using reproducible threshold volumes. Excitatory and inhibitory latencies, maximum excitatory and inhibitory pressures, amplitude, and slope of inhibition, slope and time of pressure recovery, and area under the inhibitory curve were estimated. Pudendal nerve terminal motor latency and endoanal magnetic resonance imaging were performed in all incontinent patients. RESULTS: Significant linear trends were found for most parameters at each sphincter level when analyzed. Recovery time and area under the inhibitory curve differed between the sphincter levels and patient groups, with the most rapid recovery occurring in the distal sphincter of incontinent patients (P < 0.001). These pressure findings were not accounted for by differences in excitation between patient groups. CONCLUSION: A coordinated response by the internal anal sphincter to rectal distention with recovery of anal pressure from the distal to the proximal sphincter is suggested. Continence may rely on the character of internal anal sphincter inhibition, and recovery and preoperative assessment of rectoanal inhibitory reflex parameters may be important for predicting functional result following low anastomosis.

Glutathione deficiency accentuates hepatocellular fluid accumulation after ischemia-reperfusion.

Liver ischemia-reperfusion is known to be associated with free radical-mediated hepatocellular damage but alterations in hepatocellular fluid flux under these conditions are incompletely understood. Deficiency of the antioxidant glutathione, which increases the liver's susceptibility to ischemia-reperfusion injury, may exacerbate pathological fluid shifts. This study examined alterations in hepatic fluid dynamics during liver ischemia-reperfusion in glutathione-deficient and glutathione-replete rats. Normal and glutathione-deficient rats underwent liver ischemia-reperfusion. Changes in hepatic extra- and intracellular fluid were monitored by calculating extra- and intracellular conductance from liver multifrequency bioelectrical impedance measurements. Liver malonyl dialdehyde content and plasma transaminase concentrations were measured and correlated with changes in hepatic impedance. Hepatic extracellular conductance decreased during ischemia and returned toward baseline values during reperfusion in a similar fashion in both study groups. Intracellular conductance increased during ischemia in both groups and continued to rise during the initial phase of reperfusion before falling toward normal. Glutathione-deficient rats had a significantly higher intracellular conductance during early reperfusion compared to controls. Glutathione-depleted rats also had higher serum transaminases and liver malonyl dialdehyde content following reperfusion. Intracellular and extracellular conductance were significantly correlated with hepatic malonyl dialdehyde content. We conclude that (1) liver ischemia-reperfusion results in movement of fluid from the extracellular to intracellular space with hepatocellular swelling; (2) glutathione deficiency accentuates hepatocyte swelling following ischemia-reperfusion; and (3) changes in extra- and intracellular fluid are related to the severity of membrane damage.(ABSTRACT TRUNCATED AT 250 WORDS)

Strategies for attenuating protein-catabolic responses in the critically ill.

Specialized enteral and parenteral nutrition are now a standard components of care in critically ill patients. This adjunctive therapy corrects and prevents nutrient deficiencies, attenuates the loss of body protein, and improves clinical outcomes in malnourished patients. Several novel strategies designed to improve the metabolic and clinical effects of specialized nutrition are under vigorous clinical investigation. These new approaches include increased emphasis on enteral feeding to maintain intestinal absorptive, immune, and barrier function; administration of conditionally essential amino acids (glutamine, arginine); use of specialized lipid products and antioxidants; and administration of growth factors such as human growth hormone. Randomized, controlled clinical trials will define the clinical and metabolic efficacy and cost-effectiveness of these therapies in specialized nutrition support.

Anabolic therapy with growth hormone accelerates protein gain in surgical patients requiring nutritional rehabilitation.

OBJECTIVE: The authors investigated the effects of exogenous growth hormone (GH) on protein accretion and the composition of weight gain in a group of stable, nutritionally compromised postoperative patients receiving standard hypercaloric nutritional therapy. SUMMARY BACKGROUND DATA: A significant loss of body protein impairs normal physiologic functions and is associated with increased postoperative complications and prolonged hospitalization. Previous studies have demonstrated that standard methods of nutritional support enhance the deposition of fat and extracellular water but are ineffective in repleting body protein. METHODS: Fourteen patients requiring long-term nutritional support for severe gastrointestinal dysfunction received standard nutritional therapy (STD) providing approximately 50 kcal/kg/day and 2 g of protein/kg/day during an initial 7-day equilibrium period. The patients then continued on STD (n = 4) or, in addition, received GH 0.14 mg/kg/day (n = 10). On day 7 of the equilibrium period and again after 3 weeks of treatment, the components of body weight were determined; these included body fat, mineral content, lean (nonfat and nonmineral-containing tissue) mass, total body water, extracellular water (ECW), and body protein. Daily and cumulative nutrient balance and substrate oxidation studies determined the distribution, efficiency, and utilization of calories for protein, fat, and carbohydrate deposition. RESULTS: The GH-treated patients gained minimal body fat but had significantly more lean mass (4.311 +/- 0.6 kg vs. 1.988 +/- 0.2 kg, p < or = 0.03) and more protein (1.417 +/- 0.3 kg vs. 0.086 +/- 0.1 kg, p < or = 0.03) than did the STD-treated patients. The increase in lean mass was not associated with an inappropriate expansion of ECW. In contrast, patients receiving STD therapy tended to deposit a greater proportion of body weight as ECW and significantly more fat than did GH-treated patients (1.004 +/- 0.3 kg vs. 0.129 +/- 0.2 kg, p < 0.05). GH administration altered substrate oxidation (respiratory quotient = 0.94 +/- 0.02 GH vs. 1.17 +/- 0.05 STD, p < or = 0.0002) and the use of available energy, resulting in a 66% increase in the efficiency of protein deposition (13.37 +/- 0.8 g/1000 kcal vs. 8.04 g +/- 3.06 g/1000 kcal, p < or = 0.04). CONCLUSIONS: GH administration accelerated protein gain in stable adult patients receiving aggressive nutritional therapy without a significant increase in body fat or a disproportionate expansion of ECW. GH therapy accelerated nutritional repletion and, therefore, may shorten the convalescence of the malnourished patient requiring a major surgical procedure.

Growth hormone attenuates the abnormal distribution of body water in critically ill surgical patients.

BACKGROUND: Catabolic illness is associated with fluid retention and extracellular space expansion. To determine the effect of human growth hormone (GH) on body water compartments, critically ill surgical patients were studied for a 2-week period during which they either continued to receive standard intensive care unit support, or in addition, received GH, 10 mg/day. METHODS: Body water compartments were measured at the beginning and end of the period by the indicator dilution technique with sodium bromide and heavy water used as the indicators of extracellular (ECW) and total body water (TBW), respectively; intracellular water (ICW) was calculated by subtraction. RESULTS: Neither group lost significant amounts of weight or TBW. A marked ECW expansion and disturbance of the ECW/TBW ratio occurred in the patients receiving standard care, which was associated with a dramatic reduction in ICW, a critical component of the body cell mass (BCM). In contrast, GH-treated patients maintained ECW and ICW, indicating a preservation of BCM, and their ECW/TBW ratio normalized. CONCLUSIONS: GH administration prevents ECW retention and stabilizes or normalizes fluid distribution during critical illness. Taken together with its known anabolic effects under these conditions, the maintenance of ICW demonstrates that GH can be used to preserve BCM in complex surgical patients.

Management of acute abdominal pain: decision making in the accident and emergency department.

In the management of patients who present to the accident and emergency department with acute abdominal pain the casualty officer has three options: to treat and discharge, to refer to the out-patient department or to refer for urgent admission. The early management of 512 adults presenting to one accident and emergency department with acute abdominal pain has been prospectively studied to determine the accuracy of the casualty officers' decisions as opposed to diagnostic accuracy. Of the 512 patients, 333 (65%) were discharged home with no further hospital follow-up having been arranged; of these 18 (5%) returned with persistent symptoms and five (2%) were admitted. Of 132 patients referred for urgent admission 113 (85.6%) were either admitted or further investigated and were followed up as out-patients. This study demonstrates a high accuracy of decision making by relatively junior hospital staff in the management of acute abdominal pain.

Questionnaire identification of surgical patients at risk of HIV infection.

The prevalence of human immunodeficiency virus (HIV) infection is increasing. Risks of hospital transmission, though small, will consequently also increase. Precautions taken during invasive procedures, particularly surgery, and in the handling of specimens from patients diminish this risk. As HIV antibody screening is not permissible, we have assessed the possible efficacy of a routine questionnaire to identify high-risk groups. Of 525 questionnaires given to routine surgical patients, 506 (96%) were completed. Twenty-eight (5.5%) indicated that they were in a high-risk group. High-risk patients were more likely to present with anorectal disease, to be male and to be young compared with patients from the remainder of the sample. The questionnaire was acceptable to 97% of patients although to a significantly smaller number (82%) of high-risk patients. Routine HIV antibody testing would be acceptable to 88% of low-risk patients but to only 60% of high-risk patients. Questionnaire assessment is an acceptable and perhaps more reliable method of assessing HIV risk status than the other currently available options. It has to be accepted that it will never result in complete identification but we recommend this method as one approach to the problem faced by the surgical team.

Three new primary pelvic carcinomas in a patient following radiotherapy for carcinoma of the cervix. Case report.

A 67-year-old woman developed three separate pelvic malignancies forty years after undergoing radiotherapy for a squamous cell carcinoma of the cervix. Although previous exposure to ionising radiation is associated with certain malignancies, review of the literature indicates that there is no strong evidence to support such an association with urothelial or colorectal malignancy.

Clinical decision making and laparoscopy versus computer prediction in the management of the acute abdomen.

A prospective study has been undertaken of 321 patients with acute abdominal pain admitted to hospital under one surgical firm over a period of 21 months. During the first 10 months patients were classified on admission according to the perceived need for operation, with laparoscopy being performed on all those in whom the need for operation was uncertain. In addition, all women with suspected appendicitis underwent laparoscopy because previous studies by us and others have demonstrated a high error rate in this group. During the second 11 months of the study a similar system of classification and procedure was used but the patient's initial assessment was entered on a structured data sheet. After the patient had been discharged home this information was entered into a computer-aided diagnosis program. Hypothetical retrospective computer-aided decisions were then made about patient management. The final management error rate (correct decision to operate or not) was compared with the actual error rate using the clinical system. The final overall error rate in the first 10 months was 11 out of 163 patients and this was improved to 3 out of 158 in the second 11 months of the study by the addition of the structured data sheet to selective laparoscopy. A management policy based entirely on diagnostic probabilities taken from the computer-aided diagnosis program would have produced an error rate of 26 out of 158. We conclude that in the management of the acute abdomen a policy based on clinical decision combined with selective laparoscopy may be superior to one based on diagnostic probabilities alone. Further improvement in results follows the introduction of a structured data sheet for initial data collection.