Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND: Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm. METHODS: Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured. RESULTS: All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively). CONCLUSIONS: When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

A prospective evaluation of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis.

OBJECTIVES: The ileal pouch anal anastomosis is a safe and effective procedure but is also associated with pouchitis, small bowel obstruction, and incontinence. We prospectively evaluated the health-related quality of life using generic and disease-specific measures in a cohort of patients with ulcerative colitis undergoing ileal pouch anal anastomosis. METHODS: Health-related quality of life measures included the Time Trade-off, Rating Form of IBD Patient Concerns, and the Short-Form 36. Assessments occurred preoperatively and 1, 6, and 12 months postoperatively. RESULTS: Time Trade-off scores had significantly improved at the 1-month postoperative assessment and approached perfect health at the 12-month postoperative assessment. The Rating Form of IBD Patient Concerns revealed a significant reduction in patient concerns at 1 month, and this difference persisted at 6 and 12 months. Seven of the eight subscales of the Short-Form 36 revealed improved health-related quality of life postoperatively. CONCLUSIONS: Health-related quality of life improved after ileal pouch anal anastomosis when assessed with both generic and disease-specific measures. Improvements were observed as early as 1 month postoperatively. These results may guide patients and physicians as they consider and prepare for the impact of ileal pouch anal anastomosis.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility.

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 +/- 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (#30 mm Hg mean distal esophageal body pressure or #80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.

Prospective randomized trial of early initiation and hospital discharge on a liquid diet following elective intestinal surgery.

Length of hospital stay after elective intestinal surgery may be related to patient tolerance of a diet. We hypothesized that early initiation and discharge home on a clear liquid diet would decrease the length of hospital stay without increasing morbidity. The aim of this study was to determine if early initiation and discharge on a clear liquid diet decreases the length of hospital stay and is safe. Forty-four patients were randomly assigned to either a standard diet or a clear liquid diet. A standard diet (n = 17) was begun after the passage of flatus or stool, and consisted of clear liquids to a volume of approximately 750 ml, then three solid meals, and discharge thereafter. Patients randomized to a clear liquid diet (n = 27) received 30 ml/hr of clear liquids on postoperative day 2, unlimited clear liquids on postoperative day 3, and were dismissed on a clear liquid diet on postoperative day 4. All patients were followed by a daily telephone call and clinic visit. The primary outcome variable was length of hospital stay. The incidence of postoperative intestinal-related sequelae, complications, and readmission rates did not differ between groups. Postdischarge intestinal symptoms were common in both groups but tended to resolve faster in the patients on a standard diet. The length of hospital stay was decreased in the patients on a clear liquid diet compared to those on a standard diet (6.1 +/- 1.1 days vs. 4.4 +/- 0.2 days; P = 0.09), but total hospital costs did not differ. Early initiation and hospital discharge on a clear liquid diet after elective intestinal surgery decreases the length of hospital stay and is safe.

Pentoxifylline alters class-specific immunoglobulin synthesis in resuscitated burn injury.

Pentoxifylline (PTXF) is a hemorheologic agent that can attenuate microvascular alterations induced by injury, resulting in improved microcirculatory flow. Burn injury-induced immunologic suppression may be caused by alterations in microvascular flow. We studied the effects of PTXF on humoral immunity in resuscitated burn injury. Male AKR mice (n = 80) were randomized to four groups: SHAM, BURN, PTXF-BURN, and NS-BURN (saline burn). Animals were resuscitated with Ringer's lactate and morphine sulfate and put to death at days 1 and 4 after injury. PTXF-BURN animals received PTXF (50 mg/kg intraperitoneally) at the time of resuscitation. Splenic lymphocytes (1 x 10(6) cells/well) were cultured with lipopolysaccharide (LPS) (2.5 and 10 micrograms/ml)). LPS-stimulated in vitro class-specific immunoglobulin (Ig) production was determined by enzyme-linked immunosorbent assay from splenic cell culture supernatants. Burn injury induced a reduction in immunoglobulin (Ig) M synthesis on postburn day 4. PTXF treatment was associated with an increase in IgG production, but a greater depression in IgM synthesis than burn injury alone. PTXF administration during resuscitation in burn injury does not ameliorate the burn-induced depression in IgM synthesis and results in significant potential adverse modulation of humoral immune function.

Health-related quality of life after ileoanal pull-through evaluation and assessment of new health status measures.

BACKGROUND & AIMS: Health-related quality of life (HRQL) after proctocolectomy is a critical parameter for management decisions in patients with chronic pancolitis. The aim of this study was to evaluate the HRQL of patients with ileoanal pull-through and to validate new, easy-to-administer HRQL measures. METHODS: The Sickness Impact Profile (SIP), Short Form 36 (SF-36), Rating Form of Inflammatory Bowel Disease (IBD) Patient Concerns (RFIPC), and the time trade-off (TTO) were used to measure HRQL of pull-through patients. The SF-36 and the RFIPC were validated. RESULTS: HRQL of patients with ileoanal pull-through was better than that of a national sample of patients with IBD (SIP and RFIPC) and similar to that of a normal population (SF-36). Physical and psychosocial subscales of the SF-36 correlated with the SIP, affirming the construct validity of the SF-36. The RFIPC results correlated with the SIP and SF-36 results, suggesting that it is also a valid health status measure for these patients. TTO results correlated with the physical subscales of the SIP and SF-36, reflecting the impact of physical health on this group. CONCLUSIONS: HRQL of patients with ileoanal pull-through is excellent. The SF-36 and RFIPC are valid health status measures that can be used by clinicians and researchers in these patients.

Haemangioma of the oesophagus: CT demonstration.

A case of haemangioma of the oesophagus is presented. The computed tomographic findings of an intramural mass with marked enhancement following intravenous contrast enable the diagnosis to be suggested pre-operatively.

The impact of femur fracture with associated soft tissue injury on immune function and intestinal permeability.

Alterations in intestinal permeability and immune function were investigated in a murine femur fracture (FFx) model. We postulated that soft tissue injury associated with closed FFx (crush injury) would result in greater immunosuppression that open FFx (surgical division). AKR mice were randomized to four groups (Normal, Sham, Open FFx, Closed FFx) and studied at 24 and 96 h post-injury. Immune function was assessed by splenocyte blastogenic response and class-specific immunoglobulin production. Intestinal permeability was assessed by measurement of whole blood fluorometry after gavage administration of fluorescein-dextran (FITC-dextran). Closed FFx is associated with increased splenocyte blastogenesis and increased immunoglobulin production at 24 h post-injury. This immunostimulatory response was associated with altered intestinal permeability early after injury (FITC-dextran:.185 +/- .070 Closed FFx vs. .069 +/- .011 Normal, p = .06). Immunosuppression was evident at 96 h post-injury in the closed FFx group, documented by significant reductions in splenocyte blastogenesis to all mitogens studied. The Open FFx group did not demonstrate any reduction in splenocyte blastogenesis at 96 h post-injury. These data suggest that the soft tissue injury associated with Closed FFx is associated with significant immunosuppression and altered gastrointestinal permeability, which may adversely affect the host by increasing the relative risk of post-trauma infection.

Chronic ethanol intake and burn injury: evidence for synergistic alteration in gut and immune integrity.

OBJECTIVE: Chronic ethanol (EtOH) intake and injury are both associated with increased susceptibility to infection in the host. This study examined the immune and gastrointestinal alterations induced by chronic EtOH intake and injury, and compared the effects of enteral and intravenous administration of EtOH. DESIGN: Rats received 20% EtOH daily for 14 days by gavage [oral (PO)] or superior vena cava [intravenous (i.v.)] infusion. Mean blood EtOH concentrations at 90 minutes after administration were 95.3 mg/dL (PO) and 94.4 mg/dL (i.v.). An additional group of animals underwent a 30% total body surface area full-thickness burn injury 4 hours after the final dose of EtOH or normal saline on experimental day 14. All animals were killed 4 days after burn injury. MATERIALS AND METHODS: Nonadherent splenic lymphocytes were tested for mitogenic responses to the T-cell mitogens concanavalin A (ConA) and phytohemagglutinin (PHA), and the B-cell mitogens lipopolysaccharide (LPS) and pokeweed. Quantitative bacterial cultures of mesenteric lymph nodes and liver were also performed. Alterations of intestinal mucosa were determined by measurement of ileal mucosal weight, DNA, protein, and diamine oxidase content. Circulating plasma endotoxin concentrations were also measured. MEASUREMENTS AND MAIN RESULTS: Chronic PO-EtOH intake induced a significant impairment in mitogenic response to T-cell mitogens, with a fourfold reduction in ConA and a twofold reduction in PHA response (p < 0.05 by analysis of variance) and increased bacterial translocation (70% vs. 10%). Chronic EtOH administered by the i.v. route did not reduce mitogenic response to any of the mitogens studied. Histologic examination of ileal segments demonstrated that chronic PO-EtOH administration was associated with significant mucosal disruption and exfoliation. Chronic administration of PO-EtOH prior to burn injury induced a significant impairment in spleen mitogenic response to ConA, PHA, and LPS when compared with all other burn injury groups. Chronic administration of EtOH by the i.v. route prior to burn injury did not alter splenic mitogenesis. In addition, chronic PO-EtOH prior to burn injury increased bacterial translocation rates (80% vs. 33%) and prevented the normal intestinal reparative response to burn injury (demonstrated by a significant reduction in ileal mucosal weight, DNA, and diamine oxidase content). CONCLUSIONS: Enteral but not i.v. administration of EtOH induced significant immunologic dysfunction (demonstrated by altered spleen mitogenic response) and gastrointestinal dysfunction (demonstrated by depressed ileal mucosal weight, DNA, and diamine oxidase content, and increased bacterial translocation rates). In addition, the administration of chronic enteral EtOH prior to injury resulted in significant immune suppression and impaired the host's ability for normal intestinal repair. These results suggest that this EtOH-induced reduction in immunocompetence may be gut-mediated and that the administration of alcohol prior to injury may result in a synergistic alteration of gut and immune integrity.

Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding.

In this multicenter prospective controlled trial, 98 evaluable patients sustaining major torso trauma were randomized to receive early enteral nutrition with a new "immune-enhancing" diet (study: n = 51) or a standard stress enteral formula (control: n = 47). At baseline, both groups had comparable demographics and Injury Severity Scores. After 7 days of feeding, the groups had equivalent increases in serum total protein, albumin, and transferrin concentrations. Patients receiving the "immune-enhancing" diet, however, experienced significantly greater increases in total lymphocyte (p = 0.014), T lymphocyte (p = 0.04), and T-helper (p = 0.004) cell numbers. Additionally, these patients had significantly fewer intraabdominal abscesses (study, 0% vs. control, 11%; p = 0.023) and significantly less multiple organ failure (study, 0% vs. control, 11%; p = 0.023). In conclusion, this multicenter trial suggests this "immune-enhancing" enteral diet offers clinical benefits in stressed surgical patients.

Peristomal pyoderma gangrenosum and inflammatory bowel disease.

Pyoderma gangrenosum (PG) is a debilitating skin disease most often associated with inflammatory bowel disease and is a reportedly rare cause of peristomal ulceration. The lesions of PG rapidly evolve from small, erythematous pustules to deep, painful, pyogenic ulcers within hours to days of onset. Although the behavior and the appearance of the lesions of peristomal PG are diagnostic, a lack of familiarity with PG often leads to misdiagnosis and inappropriate therapy. This study reports four cases of peristomal PG and discusses the 20 previously reported cases in patients with inflammatory bowel disease. Seventy-five percent of patients were female and 67% had Crohn's disease. All patients had colitis, including all of the patients with Crohn's disease, 82% of whom had additional perineal complications. The diagnosis of peristomal PG was based on clinical appearance alone in 83% of cases. The onset of peristomal PG ranged from 2 weeks to 3 years following ostomy. The response to medical therapy was variable. All cases (17 of 17) treated with high-dose corticosteroids and local wound care responded, but five cases required additional therapy. No patient was successfully treated with stoma revision. Risk factors for the development of peristomal PG include Crohn's colitis, female gender, and perineal disease. While most patients respond well to systemic steroids and local wound care, up to one third of patients require long-term medical management.

Differential changes in intestinal permeability following burn injury.

Increased gut permeability (GP) following burn injury has been implicated in the predisposition to sepsis and multiple systems organ failure (MSOF). Since previous studies have identified only "global" alterations in GP, we examined the jejunum, ileum, and colon individually for GP using probes of two different sizes: fluorescein isothiocyanate-dextran-3 (FDEX, molecular weight 4387 d) and horseradish peroxidase (HRP, molecular weight 40,000 d). Animals were examined for GP at 1, 2, or 4 days following burn. The GP was significantly increased in all segments combined following burn injury to both the small probe (FDEX, p < 0.001) and the larger probe (HRP, p < 0.06) versus controls. The GP was significantly greater for FDEX versus HRP (p < 0.001). Jejunal permeability to FDEX and HRP increased most at 24 hours. Ileal and colonic GP to FDEX increased early also, but were higher at days 2 and 4. These results suggest that, following burn injury, there is differential GP that is size and site dependent, and that increased GP may last well beyond 24 hours postburn despite feeding.

Dietary fiber and gastrointestinal disease.

Fiber is an important physiologic component of the diet. Dietary fiber contains soluble and insoluble substrates. Soluble fiber components are fermented by colonic microflora, with the resultant production of SCFAs and gas. SCFAs are important fuels, not only for colonic mucosa, but also for the small intestine through secondary metabolism to glutamine and ketone bodies. The clinical importance of dietary fiber and its metabolic products on gastrointestinal and nongastrointestinal functions have yet to be fully realized.

Gut sterilization to prevent nosocomial infection.

Nosocomial infections, particularly respiratory tract infections, are common complications that not only lengthen ICU stay but also increase mortality. Since it has been recognized that colonization of the oropharynx and proximal gastrointestinal tract by Gram-negative bacteria is predictive of subsequent pneumonia, attempts have been directed toward sterilizing the upper gastrointestinal tract of pathogenic organisms. Selective decontamination of the digestive tract (SDD) utilizes the administration of topical, nonabsorbable antimicrobials to the gastrointestinal tract and parenteral antibiotics to eradicate the carriage of pathogenic bacteria and, hopefully, improve outcome in critically ill patients. This review of 19 recently published studies indicates that SDD significantly reduces colonization with pathogenic bacteria and nosocomial respiratory tract infections. Reduction in mortality, however, is not a proven effect of SDD.

Laparoscopic cholecystectomy: comparison of university and community experience.

We compared the first year's experience in performing laparoscopic cholecystectomy in a university hospital and a community hospital to determine the impact of postgraduate surgical training on outcome. Laparoscopic cholecystectomy was attempted on 446 patients. The conversion rate to open cholecystectomy was 8.3% and did not differ between institutions. Surgical house staff performed 43% of the cases at the university hospital compared with 8% at the community hospital. The greater use of laser and cholangiograms resulted in significantly longer mean operative time at the university hospital (141 +/- 26 min) than at the community hospital (114 +/- 52 min). The overall complication rate did not differ significantly (p = 0.15). Complications included common duct injury (three cases), bile leak (five cases), bleeding or hematoma (six cases), epigastric artery hematoma (one case), and death (one case). Operative inexperience during this first year may be a major determinant for the complication rates at both hospitals. It is too early to determine the impact of graduate surgical education on complications. Intense education and supervised instruction is requisite to minimizing the morbidity associated with laparoscopic cholecystectomy regardless of whether it is performed at a university or community hospital.

Ranitidine does not alter adinazolam pharmacokinetics or pharmacodynamics.

Adinazolam is a triazolobenzodiazepine with anxiolytic and antidepressant activity. Adinazolam is metabolized extensively; the major metabolite, N-desmethyladinazolam (NDMAD), possesses significant pharmacologic activity. NDMAD is eliminated predominantly by renal excretion. Ranitidine, a histamine H2-receptor antagonist, is also excreted renally and may compete with NDMAD for renal secretion. The purpose of this study was to examine the effect of ranitidine on the pharmacokinetics and pharmacodynamics of adinazolam and NDMAD. In a randomized, cross-over study, 12 healthy male volunteers received 300 mg of ranitidine orally followed by 30 mg of adinazolam 1 hour later (treatment A), or adinazolam alone (treatment B). Pharmacodynamic alterations were assessed using card sorting, digit-symbol substitution, and short-term memory tests. Venous blood samples were obtained over 24 hours for analysis of adinazolam and NDMAD by high-performance liquid chromatography. Urine samples also were collected and analyzed for NDMAD. No significant difference in adinazolam oral clearance (1,149 vs. 1,135 ml/hr/kg) was noted between treatments (A vs. B, respectively). Furthermore, the renal clearance of NDMAD (196 vs. 198 ml/min) and the cumulative urinary excretion of NDMAD (% dose; 61.2 vs. 62.3) were not significantly different. Repeated-measures analysis of variance indicated no significant differences in psychomotor performance or short-term memory between treatments. Results suggest that ranitidine has no effect on adinazolam disposition, NDMAD renal clearance, or the central nervous system effects mediated by the drug.