Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study.

PURPOSE: Efficient mechanical bowel preparation has been regarded as essential in preventing postoperative complications of colorectal surgery, but the necessity of bowel cleansing has been disputed recently. The aim of this study was to evaluate the outcome of elective colorectal surgery in patients with or without bowel preparation. METHODS: Altogether, 267 consecutive adult patients admitted for elective open colorectal surgery were randomly assigned either to the bowel preparation group with oral polyethylene glycol electrolyte solution (138 patients) or no preparation group (129 patients). Patients who were unable to drink polyethylene glycol electrolyte solution, those who had had bowel preparation within the previous week, and patients not needing opening of the bowel were excluded. Routine colorectal surgery was undertaken, and infectious and other complications were registered daily. Late complications were checked up one to two months after surgery. RESULTS: No deaths were recorded, and 76 percent of the patients in the polyethylene glycol electrolyte solution group and 81 percent in the unprepared group recovered without complication. Anastomotic leaks occurred in 4 percent of the polyethylene glycol electrolyte solution patients and in 2 percent of the other cases, and other surgical site infections occurred in 6 and 5 percent, respectively. None of the differences was statistically significant. There was no difference in restoration of bowel function. The median postoperative stay was eight days in both groups. CONCLUSIONS: Preoperative bowel preparation seems to offer no benefit in elective open colorectal surgery.

Analysis of late stomal complications following ostomy surgery.

BACKGROUND AND AIMS: This study was aimed to evaluate the late complications of ostomy surgery in a strictly followed patient population of a university hospital. MATERIAL AND METHODS: An actuarial analysis of the complications of 156 patients with permanent ostomies using the life-table method was performed. RESULTS: The crude and actuarial risks of late stomal complications in 156 patients after a mean follow-up of 8 years were 39 per cent and 59 per cent. The cumulative risk of complications did not differ between the stoma types. Paracolostomy hernia was the most common complication of the colostomy, 27 per cent, retraction of ileostomy, 24 per cent, and intestinal obstruction of urostomy, 28 per cent. Mesenteric fixation was here associated with a lower chance of prolapse (P < 0.025), but the closure of lateral space did not reduce the risk of intestinal obstruction. Skin irritation was more common after a creation of ileostomy than after other stoma creations (P < 0.001). The revisional surgery rate was lower following colostomy than following other stoma formations (P < 0.034). Adaptation to the stoma had occurred in 74% of the patients, but 8 per cent of the patients had intractable symptoms at the time of the analysis. CONCLUSION: Ostomy surgery involves a high rate of late complications and there is a small but important subgroup of patients whose quality of life is seriously affected.

Randomized trial of endoscopic injection sclerosis with ethanolamine oleate and ethanol for bleeding peptic ulcer.

BACKGROUND: Few studies have been done comparing ethanolamine oleate injection therapy with other sclerosing agents. Between September 1992 and August 1995, 78 consecutive patients presenting with a high-risk bleeding ulcer were randomized in a trial comparing endoscopic injection sclerotherapies with ethanolamine oleate and absolute ethanol. METHODS: The groups were well matched in terms of sex, age, clinical features, endoscopic findings, and non-steroidal anti-inflammatory drug usage. We recorded in a prospective randomized trial the initial success of endoscopy, the rebleeding rate, permanent hemostasis, treatment failures, the need for surgery, mortality, and factors related to mortality. RESULTS: Initial hemostasis was achieved in 90% (38 of 42) of the ethanolamine oleate group and in 97% (35 of 36) of the ethanol group, and permanent hemostasis in 88% (37 of 42) and 92% (33 of 36), respectively. The rebleeding rate, 7% and 8%; the emergency surgery rate, 10% and 6%; the transfusion requirement, 4.8 +/- 3.3 units and 4.0 +/- 3.0 units; and the 30-day mortality, 12% and 3%, did not differ significantly between the ethanolamine oleate and ethanol groups. Mortality was significantly related to shock at admission, duodenal site of the ulcer, ulcer size greater than 2 cm, and blood transfusion of over 5 units. CONCLUSION: Endoscopic injection sclerotherapies using ethanolamine oleate or absolute ethanol are safe and equally effective for bleeding peptic ulcers.

Abdominal operations for intraabdominal metastases from extraabdominal primary tumors.

Forty consecutive patients with an extraabdominal primary tumor, later treated surgically for intraabdominal problems, were investigated. The most common causes of abdominal operations were intestinal obstruction (N = 17), intraabdominal tumor mass (N = 8), and intraabdominal hemorrhage (N = 5). The overall postoperative mortality was 25%, morbidity 48%, median survival 3 months, and cumulative 5 year survival 3%. The mortality after emergency procedures, 67%, was significantly higher (P less than 0.01) than after elective operations, 18%. Conditions requiring enterostomy (N = 14) were associated with a mortality of 36%, whereas the figures in resected (N = 13) and bypassed (N = 7) patients were 14% and 17%, respectively. Wound infection (N = 5) and pulmonary infection (N = 5) were the most common complications, and pulmonary infection was fatal in three of the five cases. Of the patients, 22 (55%) were discharged from hospital to their home; ten (25%) of them had postoperatively a 3 month relief of cancer symptoms and four (10%) a 6 month relief. Nine patients (25%) have survived for over 1 year and one (3%) for over 5 years. It is concluded that abdominal procedures seldom prevent further cancer growth within these patients and that symptoms are relieved only in one in every four patients. According to strict criteria, these operations are useful and can add to patient comfort.

Sutureless colon anastomosis with fibrin glue in the rat.

The only technique available for creating an intestinal anastomosis without tissue strangulation is gluing. Theoretically, this could lead to a higher hydroxyproline content and greater mechanical strength than in a sutured anastomosis. To test the hypothesis, 83 rats underwent left colon resection and inverted primary anastomosis with either one layer of sutures (NG group) or fibrin glue (FG group). Seven-day FG anastomoses showed less adhesions (P = .02) but one subclinical leakage and a further radiologic one, compared with a greater amount of adhesions but no leakages in the NG group. The mean bursting pressures (mmHg) in the FG and NG groups, respectively, were 25 +/- 20 (SD) and 63 +/- 23 (N.S.) 30 minutes after surgery, 107 +/- 33 and 115 +/- 30 after one day, 81 +/- 31 and 133 +/- 26 (P less than .001) after four days, and 161 +/- 36 and 175 +/- 24 after seven days. The somewhat earlier rise in hydroxyproline content in the glued anastomoses did not lead to significant intergroup differences. The glued anastomoses were thus weak during the critical lag period of healing. Also, by preventing adhesion formation, the glue may reduce the extra blood supply from perianastomotic vessels. The outcomes might have differed more under demanding experimental or clinical situations.

Fibrin glue protection of primary anastomosis in the obstructed left colon. An experimental study on the rat.

A left-sided colon obstruction was produced with a polypropylene sling in 65 rats. Colon resection and primary anastomosis were performed three days later. The animals were then randomly allocated to the FG (fibrin glue) group receiving sealing of the anastomosis with 0.4 ml of fibrin glue (Beriplast R), or to the NG (non-glue) group. The anastomoses were assessed 30 min, two days and four days later. Adhesion formation was similar in both groups. The number of macroscopic or radiological leakages did not differ either. At 30 min the mean bursting pressure was 74.6 +/- 8.6 (SD) mmHg in the FG group and 58.3 +/- 21.6 mmHg in NG (non-glue) group (p less than 0.05, Mann-Whitney test). Later on the strength of the anastomoses was equal in both groups. We conclude that the initial sealing of weak points in the anastomoses was beneficial but the inherent strength per se could not be enhanced.

The Hartmann procedure for the treatment of colorectal emergencies.

A total of 80 patients with colorectal emergencies were treated by the Hartmann procedure at the Oulu University Central Hospital during the years 1973-1984. The median age of the patients was 65 (18-81) years. The operative indications were: diverticular disease (n = 26), cancer (n = 21), stercoraceous perforation (n = 9), vascular accident (n = 5), radiation damage (n = 4) and miscellaneous (n = 11). 13 patients (16.3%) died after a median of 8 (1-33) days, mostly due to organ failure. 44 of the surviving 67 patients (65.7%) had postoperative complications. Intestinal continuity was restored in 34 patients (42.5%) after a median of 139 (65-794) days. Two patients (5.6%) died after the reconstruction. The permanency of the stoma in half of the surviving patients and the technical difficulties encountered in stoma closure are disadvantages attached to the Hartmann procedure which are sufficiently serious that alternative operative methods should always be considered.