Eur J Surg

Forced air warming and intraoperative hypothermia.

Year 1998
Lindwall R. Svensson H. Soderstrom S. Blomqvist H.
Department of Anaesthesia and Intensive care, Danderyd Hospital, Sweden. Robert.Lindwall@Ane.ds.sll.se
ABSTRACT OBJECTIVES: To compare a forced air warming system with passive measures to avoid perioperative hypothermia. DESIGN: Prospective open study. SETTING: University hospital, Sweden. SUBJECTS: 28 Patients scheduled for extensive thoracoabdominal operations under standard combined general and regional anaesthesia. MAIN OUTCOME MEASURES: Temperature measured before, repeatedly under anaesthesia and during the operation for up to three hours, and then up to eight hours postoperatively. RESULTS: Three patients were excluded. In the 12 patients who had forced air warming, temperature was preserved, and ranged from a mean (SD) of 36.8 (0.7) degrees C, (95% confidence interval (CI) 36.4 to 37.2) at the start to 36.9 (0.8) degrees C, (95% CI 36.5 to 37.3) after 3 hours. In patients who had conservative passive heat preservation techniques the mean temperature fell significantly perioperatively, from 36.8 (0.6) degrees C (95% CI 36.5 to 37.1) at the start to 35.1 (0.5) degrees C, (95% CI 34.9 to 35.3), after three hours of anaesthesia and surgery. This was a significant fall compared with the temperature in the study group (p < 0.001). CONCLUSION: Forced air warming intraoperatively can preserve normothermia during extensive thoracoabdominal operations.

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies.

Year 1998
Kald A. Nilsson E. Anderberg B. Bragmark M. Engstrom P. Gunnarsson U. Haapaniemi S. Lindhagen J. Nilsson P. Sandblom G. Stubberod A.
Department of Surgery at the University of Linkoping, Sweden.
OBJECTIVE: Analysis of reoperation and recurrence rates three years after repair of groin hernias. DESIGN: Prospective audit by questionnaire and selective follow-up. SETTING: Eight Swedish hospitals. SUBJECTS: All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years. MAIN OUTCOME MEASURES: Postoperative complications, reoperation for recurrence, and recurrence. RESULTS: During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence. CONCLUSIONS: The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Small bowel volvulus: a common cause of mechanical intestinal obstruction in our region.

Year 1998
Gurleyik E. Gurleyik G.
Department of Surgery, Haydarpasa Numune Hospital, Istanbul, Turkey.
OBJECTIVE: To find out the incidence and causes of small bowel volvulus in our region, and to analyse the results of our management. DESIGN: Retrospective study. SETTING: Teaching hospital, Turkey. SUBJECTS: 38 Patients who had had no previous abdominal operations who were operated on for mechanical intestinal obstruction caused by small bowel volvulus. MAIN OUTCOME MEASURES: Incidence of small bowel volvulus, details of patients, treatments, complications, and outcome. RESULTS: Small bowel volvulus constituted 8%(38/466) of all cases of mechanical intestinal obstruction and 13%(38/292) of small bowel obstruction. Volvulus was primary in 18 (47%), and secondary in 20 (53%) patients. 33 Patients (87%) were male. The mean age of the whole group was 30 years, 42 and 19 in patients with primary and secondary volvulus, respectively (p=0.0005). The incidence of small bowel volvulus was 19%(27/143) in patients under 40 years, and 7%(11/149) in those over 40 years of age (p=0.005). Sixty percent of patients with secondary volvulus (12/20) were under 20 years of age compared with 17% of those with primary volvulus (3/18; p=0.009). The causes of secondary volvulus were Meckel's diverticulum in 14 patients (70%), and malrotation and ileosigmoid knotting in 3 patients each (15%). Segments of bowel were gangrenous in 12 patients (32%). Treatment was by simple untwisting in patients with viable segments of gut, or with resection of gangrenous segments and primary small bowel anastomosis. One patient died postoperatively of septic shock. CONCLUSIONS: Small bowel volvulus is a common form of intestinal obstruction in our region. It carries a high risk of gangrene of twisted segments of bowel. Fortunately perforation of small bowel is uncommon, and resection and primary anastomosis is a safe procedure in cases of necrosis. Today the outcome of such patients is satisfactory. Early and proper management is essential for a good outcome.

Pathophysiological response of cytokines and vasoactive agents in patients undergoing total gastrectomy.

Year 1998
Shito M. Ueda M. Wakabayashi G. Endo M. Kitajima M.
Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
OBJECTIVE: To investigate the involvement of vasoactive agents, endothelin (ET)-1, and atrial natriuretic peptide (ANP), and the responses of cytokines in patients undergoing total gastrectomy. DESIGN: Prospective study. SETTING: University hospital, Japan. SUBJECTS: 20 patients with advanced gastric cancer who had undergone total gastrectomy with lymph node dissection. INTERVENTIONS: Serum or plasma samples collected on the day before the operation, at the time of skin closure, and on postoperative days 1, 3, 5, and 7. MAIN OUTCOME MEASURES: Concentrations of acute phase reactants, cytokines (interleukin (IL)-1, tumour necrosis factor (TNF) and interleukin (IL)-6), and vasoactive agents (ET-1 and ANP). RESULTS: There were significant increases in concentrations of IL-6 and acute phase reactants postoperatively. ET-1 and ANP concentrations did not change significantly. CONCLUSION: There was no correlation between concentrations of the vasoactive agents ET-1 and ANP, and those of acute phase reactants or cytokines in serum or plasma in patients undergoing total gastrectomy.

Quality of life after surgical treatment of gastric carcinoma.

Year 1998
Zieren HU. Zippel K. Zieren J. Muller JM.
Department of Surgery, Charite, Humoldt University of Berlin, Germany.
OBJECTIVE: To see if there was a correlation between self-assessment and external evaluation of quality of life (QL) after resection of gastric carcinoma, a correlation between overall QL and different components, and the impact of social and medical factors on QL. DESIGN: Prospective study. SETTING: University hospital, Germany. SUBJECTS: 71 patients assessed once 12 months after R0-resection of gastric carcinoma and 35 patients assessed regularly, starting postoperatively. INTERVENTIONS: QL was assessed by the patients using the European Organisation for Research and Treatment of Cancer (EORTC) core QL questionnaire (QLQ-C36) and by a psychologist using the Spitzer Index. MAIN OUTCOME MEASURES: Correlations between self-assessment and external assessment, between overall scores and single items of QL, and between social and medical factors and QL, as well as changes in QL-scores during postoperative follow-up. RESULTS: Self-assessment and external evaluation of global QL showed a significant but not particularly close correlation (r = 0.40) and QL was evaluated as better by the external observer using the Spitzer Index. All physical, emotional, and social components of the QLQ-C36 correlated significantly with patients overall evaluation of QL. Postoperative QL was affected mainly by somatic complaints and physical limitations. Of several factors analysed, tumour recurrence was the decisive factor in deciding patients' QL. Compared with the preoperative assessment, QL had deteriorated on discharge from hospital but was restored during the following six months in patients who remained disease-free. CONCLUSION: Compared with the Spitzer Index the QLQ-C36 differentiates the QL of patients with gastric cancer better and disease-specific complaints are included.

Is pyloric function preserved in pylorus-preserving pancreaticoduodenectomy?

Year 1998
Lupo LG. Pannarale OC. Altomare DF. Caputi L. Dell'Erba L. Ricci P. Memeo V.
Istituto di Clinica Chirurgica, Cattedra di Metodologia Clinica, Universita di Bari, Italy.
OBJECTIVE: To assess the function of the pylorus after pylorus-preserving pancreaticoduodenectomy (PPPD) done for periampullary or pancreatic cancer. DESIGN: Prospective, observational controlled clinical study. SETTING: Teaching hospital, Italy. SUBJECTS: 17 patients who had undergone PPPD, and 15 healthy control subjects. INVESTIGATIONS: Endoscopy to check for gastritis and marginal ulcers and 24 h-pH monitoring and 99mTc HIDA scintigraphy to detect jejunogastric reflux. Scintigraphy was also used to evaluate gastric and jejunal transit after a solid meal labelled with 99mTc colloid sulphur. MAIN OUTCOME MEASURES: Signs of delayed gastric emptying, jejunogastric reflux and gastric outlet obstruction in the short and long term. RESULTS: In the early postoperative period only 1 patient had delayed gastric emptying. In the long term, two patients had symptoms of dyspepsia and 8/11 showed alkaline reflux with persistent gastric pH more than 4 for more than 12 hours; 3 had histological signs of gastritis. There was no difference in gastric emptying compared with controls, but three patients had prolonged emptying time (T1/2 more than 85 minutes). Endoscopy findings correlated with pH monitoring results. CONCLUSIONS: After PPPD, most patients have abnormal pyloric function, but it is clinically evident in only a small proportion.

Systemic cytokine response to hepatic resections under total vascular exclusion.

Year 1998
Badia JM. Ayton LC. Evans TJ. Carpenter AJ. Nawfal G. Kinderman H. Zografos G. Uemoto S. Cohen J. Habib NA.
Department of Surgery, Imperial College School of Medicine, Hammersmith Hospital, London, United Kingdom.
OBJECTIVE: To investigate the systemic cytokine response to major liver surgery as the basis for assessing potential new treatments. DESIGN: Open prospective study. SETTING: University hospital, UK. SUBJECTS: Thirteen patients undergoing elective hepatic resections that involved total vascular exclusion of the liver. INTERVENTIONS: Blood samples were taken preoperatively, during the operation, and during the first four postoperative days. Concentrations of endotoxin, interferon gamma (IFN-gamma), tumour necrosis factor alpha (TNFalpha), interleukin-1 (IL-1), and interleukin-6 (IL-6) were measured. RESULTS: Endotoxin concentrations were raised in 3/13 patients before operation and in 6 patients during the postoperative period. TNFalpha concentrations were undetectable. IFN-gamma and IL-1 responses followed a low and inconclusive pattern. IL-6 was significantly increased from 6 hours after operation to the third postoperative day, peaking at 699 (+/-277) pg/ml at 24 hours (p < 0.01). The two patients who died had the highest postoperative concentrations of IL-6. CONCLUSIONS: There is a pronounced systemic response to hepatic resection under total vascular exclusion that is reflected by the increase in IL-6 concentration and correlates with the operative blood loss and postoperative outcome. This might be used as an indicator of the response to specific treatments in this type of surgery. Treatments that minimise the IL-6 response to major hepatic resection may be of value.

Prosthetic repair of femoral hernia: audit of long term follow-up.

Year 1998
Sanchez-Bustos F. Ramia JM. Fernandez Ferrero F.
Servicio de Cirugia General, Hospital 12 de Octubre, Madrid, Spain.
OBJECTIVE: To study the long term results of 93 femoral hernia repairs by cylindrical prothesis with a polypropylene mesh. DESIGN: Prospective open study. SETTING: District hospital, Spain. SUBJECTS: 92 patients who had 93 hernias repaired between 1989 and 1992. INTERVENTIONS: Lichtenstein repair of femoral hernias. MAIN OUTCOME MEASURES: Complications and recurrences. RESULTS: The mean follow up was 64 months (range 43-84). There was one recurrence 4 months postoperatively in a patient who had been operated on as an emergency for an incarcerated hernia, and in one patient the prosthesis had to be removed 10 days after the initial operation. This was subsequently repaired with polypropylene mesh and had not recurred at 4 years. CONCLUSION: Herniorrhaphy with cylindrical prosthesis is our preferred elective technique for repair of primary femoral hernias although other techniques are advisable for incarcerated or recurrent hernias.

Acute mesenteric vascular occlusion: analysis of 39 patients.

Year 1998
Urayama H. Ohtake H. Kawakami T. Tsunezuka Y. Yokoi K. Watanabe Y.
First Department of Surgery, Kanazawa University School of Medicine, Ishikawa, Japan.
OBJECTIVE: To study the factors that influence mortality and long term outcome of patients with acute mesenteric vascular occlusion. DESIGN: Retrospective study. SETTING: University hospital, Kanazawa, Japan. PATIENTS: Thirty-nine patients treated between 1978 and 1995 for acute mesenteric vascular occlusion. INTERVENTIONS: 34 patients underwent laparotomy. Bowel was resected in 29 patients, and primary anastomosis was done in 20. The occluded vessel was revascularised in 5 patients. MAIN OUTCOME MEASURES: mortality, short bowel syndrome and long term survival. RESULTS: 25 patients had arterial occlusions, and 8 venous. In the remaining 6, the occluded vessel was not identified. 11 Patients developed renal failure, 11 respiratory failure, and 10 disseminated intravascular coagulation (DIC). Twelve patients died within 30 days. The factors associated with early death were acidosis and high serum amylase activity. 9 Patients developed the short bowel syndrome. Survival was 49% at 1 year, and 34% at 5 years. CONCLUSION: Mortality was higher in patients with advanced peritonitis. Mesenteric revascularisation should be attempted to avoid the short bowel syndrome.

Influence of ultrasound on clinical decision making in acute appendicitis: a prospective study.

Year 1998
Zielke A. Hasse C. Sitter H. Rothmund M.
Department of Surgery, Phillips-University of Marburg, Germany. zielke@mailer.uni-marburg.de
OBJECTIVE: To assess the efficacy of ultrasound (US) as part of an algorithm to establish the indication for laparotomy in patients with suspected acute appendicitis. DESIGN: Prospective investigation. SETTING: University department of surgery, Germany. SUBJECTS: 669 unselected patients admitted with suspected acute appendicitis. INTERVENTIONS: Clinicopathological and procedural diagnoses of the algorithm were evaluated by correlating clinical and US findings with the results of laparotomy in 171 patients of whom 143 had acute appendicitis (prevalence 21%), and clinical as well as follow up data in the remainder. MAIN OUTCOME MEASURES: The major clinicopathological variables were accuracy and positive predictive value; the rate of negative laparotomies and that of bad diagnostic errors served as the main procedural variables. RESULTS: The overall sensitivity, specificity, and accuracy of the clinical diagnosis were 0.503, 0.950, and 0.855, respectively (positive predictive value: PPV 0.734, negative predictive value: NPV 0.875), those of ultrasound: 0.797, 0.967, and 0.931 (PPV 0.870, NPV 0.946); and 0.853, 0.927, and 0.940 at the end of the algorithm (PPV 0.762, NPV 0.958). However, the algorithm would have resulted in a significant increase in the rate of unnecessary laparotomies (from 13% to 16%). A revised clinical algorithm gave an overall diagnostic accuracy of 0.940 (p < 0.001) together with a low rate of negative laparotomies (11%, p < 0.01) and a significantly reduced number of diagnostic errors (from 71 to 21, p < 0.001). CONCLUSION: Ultrasonography enabled us to diagnose acute appendicitis in more patients more often and more quickly than clinical evaluation alone, suggesting that US may produce a better outcome. The revised clinical algorithm may be helpful in the study of US in patients with suspected acute appendicitis in prospective randomised controlled clinical trials.

Haemostatic aspects of recombinant human erythropoietin in colorectal surgery.

Year 1998
Poulsen KA. Qvist N. Winther K. Boesby S.
Department of Surgical Gastroenterology, Odense, Odense C, Denmark.
OBJECTIVE: To find out whether recombinant human erythropoietin (r-HuEPO) given perioperatively has any effect on haemostatic activity in patients undergoing elective colorectal resection. DESIGN: A placebo-controlled double-blind study. SETTING: Odense university hospital, Denmark. SUBJECTS: 24 patients undergoing elective colorectal resection, 13 of whom were given r-HuEPO (Eprex) and 11 placebo. MAIN OUTCOME MEASURES: Concentrations of haemoglobin, tissue-type plasminogen activator and plasminogen activator inhibitor-1; activated partial thromboplastin time; prothrombin time; platelet and reticulocyte counts; blood loss; and transfusions. RESULTS: There was no significant change in fibrinolytic activity, prothrombin time, or activated prothrombin time in the treatment group. Platelet counts differed slightly but not significantly, being higher in the r-HuEPO group. There was a significant increase in reticulocyte counts in the r-HuEPO group. CONCLUSION: R-HuEPO given perioperatively significantly increased erythropoiesis in patients undergoing elective colorectal operations but had no influence on haemostatic activity.