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BACKGROUND: The indications for temporary abdominal closure in nontrauma surgery are heterogeneous and with limited data on clinical outcomes. This study aimed to report the outcomes of primary closure compared with temporary abdominal closure after nontrauma emergency laparotomy within a standardized clinical setting adapted from international guidelines. METHODS: Included were all nontrauma patients undergoing emergency laparotomy between January 1, 2021, and December 31, 2022, at Copenhagen University Hospital Herlev in Denmark. All patients received treatment on the basis of standardized bundle of care trajectory for major emergency abdominal surgery. Mortality, risks of re-laparotomy, and postoperative complications were assessed using Kaplan-Meier plots and multiple logistic regression modeling. RESULTS: Of the 576 included patients, temporary abdominal closure was performed in 57 (10%) patients in the initial surgery. Indications for temporary abdominal closure included damage control strategy as the result of considerable hemodynamic instability in 21 (37%) patients, need for reassessment of bowel viability in 21 (37%) patients, and loss of domain in 15 (25%) patients. Fascial closure was achieved after a median period of 2 days. Sixty-seven patients (12%) underwent re-laparotomy, with temporary abdominal closure performed in 10 (15%) of the cases. Patients with temporary abdominal closure had a significantly greater risk of postoperative complications (odds ratio 2.58, 95% confidence interval 1.38-4.89, P = .003). There were no significant differences in the risks of fascial dehiscence, re-laparotomy, or 30- or 90-days mortality. CONCLUSION: Temporary abdominal closure was performed in 10% of patients undergoing nontrauma emergency laparotomy, with the primary indications being damage control strategy and need for reassessment of bowel viability. Patients undergoing temporary abdominal closure had a significantly greater risk of postoperative complications.
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Técnicas de Cierre de Herida Abdominal , Laparotomía , Complicaciones Posoperatorias , Humanos , Femenino , Masculino , Estudios Prospectivos , Laparotomía/métodos , Laparotomía/efectos adversos , Persona de Mediana Edad , Anciano , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Dinamarca , Urgencias Médicas , Reoperación/estadística & datos numéricos , Anciano de 80 o más Años , Resultado del Tratamiento , Adulto , Técnicas de Abdomen Abierto/métodos , Abdomen/cirugíaRESUMEN
Perioperative neurocognitive disorders (PND) are intractable, indistinct, and considerably diminish the postoperative quality of life of patients. It has been proved that Peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) was involved in neurodegenerative diseases by regulating mitochondrial biogenesis. The underlying mechanisms of PGC-1α and Nod-like receptor pyrin domain-containing protein 3 (NLRP3) inflammasome in PND are not well understood. In this study, we constructed a model of laparotomy in aged mice, and then examined the cognition changes with novel object recognition tests and fear condition tests. The protein levels of PGC-1α and NLRP3 in the hippocampus were detect after surgery. Our results showed that NLRP3 and downstream PI3K/AKT pathway expressions were augmented in the hippocampus after surgery, whereas, the expressions of PGC-1α/estrogen-related receptor α (ERRα)/Unc-51-like autophagy activating kinase 1 (ULK1) pathway were diminished after surgery. In addition, we found that NLRP3 was mainly co-localized with neurons in the hippocampus, and synaptic-related proteins were reduced after surgery. At the same time, transmission electron microscopy (TEM) showed that mitochondria were impaired after surgery. Pharmacological treatment of MCC950, a selective NLRP3 inhibitor, effectively alleviated PND. Activation of PGC-1α with ZLN005 significantly ameliorated PND by enhancing the PGC-1α/ERRα/ULK1 signaling pathway, and further suppressing NLRP3 activation. As a result, we conclude that suppression of the PGC-1α/ERRα/ULK1 signaling pathway is the primary mechanism of PND which caused mitochondrial dysfunction, and activated NLRP3 inflammasome and downstream PI3K/AKT pathway, eventually improved cognitive dysfunction.
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Homólogo de la Proteína 1 Relacionada con la Autofagia , Hipocampo , Inflamasomas , Ratones Endogámicos C57BL , Mitocondrias , Proteína con Dominio Pirina 3 de la Familia NLR , Trastornos Neurocognitivos , Coactivador 1-alfa del Receptor Activado por Proliferadores de Peroxisomas gamma , Receptores de Estrógenos , Transducción de Señal , Animales , Proteína con Dominio Pirina 3 de la Familia NLR/metabolismo , Coactivador 1-alfa del Receptor Activado por Proliferadores de Peroxisomas gamma/metabolismo , Inflamasomas/metabolismo , Ratones , Transducción de Señal/fisiología , Transducción de Señal/efectos de los fármacos , Hipocampo/metabolismo , Homólogo de la Proteína 1 Relacionada con la Autofagia/metabolismo , Mitocondrias/metabolismo , Masculino , Receptores de Estrógenos/metabolismo , Trastornos Neurocognitivos/metabolismo , Trastornos Neurocognitivos/etiología , Envejecimiento/metabolismo , Laparotomía/efectos adversos , Sulfonamidas/farmacología , Furanos , IndenosRESUMEN
OBJECTIVE: To determine which locoregional techniques are effective in managing post-operative pain in major open oncologic gynecologic surgery in terms of pain scores and opioid consumption when epidural analgesia is not a feasible option. METHODS: A systematic review of the literature, based on the Preferred Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, was conducted. The ROB-2 assessment was used to assess bias. The primary outcomes were opioid consumption and post-operative pain scores. Secondary outcomes included post-operative markers such as time to mobilization and bowel movement. RESULTS: A total of nine studies (n=714) were included in the analysis. Eight studies had a low risk of bias. Five different forms of locoregional analgesia were described. Eight studies compared with placebo and one study compared rectus sheath block with epidural analgesia. Three of the five studies investigating transversus abdominis plane (TAP) blocks showed an improvement in pain scores and opioid consumption when compared with the placebo group. One study investigating rectus sheath blocks and another investigating paravertebral blocks demonstrated significantly less opioid consumption and improved pain scores at certain time points. The studies investigating continuous wound infiltration and superior hypogastric plexus block found no significant effect. No adverse effects of locoregional anesthesia were found. CONCLUSION: Our study showed that TAP blocks, rectus sheath blocks, and paravertebral blocks may decrease opioid consumption and improve pain scores in patients undergoing open abdominal surgery for gynecologic cancer. Additionally, these techniques might serve as a viable alternative for patients with contraindications to epidural analgesia.
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Neoplasias de los Genitales Femeninos , Dolor Postoperatorio , Humanos , Femenino , Neoplasias de los Genitales Femeninos/cirugía , Dolor Postoperatorio/tratamiento farmacológico , Laparotomía/efectos adversos , Bloqueo Nervioso/métodos , Procedimientos Quirúrgicos Ginecológicos/métodos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Analgesia Epidural/métodosRESUMEN
BACKGROUND: A proportion of patients undergoing midline laparotomy will develop surgical site infections after surgery. These complications place considerable financial burden on healthcare economies and have negative implications for patient health and quality of life. The prophylactic application of negative pressure wound therapy devices has been mooted as a pragmatic strategy to reduce surgical site infections. Nevertheless, further availability of multicentre randomized clinical trial data evaluating the prophylactic use of negative pressure wound therapy following midline laparotomy is warranted to definitely provide consensus in relation to these closure methods, while also deciphering potential differences among subgroups. The aim of this study is to determine whether prophylactic negative pressure wound therapy reduces postoperative wound complications in patients undergoing midline laparotomy. METHODS: PROPEL-2 is a multicentre prospective randomized clinical trial designed to compare standard surgical dressings (control arm) with negative pressure wound therapy dressings (Prevena™ and PICO™ being the most commonly utilized). Patient recruitment will include adult patients aged 18 years or over, who are indicated to undergo emergency or elective laparotomy. To achieve 90% power at the 5% significance level, 1006 patients will be required in each arm, which when allowing for losses to follow-up, 10% will be added to each arm, leaving the total projected sample size to be 2013 patients, who will be recruited across a 36-month enrolment period. CONCLUSION: The PROPEL-2 trial will be the largest independent multicentre randomized clinical trial designed to assess the role of prophylactic negative pressure wound therapy in patients indicated to undergo midline laparotomy. The comparison of standard treatment to two commercially available negative pressure wound therapy devices will help provide consensus on the routine management of laparotomy wounds. Enrolment to PROPEL-2 began in June 2023. Registration number: NCT05977816 (http://www.clinicaltrials.gov).
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Laparotomía , Terapia de Presión Negativa para Heridas , Infección de la Herida Quirúrgica , Adulto , Femenino , Humanos , Masculino , Laparotomía/efectos adversos , Estudios Multicéntricos como Asunto , Terapia de Presión Negativa para Heridas/métodos , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Infección de la Herida Quirúrgica/prevención & control , Cicatrización de HeridasRESUMEN
INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols are an evidence-based, multidisciplinary, and systematic approach to peri-operative care, which attempt to reduce the anticipated physiological strain on patients after major surgery. This meta-analysis of randomised clinical trials (RCTs) evaluated the impact of ERAS following emergency laparotomy versus standard care. METHODS: A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using RevMan v5.4. RESULTS: Six RCTs involving 509 patients were included. Patients randomised to ERAS had reduced post-operative nausea and vomiting (PONV) (odds ratio (OR): 0.32, 95 â% confidence interval (CI): 0.20-0.51), time to ambulation (mean difference (MD): 1.67, 95 â% CI: -2.56 to -0.78) and bowel opening (MD: -1.26, 95 â% CI: -2.03 to -0.49), length of stay (LOS) (MD: -2.92 95 â% CI: -3.73 - - 2.10), pulmonary complications (OR: 0.43, 95 â% CI: 0.24-0.75), surgical site (OR: 0.33 95 â% CI: 0.2-0.50) and urinary tract infections (OR: 0.48 95 â% CI: 0.19-1.16). CONCLUSION: ERAS successfully reduced patient recovery, LOS, and complications. ERAS protocols should be deployed, where feasible, for emergency laparotomy.
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Recuperación Mejorada Después de la Cirugía , Laparotomía , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Laparotomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Tiempo de Internación/estadística & datos numéricos , Urgencias MédicasRESUMEN
INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery. METHODS: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes. RESULTS: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (ß + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001). CONCLUSION: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers. LEVEL OF EVIDENCE: III. STUDY TYPE: Epidemiologic.
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Oclusión con Balón , Hemorragia , Humanos , Masculino , Estudios Retrospectivos , Femenino , Adulto , Oclusión con Balón/métodos , Oclusión con Balón/normas , Oclusión con Balón/estadística & datos numéricos , Persona de Mediana Edad , Hemorragia/etiología , Hemorragia/epidemiología , Resucitación/métodos , Resucitación/estadística & datos numéricos , Resucitación/normas , Tiempo de Tratamiento/estadística & datos numéricos , Tiempo de Tratamiento/normas , Factores de Tiempo , Modelos Logísticos , Puntaje de Gravedad del Traumatismo , Aorta/cirugía , Laparotomía/métodos , Laparotomía/estadística & datos numéricos , Laparotomía/efectos adversosRESUMEN
BACKGROUND: Emergency laparotomy has high morbidity and mortality rates. Frailty assessment remains underutilized in this setting, in part due to time constraints and feasibility. The Clinical Frailty Scale has been identified as the most appropriate tool for frailty assessment in emergency laparotomy patients and is recommended for all older patients undergoing emergency laparotomy. The prognostic impact of measured frailty using the Clinical Frailty Scale on short- and long-term mortality and morbidity rates remains to be determined. METHODS: Observational cohort studies were identified by systematically searching Medline, Embase, Scopus and CENTRAL databases up to February 2024, comparing outcomes following emergency laparotomy for frail and non-frail participants defined according to the Clinical Frailty Scale. The primary outcomes were short- and long-term mortality rates. A random-effects model was created with pooling of effect estimates and a separate narrative synthesis was created. Risk of bias was assessed. RESULTS: Twelve articles comprising 5704 patients were included. Frailty prevalence was 25% in all patients and 32% in older adults (age ≥55 years). Older patients with frailty had a significantly greater risk of postoperative death (30-day mortality rate OR 3.84, 95% c.i. 2.90 to 5.09, 1-year mortality rate OR 3.03, 95% c.i. 2.17 to 4.23). Meta-regression revealed that variations in cut-off values to define frailty did not significantly affect the association with frailty and 30-day mortality rate. Frailty was associated with higher rates of major complications (OR 1.93, 95% c.i. 1.27 to 2.93) and discharge to an increased level of care. CONCLUSION: Frailty is significantly correlated with short- and long-term mortality rates following emergency laparotomy, as well as an adverse morbidity rate and functional outcomes. Identifying frailty using the Clinical Frailty Scale may aid in patient-centred decision-making and implementation of tailored care strategies for these 'high-risk' patients, with the aim of reducing adverse outcomes following emergency laparotomy.
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Fragilidad , Evaluación Geriátrica , Laparotomía , Complicaciones Posoperatorias , Humanos , Fragilidad/complicaciones , Laparotomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Anciano , Anciano Frágil , Urgencias Médicas , Estudios Observacionales como Asunto , Pronóstico , Anciano de 80 o más AñosRESUMEN
INTRODUCTION: Damage-control laparotomy has been widely used in general surgery. However, associated surgical-site infection risks have rarely been investigated. Damage-control laparotomy allows for additional opportunities for decontamination. We hypothesized that damage-control laparotomy would be associated with lower surgical-site infection risks compared with laparotomy with only primary fascial closure or with primary fascial and skin closure. METHODS: Patients admitted for emergent intestinal surgery from 2006 to 2021 were included. Multivariate analyses were performed to identify surgical-site infection-associated risk factors. Although variables like laparotomy type (damage-control laparotomy, primary fascial closure, and primary fascial and skin closure) were provided by National Surgical Quality Improvement Program, other variables such as number of operations were retrospectively collected. P < .05 was considered significant. RESULTS: Overall, 906 patients were included; 213 underwent damage-control laparotomy, 175 primary fascial closure, and 518 primary fascial and skin closure. Superficial, deep, and organ-space surgical-site infection developed in 66, 6, and 97 patients, respectively. Compared with primary fascial and skin closure, both damage-control laparotomy (odds ratio, 0.30 [95% CI, 0.13-0.73], P = .008) and primary fascial closure (odds ratio, 0.09 [95% CI, 0.02-0.37], P = .001) were associated with lower superficial incisional surgical-site infection but not organ-space surgical-site infection risk (odds ratio, 0.80 [95% CI, 0.29-2.19] P = .667 and odds ratio, 0.674 [95% CI, 0.21-2.14], P = .502, respectively). Body mass index was associated with increased risk of superficial incisional surgical-site infection (odds ratio, 1.06 [95% CI, 1.03-1.09], P < .001) whereas frailty was associated with organ space surgical-site infection (odds ratio, 3.28 [95% CI, 1.29-8.36], P = .013). For patients who underwent damage-control laparotomy, the number of operations did not affect risk of either superficial incisional surgical-site infection or organ space SSI. CONCLUSION: Herein, compared with primary fascial and skin closure, both damage-control laparotomy and primary fascial closure were associated with lower superficial but not organ space surgical-site infection risks. For patients who underwent damage-control laparotomy, number of operations did not affect surgical-site infection risks.
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Laparotomía , Infección de la Herida Quirúrgica , Humanos , Femenino , Masculino , Laparotomía/efectos adversos , Laparotomía/métodos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Factores de Riesgo , Intestinos/cirugía , Adulto , Fasciotomía/métodosRESUMEN
BACKGROUND: Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. METHODS: A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. RESULTS: A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'. CONCLUSION: Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.
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Técnica Delphi , Laparotomía , Humanos , Laparotomía/efectos adversos , Complicaciones Posoperatorias/etiología , Consenso , Urgencias Médicas , Evaluación de Resultado en la Atención de SaludRESUMEN
Enterovesical fistula (EVF) in Crohn's disease (CD) often does not improve with medical treatment and requires surgical treatment. The surgical treatment strategy for EVF in CD is definitive resection of the intestinal tract side, and performing a leak test using dye injection into the bladder after EVF dissection to determine the appropriate surgical procedure for the bladder side. This study aimed to evaluate the outcomes of surgical treatment for EVF in CD. Twenty-one patients who underwent surgery for EVF between 2006 and 2021 were included and retrospectively evaluated for clinical background, surgical procedures, and postoperative complications. The most common origin of EVF was the ileum (17 cases; 81%), and the most common site of EVF formation was the apex (12; 57%). Surgical approaches were laparotomy in 11 (52%) cases and laparoscopy in 10 (48%). Surgical procedures on the bladder side were fistula dissection in 13 (62%) cases and sutured closure of fistula in 8 (38%). A comparison of approaches revealed no significant difference in operative time, but the amount of blood loss was significantly less in the laparoscopy (p < 0.01). There was no significant difference in the occurrence of postoperative complications between approaches. Postoperative anti-TNF-α antibody agents were used in 17 (81%) cases, and there were no cases of recurrent EVF. In conclusion, definitive resection of the intestinal tract and minimal treatment on the bladder side were sufficient to achieve satisfactory outcomes for EVF in CD.
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Enfermedad de Crohn , Fístula Intestinal , Fístula de la Vejiga Urinaria , Humanos , Enfermedad de Crohn/cirugía , Enfermedad de Crohn/complicaciones , Masculino , Femenino , Adulto , Fístula Intestinal/cirugía , Fístula Intestinal/etiología , Persona de Mediana Edad , Estudios Retrospectivos , Fístula de la Vejiga Urinaria/cirugía , Fístula de la Vejiga Urinaria/etiología , Resultado del Tratamiento , Complicaciones Posoperatorias , Adulto Joven , Laparoscopía/métodos , Adolescente , Laparotomía/métodos , Laparotomía/efectos adversos , AncianoRESUMEN
BACKGROUND: Patients undergoing emergency laparotomy present with a profound inflammatory response, which could be an independent pathophysiological component in prolonged recovery. The aim of this study was to investigate the effects of a single preoperative high dose of intravenous dexamethasone on the inflammatory response and recovery after emergency laparotomy. METHODS: In this double-blinded placebo-controlled trial, patients were prospectively stratified according to surgical pathology (intestinal obstruction and perforated viscus) and randomized to preoperative 1â mg/kg dexamethasone or placebo at a ratio of 1 : 1. The primary outcome was C-reactive protein on postoperative day 1. Secondary outcomes were postoperative recovery, morbidity, and mortality. RESULTS: A total of 120 patients were included in the trial. On postoperative day 1, the C-reactive protein response was significantly lower in the dexamethasone group (a median of 170 versus 220â mg/l for dexamethasone and for placebo respectively; P = 0.015; mean difference = 49 (95% c.i. 13 to 85)â mg/l) and when stratified according to intestinal obstruction (a median of 60 versus 160â mg/l for dexamethasone and for placebo respectively; P = 0.002) and perforated viscus (a median of 230 versus 285â mg/l for dexamethasone and for placebo respectively; P = 0.035). Dexamethasone administration was associated with improved recovery (better haemodynamics, better pulmonary function, less fatigue, and earlier mobilization). Furthermore, the dexamethasone group had a lower 90-day mortality rate (7% versus 23% for dexamethasone and for placebo respectively; relative risk 0.33 (95% c.i. 0.11 to 0.93); P = 0.023) and a decreased incidence of postoperative major complications (27% versus 45% for dexamethasone and for placebo respectively; relative risk 0.62 (95% c.i. 0.37 to 1.00); P = 0.032). CONCLUSION: A single preoperative high dose of intravenous dexamethasone significantly reduces the inflammatory response after emergency laparotomy and is associated with enhanced recovery and improved outcome. REGISTRATION NUMBER: NCT04791566 (http://www.clinicaltrials.gov).
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Proteína C-Reactiva , Dexametasona , Obstrucción Intestinal , Perforación Intestinal , Laparotomía , Cuidados Preoperatorios , Humanos , Dexametasona/administración & dosificación , Método Doble Ciego , Masculino , Femenino , Persona de Mediana Edad , Laparotomía/efectos adversos , Obstrucción Intestinal/cirugía , Proteína C-Reactiva/metabolismo , Cuidados Preoperatorios/métodos , Estudios Prospectivos , Perforación Intestinal/cirugía , Adulto , Anciano , Urgencias Médicas , Complicaciones Posoperatorias/prevención & control , Resultado del Tratamiento , Antiinflamatorios/administración & dosificaciónRESUMEN
BACKGROUND/AIM: There is lack of studies assessing the correlation between pain scales and acute phase immune response (APR) following surgery. The purpose of this work was to assess the correlation between cysteine protease caspase-1 (Casp1) blood levels and two pain scales in a cohort of 56 midline laparotomy (MLa) patients and to assess their link with other cytokines (CYTs). PATIENTS AND METHODS: Blood levels of Casp1 and other CYTs (IL-18, IL-18BP, IL-1ra, IL-6, IL-8, IL-10, IL-1ß) were measured before operation and following surgery in patients with MLa. Pain levels were assessed using the Numerical Rating Scale (NRS) and Brief Pain Inventory (BPI) scale, both preoperatively and postoperatively. RESULTS: Casp1 blood levels showed an increasing trend at postoperative day 1 (POP1) and this increase was almost significant in a linear mixed effect model (LME) analysis (p=0.06). Additionally, Casp1 blood levels were higher in patients with cancer than those with benign disease and correlated with IL-18 blood levels (r=0.24, p=0.007). Furthermore, Casp1 blood levels correlated with BPIsev (severity) score values in MLa patients (r=-0.49, p=0.048). A significant correlation was also observed between Casp1 blood levels and NRS scores in patients with MLa. CONCLUSION: This is the first report to evaluate two pain surveys (NRS and BPI) in MLa patients in relation to blood levels of Casp1 and eight CYTs. This analysis is important in confirming the significant correlation between NRS and BPI pain scales and Casp1 blood levels. Our study is also the first to demonstrate that adequate postoperative analgesia in patients with MLa provides better functional ability and improved patient satisfaction.
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Caspasa 1 , Laparotomía , Neoplasias , Dimensión del Dolor , Dolor Postoperatorio , Humanos , Femenino , Laparotomía/efectos adversos , Masculino , Caspasa 1/sangre , Persona de Mediana Edad , Estudios Prospectivos , Dimensión del Dolor/métodos , Neoplasias/cirugía , Neoplasias/sangre , Dolor Postoperatorio/sangre , Dolor Postoperatorio/etiología , Anciano , Adulto , Citocinas/sangreRESUMEN
OBJECTIVE: To identify the effects of subcutaneous drain insertion on wound dehiscence and infection in patients who underwent gynecological midline laparotomy. METHODS: This analysis identified the secondary endpoints of the KGOG 4001 study, a prospective, multicenter, non-blind, randomized controlled trial. Patients scheduled to undergo midline laparotomy for gynecological diseases and, with body mass index<35 kg/m2, were randomized (1:1) to treatment (with subcutaneous drain) and control (without subcutaneous drain) groups from February 2021 to December 2021. We compared the incidence rate of wound dehiscence 4 weeks post-surgery and the cumulative incidence rate of wound dehiscence and infection up to 4 weeks post-surgery between the two groups. RESULTS: Of 174 patients randomized to the treatment (n = 84) and control (n = 90) groups, 12 were excluded owing to loss to follow-up; finally, 162 patients (treatment, n = 79; control, n = 83) were included in intention-to-treat analysis. The frequency of cancer surgery (79.7 % vs. 77.1 %, p = 0.683), mean surgery time (227.7 vs. 226.7 min, p = 0.960), and mean wound length (24.2 vs. 24.3 cm, p = 0.933) were comparable between two groups. No significant differences were observed in the incidence rate of wound dehiscence 4 weeks post-surgery (1.3 % vs. 2.4 %, p > 0.999), cumulative incidence rate of wound dehiscence (8.9 % vs. 6.0 %, p = 0.491), and cumulative incidence rate of wound infection (1.3 % vs. 0.0 %, p = 0.488) up to 4 weeks post-surgery between the two groups. CONCLUSION: Subcutaneous drain insertion is not associated with a significant improvement in the incidence of wound dehiscence and infection in patients who undergo gynecological midline laparotomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04643197.
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Drenaje , Laparotomía , Dehiscencia de la Herida Operatoria , Infección de la Herida Quirúrgica , Humanos , Dehiscencia de la Herida Operatoria/epidemiología , Dehiscencia de la Herida Operatoria/etiología , Femenino , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Laparotomía/efectos adversos , Laparotomía/métodos , Drenaje/métodos , Persona de Mediana Edad , República de Corea/epidemiología , Estudios Prospectivos , Adulto , Neoplasias de los Genitales Femeninos/cirugía , Procedimientos Quirúrgicos Ginecológicos/métodos , Incidencia , AncianoRESUMEN
Surgical site infection (SSI) is a common complication after celiotomy in horses, leading to increased morbidity and costs. Increased concern about antibiotic resistance justifies evaluation of alternative preventive approaches, such a Manuka honey which has displayed antimicrobial properties. Pectin-Honey Hydrogels (PHH), composed by Manuka honey and pectin provide a moist wound environment and microbial growth inhibition. The aim of the study was to evaluate the effectiveness of PHHs in preventing SSI in horses subjected to emergency laparotomy. Horses undergoing laparotomy were evaluated. Horses were randomly divided into two groups: Group 1 received PHH application onto the sutured linea alba before skin closure, while Group 2 received no treatment. Horses with postoperative antimicrobial administration or survival of less than 5 days were excluded. The incidence of SSIs was reported as percentages and compared between groups. Out of 44 horses enrolled in the study, only thirty-six were ultimately included. Exclusions occurred either due to death before 5 days postoperatively (2 horses) or the administration of postoperative antimicrobials (6 horses). The median length of hospitalization was 9 days (range 8-14 days). The overall occurrence of SSI was 19.4 %. One out of eighteen horses (5.5 %) in Group 1 and 6 out of 18 (33.3 %) horses in Group 2 developed SSI. Group 2 had an 8.5-fold increased risk of SSI (p = 0.035, OR = 8.5, 95 % CI. 0.9-80.07). No macroscopically visible adverse reactions were associated with PHH. PHH placed at the abdominal incision during surgery was safe and reduced the prevalence of SSI in horses.
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Miel , Enfermedades de los Caballos , Hidrogeles , Laparotomía , Pectinas , Infección de la Herida Quirúrgica , Animales , Caballos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/veterinaria , Infección de la Herida Quirúrgica/epidemiología , Proyectos Piloto , Laparotomía/efectos adversos , Laparotomía/veterinaria , Enfermedades de los Caballos/prevención & control , Enfermedades de los Caballos/cirugía , Hidrogeles/administración & dosificación , Pectinas/administración & dosificación , Masculino , FemeninoRESUMEN
BACKGROUND: The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons' choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis. METHODS: Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis. RESULTS: Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy. CONCLUSIONS: A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.
Asunto(s)
Heces , Peritonitis , Humanos , Femenino , Masculino , Estudios Retrospectivos , Peritonitis/cirugía , Persona de Mediana Edad , Anciano , Suturas , Fuga Anastomótica , Complicaciones Posoperatorias , Factores de Riesgo , Biomarcadores/sangre , Laparotomía/métodos , Laparotomía/efectos adversosRESUMEN
INTRODUCTION: Postoperative Ileus (POI) negatively impacts patient outcomes and increases healthcare costs. Transcutaneous electrical nerve stimulation (TENS) has been found to improve gastrointestinal (GI) motility following abdominal surgery. However, its effectiveness in this context is not well-established. This study was designed to evaluate the role of TENS on the recovery of GI motility after exploratory laparotomy. METHODS: Patients undergoing exploratory laparotomy were randomized in a 1:1 ratio into control (standard treatment alone) and experimental (standard treatment + TENS) arms. TENS was terminated after 6 days or after the passage of stool or stoma movement. The primary outcome was time for the first passage of stool/functioning stoma. Non-passage of stool or nonfunctioning stoma beyond 6 days was labeled as prolonged POI. Patients were monitored until discharge. RESULTS: Median (interquartile range) time to first passage of stool/functioning stoma was 82.6 (49-115) hours in the standard treatment group and 50 (22-70.6) hours in the TENS group [p < 0.001]. Prolonged POI was noted in 11 patients in the standard treatment group (35.5%) and one in the TENS group (3.2%) [p = 0.003]. Postoperative hospital stay was similar in the two groups. CONCLUSION: TENS resulted in early recovery of GI motility by shortening the duration of POI without any improvement in postoperative hospital stay. TRIAL REGISTRATION NUMBER: CTRI/2021/10/037054.
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Motilidad Gastrointestinal , Ileus , Laparotomía , Complicaciones Posoperatorias , Recuperación de la Función , Estimulación Eléctrica Transcutánea del Nervio , Humanos , Estimulación Eléctrica Transcutánea del Nervio/métodos , Femenino , Masculino , Motilidad Gastrointestinal/fisiología , Persona de Mediana Edad , Laparotomía/efectos adversos , Laparotomía/métodos , Anciano , Ileus/etiología , Ileus/terapia , Resultado del Tratamiento , AdultoRESUMEN
Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may jeopardize return to athletic function. Therefore, many techniques have been developed to reduce their occurrence and expedite their resolution when they occur. Our technique of celiotomy incision closure includes the use of tension sutures (vertical U mattress) of polyglactin 910 on the linea alba, which is then apposed by polyglactin 910 interrupted sutures or a simple continuous pattern suture with a stop midway before routine closure of the superficial layers. The celiotomy incision is protected by an elastic bandage during the immediate postoperative period. This technique has been associated with favorable results: 5.3% confirmed incisional infections after a single celiotomy and 26.7% after repeat celiotomy. The overall incisional complication (serous/sanguineous discharge, hematoma, infection, hernia formation, and complete wound breakdown) occurrence was 9.5% and 33.3% after single and repeat laparotomy, respectively. In cases considered more susceptible to infection (early relaparotomy or laparotomy incisions longer than 30 cm), negative pressure therapy was found easy to apply on closed incisions. No detrimental effects were observed. However, the potential prophylactic benefit of this therapy needs to be confirmed in a larger group. In infected laparotomy wounds requiring drainage, the use of negative pressure therapy seemed to have a positive effect on the formation of granulation tissue. However, there was no control group to allow statistical confirmation. Finally, one case of complete breakdown of the laparotomy incision was managed by stainless steel retention sutures, the application of negative pressure therapy, and a hernia belt. At re-evaluation 15 months post-surgery, several small hernias were detected, but the horse had returned to his previous level of sports performance and had not shown any episode of colic.
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Complicaciones Posoperatorias , Animales , Caballos , Complicaciones Posoperatorias/prevención & control , Técnicas de Sutura , Técnicas de Cierre de Herida Abdominal , Enfermedades de los Caballos/cirugía , Enfermedades de los Caballos/prevención & control , Laparotomía/métodos , Laparotomía/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiología , Abdomen/cirugíaRESUMEN
Anesthesia and surgery activate matrix metalloproteinase 9 (MMP9), leading to blood-brain barrier (BBB) disruption and postoperative delirium (POD)-like behavior, especially in the elderly. Aged mice received intraperitoneal injections of either the MMP9 inhibitor SB-3CT, melatonin, or solvent, and underwent laparotomy under 3 % sevoflurane anesthesia(anesthesia/surgery). Behavioral tests were performed 24 h pre- and post-operatively. Serum and cortical tissue levels of interleukin (IL)-1ß, IL-6, and tumor necrosis factor-α (TNF-α) were measured using ELISA. Levels of PDGFRß, MMP9, tight junction, Mfsd2a, caveolin-1, synaptophysin, and postsynaptic densin (PSD)-95 proteins in the prefrontal cortex were assayed using Western blotting. BBB permeability was assessed by detecting IgG in the prefrontal cortex and serum S100ß levels. Anesthesia/surgery-induced peripheral inflammation activated MMP9, which in turn injured pericytes and tight junctions and increased transcytosis, thereby disrupting the BBB. Impaired BBB allowed the migration of peripheral inflammation into the central nervous system (CNS), thereby inducing neuroinflammation, synaptic dysfunction, and POD-like behaviors. However, MMP9 inhibition reduced pericyte and tight junction injury and transcytosis, thereby preserving BBB function and preventing the migration of peripheral inflammation into the CNS, thus attenuating synaptic dysfunction and POD-like behavior. In addition, to further validate the above findings, we showed that melatonin exerted similar effects through inhibition of MMP9. The present study shows that after anesthesia/surgery, inflammatory cytokines upregulation is involved in regulating BBB permeability in aged mice through activation of MMP9, suggesting that MMP9 may be a potential target for the prevention of POD.
Asunto(s)
Barrera Hematoencefálica , Metaloproteinasa 9 de la Matriz , Melatonina , Enfermedades Neuroinflamatorias , Sevoflurano , Animales , Metaloproteinasa 9 de la Matriz/metabolismo , Barrera Hematoencefálica/metabolismo , Barrera Hematoencefálica/efectos de los fármacos , Masculino , Ratones , Sevoflurano/farmacología , Enfermedades Neuroinflamatorias/inmunología , Melatonina/farmacología , Envejecimiento , Ratones Endogámicos C57BL , Corteza Prefrontal/metabolismo , Corteza Prefrontal/efectos de los fármacos , Citocinas/metabolismo , Complicaciones Posoperatorias , Anestesia , Conducta Animal/efectos de los fármacos , Laparotomía/efectos adversos , Uniones Estrechas/metabolismo , Uniones Estrechas/efectos de los fármacos , Compuestos Heterocíclicos con 1 Anillo , SulfonasRESUMEN
OBJECTIVE: To evaluate the efficacy of negative pressure therapy in patients with peritonitis. MATERIAL AND METHODS: The study included 127 patients with advanced secondary peritonitis between 2019 and 2022. All patients were divided into 2 groups. All ones underwent staged sanitation of the abdominal cavity. In the first group (n=76), re-laparotomies were accompanied by skin suture only and passive abdominal drainage. The second group included patients (n=51) with open abdominal cavity strategy and negative pressure therapy (vacuum-assisted laparostomy). We analyzed the number of surgeries, postoperative complications, duration of hospital-stay and mortality. RESULTS: In the second group, there were significantly lower morbidity, mean number of surgeries and hospital-stay. In addition, incidence of fascial closure of abdominal cavity was higher and mortality rate was lower in the same group. CONCLUSION: Vacuum-assisted laparostomy in patients with advanced peritonitis can reduce the number of secondary purulent complications and mortality, as well as increase the incidence of fascial closure of abdominal cavity. This approach reduces the number of surgical interventions and duration of in-hospital treatment.
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Laparotomía , Terapia de Presión Negativa para Heridas , Peritonitis , Complicaciones Posoperatorias , Humanos , Masculino , Femenino , Peritonitis/cirugía , Peritonitis/etiología , Persona de Mediana Edad , Laparotomía/métodos , Laparotomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Terapia de Presión Negativa para Heridas/métodos , Tiempo de Internación/estadística & datos numéricos , Anciano , Cavidad Abdominal/cirugía , Adulto , Resultado del Tratamiento , Drenaje/métodosRESUMEN
OBJECTIVE: To determine the effect of a single intraoperative dose of dexamethasone on the risk of postoperative reflux (POR) in horses undergoing small intestinal surgery and to investigate its association with incisional complications and short-term survival. DESIGN: Retrospective cohort study over an 11-year period (2008-2019). SETTING: UK-based private referral center. ANIMALS: Two hundred and forty client-owned horses >6 months of age undergoing exploratory laparotomy for treatment of a small intestinal lesion. INTERVENTIONS: Ninety-seven horses received a single intraoperative dose of dexamethasone (0.1 mg/kg, IV). MEASUREMENTS AND MAIN RESULTS: Of 97 horses that received dexamethasone, 52 (53.6%) required small intestinal resection. Of 143 horses that did not receive dexamethasone, small intestinal resection was performed in 78 (54.5%). A total of 70 horses (29%) developed POR. There was no difference in the risk of POR between horses that received dexamethasone (25/97; 26%) and those that did not (45/143; 31%, P = 0.34). Risk factors associated with the development of POR included small intestinal resection (odds ratio [OR]: 4.55, 95% confidence interval [CI]: 2.27-9.11, P < 0.001), a PCV >40% 24 hours postoperatively (OR: 4.11, 95% CI: 2-8.45, P < 0.001), and a WBC count >10 × 109/L on admission (OR: 3.29, 95% CI: 1.47-7.41, P = 0.004). Dexamethasone was not associated with the odds of POR. Horses undergoing repeat laparotomy had a higher risk of incisional infection (OR: 8.07, 95% CI: 1.98-32.81, P = 0.004). Dexamethasone administration was not associated with incisional infection. The development of POR was negatively associated with short-term survival (OR: 0.07, 95% CI: 0.03-0.17, P ≤ 0.001). Dexamethasone administration was not retained in the final multivariable model for survival. CONCLUSIONS: Intraoperative dexamethasone was not associated with the development of POR in this study population, nor did it have an effect on postoperative survival or incisional infection in horses undergoing surgical management of small intestinal disease.