The European journal of surgery = Acta chirurgica最新文献

Objective: To find out whether contrast radiography helps to resolve small bowel obstruction.

Design: Prospective randomised trial.

Setting: University hospital, Norway.

Subjects: 98 consecutive patients with symptoms of small bowel obstruction and a plain abdominal radiograph that confirmed the diagnosis.

Interventions: The patients were randomly allocated to receive a mixture of barium and sodium diatrizoate (Gastrografin) (n = 48) or not (n = 50). Both groups were followed up clinically and by repeated abdominal films.

Main outcome measures: Non-operative resolution of small bowel obstruction; number of patients with strangulated bowel; bowel resections; mortality; complications; hospital stay; and time from admission to operation.

Results: No significant differences were observed between the groups in the incidence of non-operative resolution (31/48 in contrast group, 35/50 in control group, OR: 0.89), strangulation obstruction (1/48 in contrast group, 4/50 in control group, OR: 0.24), bowel resection (3/48 in contrast group, 4/50 in control group, OR: 0.76), complications (8/48 in contrast group, 5/50 in control group, OR: 1.80), mortality (3/48 in contrast group, 1/50 in control group, OR: 3.26), and hospital stay (0-7 days: 34/48 in contrast group, 38/50 in control group, p = 0.95). The contrast group had a shorter interval between admission and operation than the control group (0-24 hours: 12/48 in contrast group, 3/50 in control group, p = 0.005).

Conclusion: The contrast examination did not contribute to the resolution of small bowel obstruction.

Objective: To investigate the role of upper gastrointestinal (GI) endoscopy in a surgical intensive care unit [ICU].

Design: Retrospective analysis.

Setting: University hospital, The Netherlands.

Subjects: 87 Male and 42 female patients, mean age 62.0 years (range 14-86).

Interventions: 198 Upper GI endoscopies.

Main outcome measures: Incidence of, indication for, and abnormalities noted at upper GI endoscopy.

Results: 52 (40%) and 18 (14%) patients underwent 82 and 27 upper GI endoscopies, respectively, for evaluation of upper GI haemorrhage and surgical anastomoses. 59 Patients (46%) underwent 89 endoscopies for placement of nasoduodenal feeding tubes (n = 86, 97%), biliary stents (n = 2, 2%) and gastrostomy cathether (n = 1, 1%). The causes of haemorrhage were: oesophagitis (n = 13, 25%), duodenal ulcer (n = 13, 25%), gastric ulcer (n = 7, 13%) and others (n = 14, 28%). In 6 cases (11%), no bleeding site was detected. As a coincidental finding, a third of all patients had oesophagitis. The incidence of haemorrhage in patients treated and not treated by mechanical ventilation was 43/1350 (3.2%) and 9/1470 (0.6%), respectively (p < 0.0001).

Conclusions: Upper GI endoscopy is a common diagnostic and therapeutic procedure in a surgical ICU. Reflux oesphagitis is often found and is clinically important. Mechanical ventilation is a risk factor for upper GI haemorrhage.

Objective: To assess the effect of intraperitoneal gallstones with and without Escherichia coli and sterile bile on the incidence of intraperitoneal complications in mice.

Design: Prospective randomised study.

Setting: Teaching hospital, Turkey.

Material: 180 Swiss albino mice in five groups, n = 20 in the control group, and n = 40 in each of the experimental groups.

Interventions: Group A laparotomy alone (controls); group B, laparotomy amd intraperitoneal instillation of E. coli 4 x 10(6) 0.1 ml; group C, laparotomy and insertion of sterilised gallstones; group D, laparotomy, insertion of gallstones and instillation of E. coli 4 x 10(6) 0.1 ml; and group E, laparotomy, insertion of gallstones, and instillation of E. coli 4 x 10(6) 0.1 ml and sterile bile 0.1 ml. A quarter of each group was killed after 1, 2, 4, and 8 weeks.

Main outcome measures: Intra-peritoneal abscesses, adhesions, perforations, fistula, or obstruction.

Results: No mice died. Adhesions were found in 3(15%), 7(18%), 30(75%), 25(63%), and 24(60%) in the five groups, respectively. No mice in groups A, B, or C developed an abscess, but 8 did in each of groups D and E (20%). One mouse in group D developed obstruction. Logistic regression showed that abscess formation was significantly increased by the addition of gallstones and E. coli to the peritoneal cavity (p < 0.001) but the addition of bile had no effect. Gallstones increased the rate of adhesions more than nine fold (p < 0.001) but E. coli with or without bile had no effect (p = 0.75).

Conclusions: Free gallstones within the peritoneal cavity with or without E. coli or sterile bile, or both, increased the rate of formation of both abscesses and adhesions in mice. These results suggest that efforts should be made retrieve gallstones that are dropped into the peritoneal cavity during laparoscopic cholecystectomy, particularly in patients with acute cholecystitis.

Objective: To compare serum phospholipase A2 activity with measurements of conventional enzymes as an indicator of the severity of acute pancreatitis.

Design: Prospective study.

Setting: University hospital, Finland.

Subjects: 80 Consecutive patients with acute pancreatitis.

Interventions: Serum and urine samples were taken daily for a week after admission.

Main outcome measures: Serum phospholipase A2, amylase, lipase, and urinary amylase activities.

Results: On admission, the serum amylase and lipase activities increased in parallel in all patients. However, the mean serum phospholipase A2 activity was three times higher in the patients with acute fulminant pancreatitis than in those with milder disease. The phospholipase A2 activity remained high during the course of the severe disease, whereas the other enzyme activities decreased appreciably during the first week. In contrast to the other enzyme activities that of serum phospholipase A2 correlated well with the severity of the acute pancreatitis. Heating at 60 degrees C for 45 minutes to inactivate the non-pancreatic thermolabile phospholipase A2 reduced the total serum phospholipase A2 activity more than the enzyme activity in the homogenates of pancreatic tissue, which suggests that extrapancreatic phospholipase A2 is present in serum. The receiver operating characteristic (ROC) curves confirmed the high sensitivity and specificity of serum phospholipase A2 activity with a mean (SEM) area under the curve up to 0.870 (0.062) compared with the other enzyme activities of which the highest area under the curve was 0.52 (0.089).

Conclusions: In contrast to amylase and lipase activities, measurement of serum phospholipase A2 activity is important in the assessment of the severity of acute pancreatitis so that optimal treatment may be given.

Objective: To compare early and late results and costs of outpatient haemorrhoidectomy under local anaesthesia with those of inpatient haemorrhoidectomy.

Design: Prospective study with historical controls.

Setting: University hospital, Brazil.

Subjects: 51 patients who required haemorrhoidectomy.

Interventions: Outpatient haemorrhoidectomy under local anaesthesia.

Main outcome measures: Early and late results and comparative costs.

Results: One patient was withdrawn from the study because of hypertension and subsequently lost to follow-up. The remaining 50 patients were discharged a mean of 68 (23) minutes after operation. Twelve patients complained of severe pain, one had faecal impaction and 2 developed bleeding. One patient developed urinary retention, compared with 18 in the historical group (p < 0.001). Forty-two patients (84%) were thoroughly satisfied with their treatment. Late complications did not differ significantly from those observed in the historical group. The estimated hospital costs were US$ 313.6 for outpatient, and US$ 716 for inpatient treatment.

Conclusion: Outpatient haemorrhoidectomy under local anaesthesia was safe and comfortable for most patients, with complication rates comparable to or better than those observed after inpatient treatment and at less than half the cost.