The alcohol patient and surgery

Alcohol abusers have a threefold increased risk of post-operative morbidity after surgery. The most frequent complications are infections, cardiopulmonary insufficiency, and bleeding episodes. Pathogenesis is suppressed immune capacity, subclinical cardiac dysfunction, and haemostatic imbalance. The economic implications of alcohol abuse in surgical patients are tremendous. Interventional studies are required to reduce future increases in post-operative morbidity.

Observer variation in the assessment of the histopathologic diagnosis of acute appendicitis

BACKGROUND

The objectives of this study were to determine observer variation in the assessment of the histopathologic diagnosis of acute appendicitis.

METHODS

Two consultant pathologists independently evaluated 415 appendectomy specimens (set I). After a consensus conference at which the observers unified the criteria of the diagnosis of acute appendicitis, another 396 appendectomy specimens (set II) were evaluated. To calculate the intra-observer variation, one observer evaluated set II once more. Finally, using the consensus diagnosis as the final diagnosis, the diagnostic accuracy of the surgeon, the primary pathology report, and the two observer evaluations was calculated.

RESULTS

In set I no difference was found in the level of agreement on the diagnosis of acute appendicitis versus other diagnoses, and a kappa value of 0.85 was obtained. In set II a kappa value of 0.88 was obtained, which was not significantly different from the kappa value in set I. However, the consensus conference did increase the level of agreement on the diagnosis of acute appendicitis. The intra-observer variation was calculated, and a kappa value of 0.88 was obtained. The cases in which the observers disagreed on a positive diagnosis were cases of mild appendicitis. The question remains how many specimens would have shown these changes if all tissue had been developed for microscopy. The observers' diagnoses were the most reliable, and there was a significant decrease in the diagnostic accuracy compared with both the primary pathology report and the surgeon's opinion, the last one being the least accurate.

CONCLUSIONS

These observations stress how important it is for the pathologist to discuss the diagnostic criteria of the diagnosis of acute appendicitis and for the surgeon to go back to the patient's record and look up the histopathologic diagnosis.

[Munchausen syndrome]

The case of 43 year old man who had numerous contacts with the health care system is reported. Since 1984 he had been treated 95 times for testicular problems at 45 different hospitals including 36 operations for torsion. Computer record systems had only once stopped the patient from going through another unnecessary operation. An alarm in the computer record system with reference to a contact place could make it easier to spot a patient with diagnosed Münchhausen's syndrome and give him treatment.

Population based cohort study of the association between alcohol intake and cancer of the upper digestive tract

OBJECTIVE

To examine the relation between different types of alcoholic drinks and upper digestive tract cancers (oropharyngeal and oesophageal).

DESIGN

Population based study with baseline assessment of intake of beer, wine, and spirits, smoking habits, educational level, and 2-19 years' follow up on risk of upper digestive tract cancer.

SETTING

Denmark.

SUBJECTS

15 117 men and 13 063 women aged 20 to 98 years.

MAIN OUTCOME MEASURE

Number and time of identification of incident upper digestive tract cancer during follow up.

RESULTS

During a mean follow up of 13.5 years, 156 subjects developed upper digestive tract cancer. Compared with non-drinkers (drinkers of <1 drink/week), subjects who drank 7-21 beers or spirits a week but no wine were at a risk of 3.0 (95% confidence interval 1.5 to 6.1), whereas those who had the same total alcohol intake but with wine as >=30% of their intake had a risk of 0.5 (0.2 to 1.4). Drinkers of >21 beers and spirits but no wine had a relative risk of 5.2 (2.7 to 10.2) compared with non-drinkers, whereas those who drank the same amount, but included wine in their alcohol intake, had a relative risk of 1.7 (0.6 to 4. 4).

CONCLUSION

A moderate intake of wine probably does not increase the risk of upper digestive tract cancer, whereas a moderate intake of beer or spirits increases the risk considerably.

Alcohol drinking, social class and cancer

This chapter reviews the data on occurrence of cancers that are potentially caused by alcohol drinking (cancers of the upper gastrointestinal and respiratory tracts, and liver cancer) in relation to social class. In order to assess the role of alcohol drinking in the observed social class gradients of these cancers, we have particularly looked for consistency in the gradients of different alcohol-related cancers, and used lung cancer occurrence to judge the role of tobacco smoking, which is the major other determinant of these diseases. Additional data on levels of alcohol drinking and on the occurrence of other alcohol-related morbidity are brought into the discussion where available. A role of alcohol drinking in the observed negative social class gradients for alcohol-related cancers is very likely in men in France, Italy and New Zealand. Evidence that is less strong, but is suggestive of a role of alcohol drinking, is seen for men in Brazil, Switzerland, the United Kingdom and Denmark. Although a role of alcohol drinking is likely or possible in certain populations, other factors may contribute as well, most notably tobacco smoking and dietary habits. Additional data on the frequency of complications after surgical procedures in alcohol drinkers are reviewed briefly.

Intestinal obstruction after appendectomy

BACKGROUND

The frequency of intestinal obstruction varies in the literature (0.2-10.7%) and requires evaluation in a proper design.

METHODS

From 1978 to 1985, 1951 patients underwent appendectomy; 58 patients were excluded because of appendectomy per occasionem, 156 because of previous laparotomy, and 190 because of simultaneous major surgery. Three foreigners were lost to follow-up. The cohort was linked to the Danish National Inpatient Register for identification of cases, defined by intestinal obstruction requiring surgical intervention.

RESULTS

The follow-up period was long (median, 3563 days; range, 2-5113). Twenty-one patients developed intestinal obstruction. The cumulated incidence was 0.33% after 30 days, 0.79% after 1 year, and 1.51% after 14 years. Female sex as compared with male sex (RR = 3.91; 95% confidence limits (CL), 1.25-12.0) and removal of a removal of a normal appendix as compared with an inflamed appendix (RR = 4.0; 95% CL, 1.28-12.5) carried a significantly higher risk of intestinal obstruction.

CONCLUSION

Intestinal obstruction after open appendectomy is rare.

[Thromboembolic complications after ambulatory herniotomy]

Thromboembolism is a serious complication of surgery and prophylaxis is therefore recommended. This study examines a new aspect of the problem, the incidence of thromboembolism after day-case surgery. From 1982 to 1992, 2281 patients underwent day-case repair for inguinal hernia management. Hospital admission for thromboembolism within the first 30 days after surgery was identified by computer linkage to the National In-Patient register, which contains details of all hospital admissions in Denmark. One patient developed non-fatal pulmonary embolism. No other patients were admitted to hospital with venous thromboembolism within 30 days of herniorrhaphy. It is concluded that there is no need for routine prophylaxis for thromboembolism in day-case hernia surgery.

Postoperative thromboembolism after day-case herniorrhaphy

Thromboembolism is a serious complication of surgery and prophylaxis is therefore recommended. This study examines a new aspect of the problem, the incidence of thromboembolism after day-case surgery. From 1982 to 1992, 2281 patients underwent day-case repair for inguinal hernia management. Hospital admission for thromboembolism within the first 30 days after surgery was identified by computer linkage to the National In-Patient Register, which contains details of all hospital admissions in Denmark. One patient developed non-fatal pulmonary embolism. No other patients were admitted to hospital with venous thromboembolism within 30 days of herniorrhaphy. It is concluded that there is no need for routine prophylaxis for thromboembolism in day-case hernia surgery.

[Cancer morbidity among alcoholics]

Data on the association between alcohol abuse and cancer morbidity are scarce in large cohorts of non-hospitalized alcoholic men an women. Of 18,368 alcohol abusers who entered an out-patient clinic in Copenhagen between 1954-1987, 18,307 were followed. Their cancer incidence was compared to that of the total Danish population. The overall morbidity of cancer was significantly increased among alcohol abusers. The men developed 1441 cancer cases (RR = 1.6), and the women 182 cases (RR = 1.5). Significantly increased incidences were found for cancer of the tongue, mouth, pharynx, oesophagus, liver, larynx, lung, pleura, and secondary cancer. The women had a significantly increased risk of cervical cancer (RR = 2.0). The men developed prostatic cancer significantly more frequently than expected (RR = 1.4). The relative risks of cancer of the stomach, pancreas, kidney and endocrine system were only slightly increased. The risk of breast cancer in women was not significantly increased (RR = 1.3).

Cancer morbidity in alcohol abusers

Data on the association between alcohol abuse and cancer morbidity are scarce in large cohorts of non-hospitalised alcoholic men and women. Of 18,368 alcohol abusers who entered an outpatient clinic in Copenhagen during 1954-87, 18,307 were followed and their cancer incidence was compared with that of the total Danish population. On average the 15,214 men were observed for 12.9 years and the 3,093 women for 9.4 years. The overall morbidity of cancer was increased significantly. Of the men, 1,441 developed cancer [relative risk (RR) = 1.6; 95% confidence interval (CI) = 1.5-1.7], while 182 women did (RR = 1.5; 95% CI 1.3-1.8). Significantly increased incidences were found of cancer in the tongue, mouth, pharynx, oesophagus, liver, larynx, lung and pleura and secondary cancer. The women had significantly increased risk of cervical cancer (RR = 2.0; 95% CI 1.2-3.0). The men developed prostatic cancer significantly more frequently than expected (RR = 1.4; 95% CI 1.2-1.8). The risk of melanomas (RR = 0.5; 95% CI 0.2-0.8) was significantly lower than expected. The relative risks of cancer of the stomach, pancreas, kidney and endocrine system were only slightly increased. The study group did not develop more colonic (RR = 1.0; 95% CI 0.8-1.3) or rectal cancer (RR = 1.0; CI 0.7-1.3) than expected. The risk of breast cancer in women was slightly increased (RR = 1.3; 95% CI 0.9-1.7), but not statistically significant. Thus, the associations between alcohol and cancer of the upper digestive and respiratory tract and the liver are confirmed. In addition, this study indicates an increased occurrence of cancer of the prostate gland, pleura and uterine cervix in alcohol abusers.

[Alcohol-induced immunosuppression is reversible]

The aim of the study was to investigate to which degree and how fast cellular immunodepression may be reversed after cessation of alcohol intake. Delayed hypersensitivity was investigated in ten severe alcoholics and in seven moderate consumers. A group of eight previous drinkers was tested for comparison. The skin test responses were modest initially with a median area of response of 12 mm2 in the heavy alcoholics, and three mm2 in the moderate consumers. It improved significantly after two weeks of sobriety. The responses stabilized after eight to nine weeks at 63-74 mm2, corresponding to the response of 70 mm2 in the group of previous drinkers.

[Course after surgery of subdural hematoma in alcohol abusers]

The postoperative course and final outcome after evacuation of subdural haematoma are described in 106 male patients in relation to their alcohol consumption. One-third of the patients were alcohol abusers, drinking at least 60 g of ethanol daily. Despite comparable head trauma, they had a significantly higher incidence of acute subdural haematomas and showed increased postoperative morbidity and mortality compared to the non-alcoholics. The postoperative hospitalization costs were initially higher and the final outcome was significantly worse for the alcohol abusers.

[Postoperative morbidity after hysterectomy is related to alcohol consumption]

Postoperative morbidity after hysterectomy was studied prospectively in 229 consecutive patients in our departments. The incidence of alcohol abuse (> or = 60 gm of alcohol daily) and moderate drinking (between 25 and 60 gm of alcohol daily) was 6.5% for each. When compared with the moderate drinkers and the control group, the alcohol abusers developed significantly more complications (80% versus 27% and 80% versus 13% respectively). Preoperative history of alcohol consumption may define a group of patients at particular risk for increased postoperative morbidity.

[Postoperative morbidity among alcohol abusers]

Retrospective studies suggest increased postoperative morbidity among alcohol misusers. We have prospectively studied the risk associated with alcohol intake among patients undergoing surgery. We investigated 15 persons who required colorectal surgery and who were drinking at least five Danish drinks per day. These patients were matched for sex, nutrition, age, weight, cardio-pulmonary disease, diagnosis anesthesia, and surgery to 15 control persons who were consuming no more than two drinks daily. None of the patients showed signs of liver disease. The alcohol group developed more postoperative complications than controls (67 vs 20%, p < 0.05) and hospital stay was prolonged (20 vs 12 days, p < 0.05). Preoperatively, alcohol misusers had reduced left ventricular ejection fraction (54 vs 68%, p < 0.01). Delayed-type hypersensitivity responses were reduced in the alcohol group before (53 mm2 vs 78, p < 0.05) and after (18 mm2 vs 55, p < 0.01) surgery. Alcohol misusers had significantly longer bleeding times. Surgical stress responses, as assessed by changes in plasma cortisol and catecholamines, were higher among alcohol misusers (p < 0.05). Postoperative morbidity was increased in alcohol misusers without signs of liver damage. The mechanisms may include subclinical cardiac insufficiency, immunosuppression, and decreased haemostatic function. Preoperative alcohol consumption may be a more important risk factor for postoperative morbidity than previously thought.

Postoperative morbidity among symptom-free alcohol misusers

Retrospective studies suggest that there is an increased postoperative morbidity among alcohol misusers. We have prospectively studied the risk of alcohol intake among patients undergoing surgery. We investigated 15 symptom-free subjects who required colorectal surgery and who were drinking at least 60 g of alcohol per day. These patients were matched for sex, nutrition, age, weight, cardiovascular and pulmonary disease, diagnosis, anaesthesia, and surgery to 15 control subjects who were consuming below 25 g of alcohol daily. Those drinking at least 60 g of alcohol per day developed more postoperative complications than controls (67% vs 20%, p less than 0.05) and hospital stay was prolonged (20 vs 12 days, p less than 0.05). Preoperatively, alcohol misusers had reduced left ventricular ejection fraction (median, 54% vs 68%, p less than 0.01). Delayed hypersensitivity responses were smaller in the alcohol group before (53 mm2 vs 78 mm2, p less than 0.05) and after (18 mm2 vs 55 mm2, p less than 0.01) surgery. Alcohol misusers had longer bleeding times during the first postoperative week (p less than 0.01). Surgical stress responses, as assessed by changes in plasma cortisol and catecholamines, were higher among alcoholics (p less than 0.05). Postoperative morbidity is increased in symptom-free alcohol misusers. The mechanism is probably subclinical cardiac insufficiency, immunosuppression, and decreased haemostatic function. Preoperative alcohol consumption may be a more important risk factor than previously thought.

Reversibility of alcohol-induced immune depression

Alcohol abusers have suppressed cellular immune function. The aim of the study was to investigate the time of sobriety required to normalize immune function. Delayed hypersensitivity was investigated during disulfiram controlled abstinence in ten heavy alcoholics and in seven moderate drinkers without liver diseases. For comparison a control group of eight previous drinkers was tested. The skin test responses were modest initially with a median area of response of 12 mm2 (range 0-31) in the heavy alcoholics and 3 mm2 (0-15) in the moderate drinkers. It improved significantly in both groups after two weeks of sobriety. The responses stabilized after 8 weeks at 74 mm2 (54-102) in the heavy alcoholics and after 9 weeks at 63 mm2 (42-76) in the moderate drinking group. The control group had skin test responses of 70 mm2 (46-87), not different from the responses of the alcohol groups after two months of abstinence. The results suggest that while 2 weeks of abstinence from alcohol will improve the depressed cellular immunity, 2 months of sobriety is necessary to normalize it.

Influence of alcohol intake on postoperative morbidity after hysterectomy

Postoperative morbidity after hysterectomy was prospectively studied in 229 consecutive patients in our departments. The incidence of alcohol abuse (greater than 60 gm of alcohol daily) and social drinking (between 25 and 60 gm of alcohol daily) was 6.5% for each. When compared with the social drinkers and the control group, the alcohol abuse group had significantly more complications (80% vs 27% and 80% vs 13%, respectively).

The influence of alcoholism on outcome after evacuation of subdural haematoma

The postoperative course and final outcome after evacuation of subdural haematoma are described in 106 male patients in relation to their alcohol consumption. One-third of the patients were alcohol abusers, drinking at least 60 g of ethanol daily. Despite comparable head trauma, they had a significantly higher incidence of acute subdural haematomas and showed increased postoperative morbidity and mortality compared to the non-alcoholics. The postoperative hospitalization costs were initially higher and the final outcome was significantly worse for the alcohol abusers.

Ankle fractures and alcoholism. The influence of alcoholism on morbidity after malleolar fractures

The postoperative morbidity after osteosynthesis of malleolar fractures was investigated retrospectively by comparing 90 alcohol abusers with 90 controls. The two groups were selected from 626 male patients and were matched regarding trauma, treatment for cardiovascular, pulmonary and endocrine diseases, age, weight, smoking habits, anaesthesia and duration of surgery. The alcohol abusers developed significantly more early complications, especially infections, after surgery. Follow-up at six, nine and 12 weeks after surgery also revealed a significantly higher morbidity among the alcoholics.

Lymphopenia in heavy drinkers--reversibility and relation to the duration of drinking episodes

Seventy-four addictive alcoholic subjects were investigated shortly after a period of excessive drinking and were compared with 18 alcoholic subjects who had not been drinking for at least six months. No difference was observed in total white cell count or number of circulating granulocytes. Lymphocyte count was significantly lower in alcoholics whose last alcoholic bout had been three months or more, but after 30 days of abstinence the difference had disappeared. The depressed lymphocyte count did not correlate with other components of the drinking pattern. These results show that lymphopenia in alcoholics is a time-dependent and reversible event.

Menstrual disturbances and fertility in chronic alcoholic women

Data on menstrual pattern, gynecological disorders and infertility were obtained from 51 chronic alcoholic women aged 20--42 years attending an outpatient clinic for alcoholics, using 51 randomly drawn age-matched healthy women as controls. A higher variability (P less than 0.05) in the duration of both menstrual cycle and menstrual flow was recorded in the chronic alcoholic women during active alcoholism. A higher frequency (P less than 0.05) of menstrual disturbances (70% vs. 55%) and uterine curettages (38% vs. 16%) were found in the alcoholic women. The latter reported more abortions (63% vs. 28%, P less than 0.001) and miscarriages (23% vs. 8%, P less than 0.05) than controls, but due to a higher number of pregnancies in the alcoholic group the proportion of abortions and miscarriages did not differ significantly. No differences existed between the groups regarding frequency of difficult conception. Social classification had no independent influence on the results. The study shows that chronic alcoholic women are more prone to menstrual abnormalities and are at greater risk of gynecological interventions, while they do not seem to have reduced fertility.

[Cimetidine treatment of stomach cancer]

The effect of cimetidine treatment in cancer of the stomach was investigated in a double-blind, multicentre study comprising eight departments in Greater Copenhagen. Immediately after operation (or the decision not to operate) 181 patients were subdivided at random to treatment with a placebo or cimetidine in a dosage of 400 mg twice daily for two years or until death. Compliance control was carried out every third month. The mean survival in the cimetidine group (450 days, 1-1,826) was significantly longer (p = 0.02) than in the placebo group (316 days, 1-1,653).

Effect of cimetidine on survival after gastric cancer

The effect of cimetidine on survival was investigated in 181 patients with gastric cancer. Immediately after operation or the decision not to operate, the patients were randomised in double-blind fashion to placebo or cimetidine 400 mg twice daily for two years or until death, with review every three months. Median survival in the cimetidine group was 450 days (range 1-1826) and in the placebo group 316 days (1-1653). The relative survival rates (cimetidine/placebo) were 45%/28% at 1 year, 22%/13% at 2 years, 13%/7% at 3 years, 9%/3% at 4 years, and 2%/0% at 5 years. Survival in the cimetidine group was significantly longer than in the placebo group.

Perforated gastric ulcer

A retrospective study is presented of 297 patients operated upon for perforated benign gastric ulcer in Denmark from 1975 to 1984. Male:female ratio was 0.9:1, mean age 64.2 years. The numbers of gastric and prepyloric perforations were almost equal (156:141), but gastric perforations were more frequent in elderly women and prepyloric perforations in younger men. Simple closure was performed in 83 per cent of the patients, gastric resection in 14 per cent and simple closure and vagotomy in 3 per cent. The postoperative mortality rate was 21 per cent and was related to the high proportion of elderly patients with concurrent diseases and delayed treatment.

Gastrocolic fistulas

Sixteen patients were treated for gastrocolic fistula arising as a complication of peptic ulcer (11 cases), colonic perforation (2), gastric cancer (1), colonic cancer (1) or pancreatitis (1). The predominant symptoms were diarrhoea, weight loss and abdominal pain. Barium meal and barium enema were the most reliable means of diagnosis, and no fistula was gastroscopically demonstrable. A one-stage en bloc resection of the involved gastrocolic region was performed in eight cases. Other operations were simple excision (3), gastric resection with closure of the colonic wall (2) and colectomy with closure of the gastric wall (2). In one case cure was achieved with cimetidine, without surgical intervention. Four patients died postoperatively and two had recurrence of fistula.