Peritoneal damage: the inflammatory response and clinical implications of the neuro-immuno-humoral axis. World J Surg. 2010;34:704-720. [PMID: 20049432 DOI: 10.1007/s00268-009-0382-y]

The impact of timing, type, and method of instillation of intraperitoneal local anaesthetic in laparoscopic abdominal surgery: a systematic review and network meta-analysis

BACKGROUND

Pain is common after laparoscopic abdominal surgery. Intraperitoneal local anaesthetic (IPLA) is effective in reducing pain and opioid use after laparoscopic surgery, although the optimum type, timing, and method of administration remains uncertain. We aimed to determine the optimal approach for delivering IPLA which minimises opioid consumption and pain after laparoscopic abdominal surgery.

METHODS

MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for randomised controlled trials comparing different combinations of the type (bupivacaine vs lidocaine vs levobupivacaine vs ropivacaine), timing (pre-vs post-pneumoperitoneum at the beginning or end of surgery), and method (aerosol vs liquid) of IPLA instillation in patients undergoing any laparoscopic abdominal surgery. A network meta-analysis was conducted to ascertain the optimum approach for delivering IPLA resulting in the least cumulative opioid consumption and pain (overall and localising to the shoulder) 24 h after surgery. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessments (PROSPERO ID: CRD42022307595).

RESULTS

Twenty-five RCTs were included, among which 15 different combinations of delivering IPLA were analysed across 2401 participants. Aerosolised bupivacaine instilled at the end of surgery, before deflation of the pneumoperitoneum, was associated with significantly less postoperative opioid consumption compared with all other approaches for delivering IPLA (98.7% of comparisons; moderate certainty), aside from liquid levobupivacaine instilled before surgery and during or after creation of the pneumoperitoneum (mean difference -11.6, 95% credible interval: -26.1 to 2.5 i.v. morphine equivalent doses). There were no significant differences between different IPLA approaches regarding overall pain scores and incidence of shoulder pain up to 24 h after surgery.

CONCLUSIONS

There are limited studies and low-quality evidence to conclude on the optimum method of delivering IPLA in laparoscopic abdominal surgery. While aerosolised bupivacaine instilled at the end of surgery but before deflation of the pneumoperitoneum minimises postoperative opioid consumption, pain scores up to 24 h did not differ between the different modalities of delivering IPLA. The generalisability of these results is limited by the lack of utilisation of non-opioid analgesics in most trials.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42022307595.

Oral Administration Evaluation of the Hydro-Ethanolic Extract of Ginger (Rhizome of Zingiber officinale) against Postoperative-Induced Peritoneal Adhesion: Investigating the Role of Anti-Inflammatory and Antioxidative Effects

Peritoneal adhesions (PAs) occur and develop after abdominal surgery. Abdominal adhesions are common and often develop after abdominal surgery. Currently, there are no effective targeted pharmacotherapies for treating adhesive disease. In this regard, ginger is wildly used in traditional medicine because of its anti-inflammatory and antioxidant effects and has been investigated for peritoneal adhesion treatment. This study analyzed ginger ethanolic extraction via HPLC to have a 6-gingerol concentration. Four groups induced peritoneal adhesion to evaluate ginger's effects on peritoneal adhesion. Then, ginger extract (50, 150, and 450 mg/kg) was administered by gavage in various groups of male Wistar rats (220 ± 20 g, 6-8 weeks). After scarifying the animals for biological assessment, macroscopic and microscopic parameters were determined via scoring systems and immunoassays in the peritoneal lavage fluid. Next, the adhesion scores and interleukin IL-6, IL-10, tumor necrosis factor-(TNF-) α, transforming growth factor-(TGF-) β1, vascular endothelial growth factor (VEGF), and malondialdehyde (MDA) were elevated in the control group. The results showed that ginger extract (450 mg/kg) notably decreased inflammatory (IL-6 and TNF-α), fibrosis (TGF-β1), anti-inflammatory cytokine (IL-10), angiogenesis (VEGF), and oxidative (MDA) factors, while increased antioxidant factor glutathione (GSH), compared to the control group. These findings suggest that a hydro-alcoholic extract of ginger is a potentially novel therapeutic strategy for inhibiting adhesion formation. Also, it might be considered a beneficial anti-inflammatory or antifibrosis herbal medicine in clinical trials. However, further clinical studies are required to approve the effectiveness of ginger.

Activating SIRT3 in peritoneal mesothelial cells alleviates postsurgical peritoneal adhesion formation by decreasing oxidative stress and inhibiting the NLRP3 inflammasome

Peritoneal adhesions (PAs) are a serious complication of abdominal surgery and negatively affect the quality of life of millions of people worldwide. However, a clear molecular mechanism and a standard therapeutic strategy for PAs have not been established. Here, we developed a standardized method to mimic the pathological changes in PAs and found that sirtuin 3 (SIRT3) expression was severely decreased in adhesion tissues, which was consistent with our bioinformatics analysis and patient adhesion tissue analysis. Thus, we hypothesized that activating SIRT3 could alleviate postsurgical PAs. Sirt3-deficient (Sirt3^−/−) mice exhibited many more PAs after standardized abdominal surgery. Furthermore, compared with wild-type (Sirt3^+/+) mice, Sirt3-deficient (Sirt3^−/−) mice showed more prominent reactive oxygen species (ROS) accumulation, increased levels of inflammatory factors, and exacerbated mitochondrial damage and fragmentation. In addition, we observed NLRP3 inflammasome activation in the adhesion tissues of Sirt3^−/− but, not Sirt3^+/+ mice. Furthermore, mesothelial cells sorted from Sirt3^−/− mice exhibited impaired mitochondrial bioenergetics and redox homeostasis. Honokiol (HKL), a natural compound found in several species of the genus Magnolia, could activate SIRT3 in vitro. Then, we demonstrated that treatment with HKL could reduce oxidative stress and the levels of inflammatory factors and suppress NLRP3 activation in vivo, reducing the occurrence of postsurgical PAs. In vitro treatment with HKL also restored mitochondrial bioenergetics and promoted mesothelial cell viability under oxidative stress conditions. Taken together, our findings show that the rescue of SIRT3 by HKL may be a new therapeutic strategy to alleviate and block postsurgical PA formation.

Treatment with honokiol, a compound found in magnolia tree bark, significantly reduces formation of internal scar tissue after abdominal surgery in mice. Healing of incisions in the peritoneum, the connective tissue lining the abdomen, can result in scar tissue bonds known as peritoneal adhesions (PA), causing complications such as infertility or bowel obstructions. The mechanism of PA formation is unknown, and no therapies are available. Xuqi Li at The First Affiliated Hospital of Xi’an Jiaotong University, China, and co-workers found that PA tissues in both mice and human patients had decreased levels of SIRT3, a stress-response protein. Mice lacking SIRT3 showed increased inflammation and PA formation. When mice were treated with honokiol the day after surgery in order to boost SIRT3 levels, PA formation was significantly decreased. These results suggest a possible preventative treatment for post-surgical PAs.

Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis

Background

This study examined whether drain placement or not is associated with the postoperative outcomes of pediatric patients following trans-umbilical single-port laparoscopic appendectomy (TUSPLA) for complicated appendicitis.

Methods

The medical records of pediatric patients undergoing TUSPLA for acute complicated appendicitis from January 2012 to September 2018 in Kaohsiung Chang Gung Memorial Hospital were reviewed retrospectively. They were classified according to whether they received passive drainage with a Penrose drain (Penrose group) (19), active drainage with a Jackson-Pratt drain with a vacuum bulb (JP group) (16), or no drain (non-drain group) (86). The postoperative outcomes of the three groups were compared.

Results

Postoperative visual analog scale pain score was significantly higher in the non-drain group than in either the JP group or Penrose group. Patients in the Penrose group had a significantly longer postoperative hospital stay than those in the non-drain group and a higher rate of intra-abdominal abscess, while patients in the JP group had a significantly shorter postoperative hospital stay; moreover, no patient in JP group developed a postoperative intra-abdominal abscess.

Conclusions

Compared to passive drainage with a Penrose drain or no drain, active drainage with a JP drain shorter the postoperative hospital stay and decreased the risk of postoperative intra-abdominal abscess.

Association of Abdominal Incision Length With Gastrointestinal Function Recovery Post-operatively: A Multicenter Registry System-Based Retrospective Cohort Study

Objective: To evaluate the influence of the abdominal incision length on the gastrointestinal function recovery post-operatively.

Background: Gut motility recovers more quickly after the minimally invasive laparoscopic surgery compared than after the traditional open surgery; however, whether the minimal abdominal incision contributes to the faster gut motility recovery is controversial and lacks solid clinical evidence.

Methods: A registry-based secondary cohort analysis was conducted to evaluate the association between the abdominal incision length and gut motility recovery post-operatively based on a multicenter, prospective, and observational study of the prolonged post-operative ileus (PPOI) incidence and the risk factors in the patients with the major abdominal surgery. The incision length, in the centimeters, was the exposure. The primary outcome measures were the PPOI incidence and its association with the incision length. The secondary outcome included the days to the first passage of flatus and the days to the first passage of stool.

Results: Overall, 1,840 patients, including 287 (15.7%) patients with the PPOI, were recruited. The PPOI incidence was 17.6% and 13.3% in the long-incision (>18 cm) and short-incision patients ( ≤ 18 cm), respectively. The incidence of the PPOI increased by 1.1% (1.0–1.1) by each centimeter increment of the incision length after adjusting for the confounding factors. In comparison to the short-incision patients, the long-incision patients had prolonged passage of stool (4.46 vs. 4.95 days, p < 0.001). Each centimeter increment of the incision length contributed to a 2% increased risk of delay in the first bowel movement [hazard ratio (HR) 0.980 (0.967, 0.994)].

Conclusion: A long abdominal incision length independently contributed to the prolonged gut function recovery post-operatively mainly by delaying the time to the first bowel movement, but not influencing the time to first passage of flatus.

The health effects of wearing facemasks on cardiopulmonary system of healthy young adults: A double-blinded, randomized crossover trial

BACKGROUND

Facemask had increasingly been utilized as a personal protective measure to reduce exposure to ambient particulate matter (PM) during heavily-polluted days and routine life. However, evidence on the potential effects on cardiovascular system by wearing particulate-filtering facemask was limited.

METHODS

We conducted a double-blinded randomized crossover trial (RCT) to evaluate the effects of wearing N95 facemasks on the molecular responses of cardiopulmonary system among 52 healthy college students in Beijing, China. We measured cardiopulmonary health indicators and collected biological samples before and after (up to 5 h at multiple time points) a 2-h walk to examine the changes in lung function, biomarkers of respiratory and systemic oxidative stress/inflammation. We applied linear mixed-effect models to evaluate the effect of the facemask-intervention on the health of cardio-pulmonary system.

RESULTS

In the trial wearing real facemasks, FEV₁ increased by 2.05% (95% CI: 0.27%-3.87%), 2.80% (95% CI: 1.00%-4.63%), and 2.87% (95% CI: 1.07%-4.70%) at V1 (30-min), V2 (3-h), and V3 (5-h) after the 2-h walk outsides, respectively. Compared with participants wearing the sham mask, the percentage change of nitrate in EBC was lower among those wearing the real mask. After the 2-h exposure, urinary MDA levels increased compared to the baseline in both trials. Real trial was lower than sham trial for 6 cytokines (i.e., IL-6, IL-10, IL-13, IL-17A, IFN-γ and TNF-α) in serum at 5-h post-exposure. Wearing facemasks on polluted days produced better improvement, however, on cleaner days, the improvement was weaker.

CONCLUSIONS

Short-term use of N95 facemasks appeared to effectively reduce the levels of lung function declines, the respiratory oxidative stress, and the systemic inflammation/oxidative stress which may be induced by short-term exposure to PM. Wearing facemasks on polluted days (PM_2.5 > 75 μg/m³) presented larger beneficial effects on the cardiopulmonary health than in clean days (PM_2.5 < 75 μg/m³).

Continuous preperitoneal infusion of ropivacaine for postoperative analgesia in patients undergoing major abdominal or pelvic surgeries. A prospective controlled randomized study

Background and Aims

This study was conducted to compare continuous preperitoneal infusion (CPI) with continuous epidural infusion (CEI) of ropivacaine for pain relief and effect on pulmonary functions after major abdominal and pelvic surgeries.

Material and Methods

One hundred patients were randomized into two equal groups. Patients in CPI group (n = 50) received analgesia by continuous infusion of 0.2% ropivacaine, whereas those in the CEI group (n = 50) received continuous epidural infusion of 0.2% ropivacaine. The primary outcome was the first request of analgesia. The secondary outcome was the influence on the pulmonary functions.

Results

The time for the first request of analgesia was longer in the CPI group compared with that in the CEI group (7.3 ± 1.6 vs. 4.1 ± 1.1 h with P value = 0.001). The daily dose of morphine was lesser in CPI versus CEI group (11.3 ± 1 against 17.4 ± 0.9 mg). The pulmonary function tests were comparable except peak expiratory flow rate, which was better in CPI (170 ± 5.4) than CEI group (148.1 ± 5.8; with P value = 0.001).

Conclusion

Continuous preperitoneal infusion provides a superior analgesic effect than the continuous epidural infusion as regards delayed first request of analgesia, better pain scores, lesser usage of additional analgesics with better respiratory function.

Laparoscopic procedures impact on mast cell mediators, extracellular matrix and adhesion scoring system in rats

Background

Laparoscopic procedures under certain pressure have the potential to cause intra-abdominal adhesions. However, the pathomechanism of this disorder is unknown. Release of mast cell mediators due to mast cell degranulation is thought to be the cause.

Materials and methods

Thirty male Sprague-Dawley rats were grouped into five groups (n = 6 per group): one control group and four intervention groups to which 60 min insufflation was performed using carbon dioxide at 5, 8, 10 and 12 mmHg. Seven days after laparoscopy, we euthanized and evaluated the levels of histamine, tryptase, and chymase of peritoneal fluid, the thickness of ECM of peritoneal tissue, and intraabdominal adhesion scoring system.

Results

Histamine and tryptase levels in peritoneal fluid were significantly higher at the 10- and 12 mm Hg intervention compared to control (histamine: 0.50 ± 0.35 vs. 0.41 ± 0.41 vs. 0.04 ± 0.02 ng/mL, respectively; and tryptase: 0.69 ± 0.11 vs. 0.65 ± 0.05 vs. 0.48 ± 0.02 ng/ml respectively). The ECM was significantly thicker in the intervention groups at 10- and 12-mm Hg compared to control (71.3 [66.7–85.2] vs. 48.4 [34.5–50.3] vs. 10.25 [8.7–12.1] μm, respectively). Moreover, the intra-abdominal scoring was also significantly higher in the intervention groups at 10- and 12 mm Hg compared to control (4 [0–4] vs. 4.5 [4–5], vs. 0, respectively).

Conclusions

Laparoscopic procedures increase the release of mast cell mediators in peritoneal fluid, the thickness of ECM and intraabdominal adhesion scoring in rats, implying that it might increase the possibility of intrabdominal adhesion in humans.

•

Laparoscopic procedures at specific pressures potentially cause intra-abdominal adhesion, however, its pathomechanism is still challenging to understand.

•

Laparoscopic procedures increase the release of mast cell mediators in peritoneal fluid, the thickness of ECM and intraabdominal adhesion scoring in rats.

•

Our findings imply that laparoscopic procedures might increase the possibility of intrabdominal adhesion in humans.

The effect of laparoscopy on mast cell degranulation and mesothelium thickness in rats

Background

Laparoscopy induces adhesion due to ischemia-reperfusion injury. However, the detail pathomechanism is poorly understood. This study aimed to investigate the impact of laparoscopy on mast cell and mesothelium morphological changes in the rat.

Methods

Forty-nine males of Sprague-Dawley Rattus norvegicus were divided into four groups: a) control and b) intervention groups P1, P2, and P3 that underwent 60 min laparoscopic using carbon dioxide (CO₂) insufflation at 8, 10, and 12 mmHg groups, respectively. Serum hydrogen peroxide (H₂O₂), catalase (CAT), superoxide dismutase (SOD), malondialdehyde (MDA), and oxidative stress index (OSI) levels were determined 24 h after laparoscopy. Histopathological analyses of mast cell infiltration and degranulation and mesothelium thickness in the liver, greater omentum, mesenterium, small intestine, and peritoneum were performed 7 days after the procedure.

Results

H₂O₂, MDA, and OSI levels were significantly increased in the intervention groups compared with the control (p<0.05), while the SOD and CAT levels were decreased in the intervention groups compared with the control (p<0.05). Mast cell infiltration and degranulation were higher in the intervention groups than in control (p<0.05), while the mesothelium thickness was significantly lower in the laparoscopic groups than in control (p<0.05). Interestingly, the decrease in mesothelium thickness was strongly associated with the increase in mast cell infiltration and degranulation (p<0.01).

Conclusions

Our study shows that laparoscopy in rats increases mast cell infiltration and degranulation, which also results in and correlates with a decrease in mesothelial thickness.

Metabolism in Acute-On-Chronic Liver Failure: The Solution More than the Problem

Chronic inflammatory liver disease with an acute deterioration of liver function is named acute-on-chronic inflammation and could be regulated by the metabolic impairments related to the liver dysfunction. In this way, the experimental cholestasis model is excellent for studying metabolism in both types of inflammatory responses. Along the evolution of this model, the rats develop biliary fibrosis and an acute-on-chronic decompensation. The acute decompensation of the liver disease is associated with encephalopathy, ascites, acute renal failure, an acute phase response and a splanchnic increase of pro- and anti-inflammatory cytokines. This multiorgan inflammatory dysfunction is mainly associated with a splanchnic and systemic metabolic switch with dedifferentiation of the epithelial, endothelial and mesothelial splanchnic barriers. Furthermore, a splanchnic infiltration by mast cells occurs, which suggests that these cells could carry out a compensatory metabolic role, especially through the modulation of hepatic and extrahepatic mitochondrial-peroxisome crosstalk. For this reason, we propose the hypothesis that mastocytosis in the acute-on-chronic hepatic insufficiency could represent the development of a survival metabolic mechanisms that mitigates the noxious effect of the hepatic functional deficit. A better understanding the pathophysiological response of the mast cells in liver insufficiency and portal hypertension would help to find new pathways for decreasing the high morbidity and mortality rate of these patients.

The LAPLAP study: a randomized placebo-controlled clinical trial assessing postoperative functional recovery using intraperitoneal local anaesthetic in laparoscopic colorectal surgery

AIM

Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery.

METHOD

Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded.

RESULTS

Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine.

CONCLUSION

Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.

The role of the intra-abdominal view in complicated intra-abdominal infections

Background

The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality.

Methods

The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission.

Results

A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05–3.73), diffuse peritonitis (OR 2.15, 1.02–4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12–15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11–30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions.

Conclusions

The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems.

Trial registration

The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0232-7) contains supplementary material, which is available to authorized users.

Extrudable salicylic acid-based poly(anhydride-esters) for injectable drug releasing applications

Injectable biomaterials have attracted more and more interest owing to their advantages over traditional open surgeries: minimal invasive procedure and ease of handling. Commonly used synthetic injectable polymers exhibited low drug loading and poor biodegradability. In this work, we describe a novel series of degradable copolymers comprising salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) subunits suitable for injectable drug releasing applications. By tuning the rheology properties, these salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) copolymers may function as injectable drug delivery vehicles that deliver salicylic acid at the injury site. These copolymers were designed to have glass transition temperatures (Tg) below 0ºC, resulting in extrudable polymers that behave like viscous fluids at room temperature. Salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol) copolymers of different ratios (2:1, 1:1, and 1:2 salicylic acid–based poly(anhydride-esters) and poly(ethylene glycol)) were synthesized and characterized by nuclear magnetic resonance and Fourier-transform infrared spectroscopies. Their shear viscosities were determined both at room and physiological temperatures. The in vitro drug release profiles, cytotoxicity, and anti-inflammatory activities were assessed. The shear viscosities were found to compare favorably with current injectable barrier materials on the market.

The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction

Background and Objectives:

Surgery provokes inflammatory and immune responses, so efforts have been made to reduce host response by using less invasive techniques. The purpose of this experimental study was to investigate the surgical stress induced by skin incision and the role of liver response in this process.

Methods:

Seventy male anesthetized Wistar rats were subjected to a midline incision confined strictly to the skin (dermis) of either 1 cm long (n = 20), 10 cm long (n = 20), or no incision (n = 20) or served as controls (n = 10). Skin trauma was left open for a 20-minutes period, and then was meticulously sutured. At 3 and 24 hours later, laparotomy was performed on half the rats of each group, for blood and liver sampling. In serum and liver homogenates, cytokine-induced neutrophil chemoattractant (CINC)1/interleukin (IL)-8 and tumor necrosis factor (TNF)-α levels were measured with enzyme-linked immunosorbent assays and nitric oxide (NO) using a Griess reaction.

Results:

Skin trauma was found to significantly (P < .01) increase all inflammatory mediators tested (CINC1/IL-8, TNF-α, NO) in serum of operated rats versus controls, the increase being proportionally dependent on the length of skin incision. In liver homogenates, CINC1/IL-8 was significantly (P < .01) increased in operated animals versus controls, similarly to serum levels. In contrast, liver TNF-α levels were inversely related to serum levels, and a significant (P < .01) decrease in TNF-α was observed in liver homogenates of operated animals compared with the controls, indicating that the increased TNF-α in blood reflects liver TNF-α secretion.

Conclusion:

Our findings suggest that inflammatory and immune reactions induced by skin-only surgical trauma are closely correlated to the length of skin incision.

Inherited genetic predispositions in F13A1 and F13B genes predict abdominal adhesion formation: identification of gender prognostic indicators

Abdominal adhesions (AA) account for the most common complication of peritoneal surgery with bowel obstruction being the severest problem in the absence of effective predicting biomarkers. Anti-AA-barriers or adhesiolysis did not completely prevent bowel obstruction, although there is evidence they might reduce related complications requiring reoperation. In addition, gender-related predispositions have not been adequately investigated. We explored the role of coagulation Factor XIII (F13A1 and F13B subunit-genes) in patients following laparotomy, mostly median/lower median incision line. Globally, 426 patients (54%,♀), were PCR-SNP-genotyped for FXIIIA V34L (rs5985), FXIIIA P564L (rs5982), FXIIIA Y204F (rs3024477) and FXIIIB H95R (rs6003). Patients' clinical phenotypes were: Group-A (n = 212), those who developed AA, and 55.2% of them developed bowel obstruction (subgroup-A1), the remaining were subgroup-A2; Group B (n = 214) were those who did not develop AA (subgroup-B1; 53.3%) or symptoms/complications (subgroup-B2). Among different laparotomy, colon surgery associated with AA at a major extent (OR = 5.1; 3.24-7.8; P < 0.0001) with different gender scores (♀OR = 5.33; 2.32-12.23; P < 0.0001 and ♂OR = 3.44; 1.58-7.49; P < 0.0001). Among SNPs, P564L (OR = 4.42; 1.45-13.4; P = 0.008) and Y204F (OR = 7.78; 1.62-37.3; P = 0.01) significantly predicted bowel obstruction and survival-analyses yielded interesting gender distinctions (♀HR = 5.28; 2.36-11.8; P = 0.00005; ♂HR = 2.22; 1.31-3.85; P = 0.0034). Active compounds preventing AA belong to the anticoagulant/fibrinolysis areas, suggesting them candidate investigation targets. We identified novel prognostic markers to predict AA/bowel obstruction giving insights to design novel therapeutic and gender prevention programs.

Intraperitoneal Local Anesthetic Instillation and Postoperative Infusion Improves Functional Recovery Following Colectomy: A Randomized Controlled Trial

BACKGROUND

Intraperitoneal local anesthetic is an analgesic technique for inclusion in the polypharmacy approach to postoperative pain management in enhanced recovery after surgery programs. Previously, augmentation of epidural analgesia with intraperitoneal local anesthetic was shown to improve functional postoperative recovery following colectomy.

OBJECTIVE

This study determines whether intraperitoneal local anesthetic improves postoperative recovery in patients undergoing colectomy, in the absence of epidural analgesia, with standardized enhanced recovery after surgery perioperative care.

DESIGN

This is a multisite, double-blinded, randomized, placebo-controlled trial (ClinicalTrials.gov Identifier NCT02449720).

SETTINGS

This study was conducted at 3 hospital sites in South Australia.

PATIENTS

Eighty-six adults undergoing colectomy were stratified by approach (35 open; 51 laparoscopic), then randomly assigned to intraperitoneal local anesthetic (n = 44) and control (n = 42) groups.

INTERVENTIONS

Patients in the intraperitoneal local anesthetic group received an intraoperative intraperitoneal ropivacaine 100-mg bolus both pre- and postdissection and 20 mg/h continuous postoperative infusion for 48 hours. Patients in the control group received a normal saline equivalent.

MAIN OUTCOME MEASURES

Functional postoperative recovery was assessed by using the surgical recovery scale for 45 days; postoperative pain was assessed by using a visual analog scale; and opioid consumption, use of rescue ketamine, recovery of bowel function, time to readiness for discharge, and perioperative complications were recorded.

RESULTS

The intraperitoneal local anesthetic group reported improved surgical recovery scale scores at day 1 and 7, lower pain scores, required less rescue ketamine, and passed flatus earlier than the control group (p < 0.05). The improvement in surgical recovery scale at day 7 and pain scores remained when laparoscopic colectomy was considered separately. Opioid consumption and time to readiness for discharge were equivalent.

LIMITATIONS

This study was powered to detect a difference in surgical recovery scale, but not the other domains of recovery, when the intraperitoneal local anesthetic group was compared with control.

CONCLUSIONS

We conclude that instillation and infusion of intraperitoneal ropivacaine for patients undergoing colectomy, including by the laparoscopic approach, decreases postoperative pain and improves functional postoperative recovery. We recommend routine inclusion of intraperitoneal local anesthetic into the multimodal analgesia component of enhanced recovery after surgery programs for laparoscopic colectomy. See Video Abstract at http://links.lww.com/DCR/A698.

STERILIZATION OF HYBRID MARMOSET ( CALLITHRIX SP.) FEMALES: AN EVALUATION OF TWO SURGICAL METHODS

Population control techniques, either permanent or reversible, are important tools for the management of wildlife in captive and natural environments. Among these, surgical sterilization provides a permanent solution to unwanted reproduction. Surgical techniques can differ in their invasiveness and in the subsequent effect on behavior and physiology. For social animals, techniques that preserve gonads, such as vasectomy for males and ligation of uterine tubes for females, may be preferred because they maintain important physiology that influences behavior. This study compared two sterilization procedures for captive hybrid marmosets ( Callithrix sp.). Twenty adult females undergoing tubal ligation were divided into two groups and received treatment either with a laparotomy or a laparoscopic method. The following parameters were evaluated for each female: duration of procedure, pain levels, weight gain, wound healing, adhesion, and inflammation. The results indicate that both techniques were equally effective. However, the conventional surgery may be more advantageous, because it is significantly shorter in duration, is only slightly more invasive, and requires less formal training of the surgeon.

Surgical and not analgesic technique affects postoperative inflammation following colorectal cancer surgery: a prospective, randomized study

AIM

Epidural analgesia reduces the surgical stress response. However, its effect on pro- and anti-inflammatory cytokines in the genesis of inflammation following major abdominal surgery remains unclear. Our main objective was to elucidate whether perioperative epidural analgesia prevents the inflammatory response following colorectal cancer surgery.

METHODS

Ninety-six patients scheduled for open or laparoscopic surgery were randomized to epidural analgesia (group E) or patient-controlled intravenous analgesia (group P). Surgery and anaesthesia were standardized in both groups. Plasma cortisol, insulin and serum cytokines [interleukin 1β (IL-1β), IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumour necrosis factor α, interferon γ, granulocyte-macrophage colony-stimulating factor, prostaglandin E₂ and vascular endothelial growth factor] were measured preoperatively (T0), 1-6 h postoperatively (T1) and 3-5 days postoperatively (T2). Mixed model analysis was used, after logarithmic transformation when appropriate, for analyses of cytokines and stress markers.

RESULTS

>There were no significant differences in any serum cytokine concentration between groups P and E at any time point except for IL-10 which was 87% higher in group P [median and range 4.1 (2.3-9.2) pg/ml] compared to group E [2.6 (1.3-4.7) pg/ml] (P = 0.002) at T1. There was no difference in plasma cortisol and insulin between the groups at any time point after surgery. A significant difference in median serum cytokine concentration was found between open and laparoscopic surgery with higher levels of IL-6, IL-8 and IL-10 at T1 in patients undergoing open surgery compared to laparoscopic surgery. No difference in serum cytokine concentration was detected between the groups or between the surgical technique at T2.

CONCLUSIONS

Open surgery, compared to laparoscopic surgery, has greater impact on these inflammatory mediators than epidural analgesia vs intravenous analgesia.

Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications

In this article the adverse effects of laparoscopic CO2 pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2 insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.

Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications

In this article the adverse effects of laparoscopic CO2 pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2 insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.

Effectiveness of continuous wound infusion of local anesthetics after abdominal surgeries

BACKGROUND

To assess the effectiveness of continuous preperitoneal wound infusion of local anesthetic drug bupivacaine in providing pain relief, reducing opioid consumption, and enhancing postoperative recovery.

METHODS

Eligible patients were randomly allocated to two groups (study group: bupivacaine and control group: normal saline). There were 47 patients in each group. The patients received continuous infusion of either 0.25% bupivacaine or 0.9% normal saline at 6 mL/h, for 48 h, based on their group allocation, through a multiholed wound infiltration catheter placed preperitoneally. All patients also received intravenous morphine through patient-controlled analgesia pump. Pain scores at rest and on cough, morphine consumption, and peak expiratory flow rate were assessed at 12, 24, and 48 h postoperatively. The time to first perception of bowel sounds and first passage of flatus was noted. All patients were assessed for postoperative nausea and vomiting and any local or systemic complications. Chi-square test was used to compare categorical variables. The morphine consumption was compared using Student t-test, the visual analogue scale (VAS) scores were compared using repeated-measures analysis of variance.

RESULTS

The mean total morphine consumption in the study group was significantly lower than the control group (18.8 ± 2.21 versus 30.8 ± 2.58 mg, P = 0.001). The median VAS scores were significantly lower in the study group than those in the control group both at rest (3 [1-4] versus 4 [2-5], P = 0.04) and during cough (4 [3-6] versus 6 [4-6] P = 0.03), except at 48 h, when the median VAS score at rest was similar (3 [1-4] versus 3 [2-4], P = 0.56). Bowel function returned earlier in study group (67.34 ± 2.61 versus 76.34 ± 5.29 h, P = 0.03). Postoperative nausea and vomiting was less in study group. Respiratory function, assessed by peak expiratory flow rate, was better in the study group (192.55 ± 12.93 versus 165.31 ± 9.32 mL, P = 0.03). The incidence of surgical site infection was similar in both the groups (3/47 versus 5/47, P = 0.06). There was no systemic toxicity of local anesthetic.

CONCLUSION

Continuous preperitoneal wound infusion of local anesthetic provides effective analgesia, reduces morphine consumption and its associated side effects, and enhances the postoperative recovery by reducing the incidence of prolonged postoperative ileus.

Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach

BACKGROUND

Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy.

METHODS

Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved.

RESULTS

Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection.

CONCLUSIONS

Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique.

Deep Pelvic Surgical Site Infection After Radiotherapy and Surgery for Locally Advanced Rectal Cancer

BACKGROUND

High morbidity, increased mortality, and impaired long-term oncologic outcome have been reported after deep surgical site infection (SSI) in rectal cancer surgery. The rate, risk factors and consequences of deep SSI after (chemo)radiotherapy [(C)RT], and surgery for locally advanced rectal cancer (LARC) in a tertiary university hospital single centre cohort of 540 patients are presented.

METHODS

Patients with LARC, operated between January 1, 2007 and December 31, 2015, were identified in the institutional prospective database. All patients had tumours threatening the mesorectal fascia or invading adjacent organs, with a high rate of T4 tumours (60 %), and all received (C)RT. Risk factors for deep SSI were calculated by multivariable logistic regression analysis. Morbidity data were assessed. Overall survival (OS) and disease-free survival (DFS) between patients with or without deep SSI were estimated.

RESULTS

Of 540 patients, 104 (19 %) experienced a deep SSI, with the highest rate in the abdominoperineal resection (APR) group with 25 %. APR, good response to (C)RT (low tumour regression grade), age, and operative blood loss were identified as significant (P < 0.05) risk factors for deep SSI in multivariable analysis. No difference was found in OS (P = 0.995) or DFS (P = 0.568). Hospital stay increased with 5 days (P < 0.001), and complete wound healing at the 3-month follow-up decreased from 86 to 45 % (P < 0.001) after deep SSI.

CONCLUSIONS

Deep SSI is a frequent and major complication after rectal surgery for LARC, with high morbidity, increased hospital stay and protracted wound healing. Interestingly, deep SSI did not influence long-term oncologic outcome.

A Novel Approach to Major Surgery: Tracking Its Pathophysiologic Footprints

BACKGROUND

To study the 'metabolic profile' of different surgical procedures and correlate it with pertinent surgical details and postoperative complications.

METHODS

We conducted a prospective pilot study of 70 patients, ten for each of the seven following groups: (1) laparoscopic cholecystectomy, (2) incisional hernia repair, (3) laparoscopic and (4) open colon surgery, (5) upper gastrointestinal, (6) hepatic, and (7) pancreatic resections. Biochemical assessment included white blood cell count (WBC), C-reactive protein (CRP), glucose, triglycerides (TG), albumin (Alb), and pre-albumin (Pre-Alb), from the day before surgery until 5 days thereafter. Biological markers were compared for major versus minor surgery groups, which were defined on a clinical basis. Univariable analysis was used to identify risk factors for postoperative complications and p < 0.05 was the significance threshold.

RESULTS

Common findings in all surgery groups were the acute inflammatory response (↑: WBC, CRP, ↓: TG, Alb, pre-Alb). Using cut-off values of 240 min operative (OR) time and 300 ml estimated blood loss (EBL), laparoscopic cholecystectomy, incisional hernia repair, and laparoscopic colectomy could be distinguished from open colectomy, upper gastrointestinal, liver, and pancreas resections. In a biochemical level, increased CRP and reduced postoperative Alb levels were highly discriminative of all types of 'major surgery.' Significant risk factors for postoperative complications were age, male gender, malignancy, longer OR time, higher blood loss, high CRP, and low Alb levels.

CONCLUSIONS

Biochemically, CRP and Alb levels can help quantify the magnitude of the surgical trauma, which is correlated with adverse outcomes.

Postoperative ileus: mechanisms and future directions for research

Postoperative ileus (POI) is an abnormal pattern of gastrointestinal motility characterized by nausea, vomiting, abdominal distension and/or delayed passage of flatus or stool, which may occur following surgery. Postoperative ileus slows recovery, increases the risk of developing postoperative complications and confers a significant financial load on healthcare institutions. The aim of the present review is to provide a succinct overview of the clinical features and pathophysiological mechanisms of POI, with final comment on selected directions for future research.Terminology used when describing POI is inconsistent, with little differentiation made between the obligatory period of gut dysfunction seen after surgery ('normal POI') and the more clinically and pathologically significant entity of a 'prolonged POI'. Both normal and prolonged POI represent a fundamentally similar pathophysiological phenomenon. The aetiology of POI is postulated to be multifactorial, with principal mediators being inflammatory cell activation, autonomic dysfunction (both primarily and as part of the surgical stress response), agonism at gut opioid receptors, modulation of gastrointestinal hormone activity and electrolyte derangements. A final common pathway for these effectors is impaired contractility and motility and gut wall oedema. There are many potential directions for future research. In particular, there remains scope to accurately characterize the gastrointestinal dysfunction that underscores an ileus, development of an accurate risk stratification tool will facilitate early implementation of preventive measures and clinical appraisal of novel therapeutic strategies that target individual pathways in the pathogenesis of ileus warrant further investigation.

Response to pathological processes in the peritoneal cavity--sepsis, tumours, adhesions, and ascites

The peritoneum is one of the commonest sites for pathological processes in pediatric surgery. Its response to pathological processes is characterized by an inflammatory reaction with specific pathways depending on the type of injury or peritoneal process involved. This review discusses the current understanding of peritoneal inflammation, adhesion formation, intra-abdominal sepsis, peritoneal metastasis, and ascites and briefly reviews new therapeutic strategies to treat or prevent these pathological entities. Recent studies have improved the understanding of peritoneal responses, resulting in possible new targets for prevention and therapy.

Preperitoneal catheter analgesia is an effective method for pain management after colorectal surgery: the results of 100 consecutive patients

Background

In a previous prospective randomized trial, we showed that local anesthetic infusion using a preperitoneal catheter is an effective postoperative analgesic method following colorectal resections. Over time, we have improved the technique of preperitoneal catheter analgesia. In this prospective cohort study, we report the results of 100 consecutive patients who underwent colorectal resections.

Materials and methods

Preperitoneal catheter analgesia was performed via a multihole catheter placed in the preperitoneal space using 10 mL 0.5% levobupivacaine every 4 hours following the operation for the first 3 days. Additional analgesics were used whenever necessary. Postoperative pain was assessed with the visual analog scale score. Short-term clinical outcomes, such as need for systemic analgesics, time to first gas and stool discharge, length of hospital stay, and morbidity, particularly surgical site infections, were reported.

Results

From May 2009 to May 2010, 100 consecutive patients were recruited in the study. A total of 83 patients were operated on for malignancy, and the tumor was located in the rectum in 52 patients and in the colon in 31 patients. The median pain score was 4 (0–6), 3 (0–9), 2 (0–8), 1 (0–8), 1 (0–6), 0 (0–6), and 0 (0–3) at postoperative hours 0, 1, 4, 12, 24, 48, and 72, respectively. Additional analgesics were required in 34 patients: 21 of them required only nonsteroidal anti-inflammatory drugs, and 13 patients needed opioids additionally. The median amounts of opioid analgesics and nonsteroidal anti-inflammatory drugs were 1.76±0.78 mg and 6.70±1.18 mg, respectively. However, almost all of the additional analgesics were given in the first 24 hours. Surgical site infections were detected in eight patients.

Conclusion

Preperitoneal catheter analgesia is an effective analgesic method. When applied and used properly, it may even be used as the sole analgesic method in some patients.

Evaluation of novel local anesthetic wound infiltration techniques for postoperative pain following colorectal resection surgery: a meta-analysis

BACKGROUND

Novel local anesthetic blocks have become increasingly popular in the multimodal pain management following abdominal surgery, but have not been evaluated in a procedure-specific manner in colorectal surgery.

OBJECTIVE

This study aims to evaluate the efficacy of novel local anesthetic techniques in colorectal surgery.

DATA SOURCES

Electronic literature search of PubMed, EMBASE, and Cochrane databases (date range, January 1990 to February 2013) STUDY SELECTION: Randomized controlled trials comparing a novel local anesthetic technique with placebo/routine analgesia in adults undergoing open or laparoscopic colonic or rectal resection were selected.

INTERVENTIONS

This is a meta-analysis of randomized controlled trials evaluating novel local anesthetic wound infiltration techniques such as wound catheter, transversus abdominis plane block, and intraperitoneal instillation in colorectal surgical procedures. The comparator group was defined as placebo/routine analgesia.

OUTCOME MEASURES

The primary outcome was opiate requirement at 24 hours. Secondary outcomes included opiate requirements at 48 hours, pain numerical rating score at 24 and 48 hours at rest and on movement, recovery (length of stay, nausea and vomiting, time until bowel movement and diet resumption), and complications. Subgroup analysis was performed to evaluate specific local anesthetic techniques and open and laparoscopic surgery.

RESULTS

Twelve randomized controlled trials compared local anesthetic techniques with placebo/routine analgesia. Local anesthetic techniques demonstrated a significant reduction in opiate requirement at 48 hours. Local anesthetic techniques were also associated with lower pain scores on movement at 24 and 48 hours, shorter length of stay, and earlier resumption of diet.

LIMITATIONS

The diverse study design led to statistical heterogeneity in several analyses.

CONCLUSIONS

Novel local anesthetic wound infiltration techniques in colorectal surgery appear to reduce opiate requirements, to reduce pain scores, and to improve recovery in comparison with placebo/routine analgesia.

Total systemic ropivacaine concentrations following aerosolized intraperitoneal delivery using the AeroSurge

STUDY OBJECTIVE

To evaluate intraperitoneal ropivacaine delivery with the AeroSurge device in the clinical setting and to evaluate the total systemic ropivacaine levels achieved following delivery of 50 mg of aerosolized ropivacaine.

DESIGN

Preliminary, prospective, nonrandomized study.

SETTING

Operating room of a university hospital.

PATIENTS

5 consecutive ASA physical status 1 and 2 patients undergoing elective laparoscopic Nissen fundoplication or cholecystectomy.

INTERVENTION

Five mL of 1% ropivacaine was delivered through the 10 mm port using the AeroSurge device at peritoneal insufflation.

MEASUREMENTS

Venous blood samples were collected and total ropivacaine concentration was determined using liquid chromatography-mass spectrometry.

MAIN RESULTS

The AeroSurge device delivered ropivacaine, visible as mist within the peritoneal cavity. Peak concentration (Cmax) was attained between 10 and 30 minutes following the end of aerosolized ropivacaine delivery. At no stage did any level approach toxic levels.

CONCLUSIONS

This preliminary study confirms that aerosolized intraperitoneal local anesthetic is feasible, with ropivacaine concentrations remaining within safe levels.

Inflammatory response after open and laparoscopic Nissen fundoplication in children: a randomized study

PURPOSE

It is assumed that laparoscopic surgery generally induces less inflammatory responses than open surgery. Since few studies have compared immune responses after laparoscopic and open surgery in children, we examined inflammatory markers in children randomized to open (ONF) or laparoscopic Nissen fundoplication (LNF).

METHODS

Blood samples were collected prior to surgery (D0), and on postoperative day 1 (D1) and day 2 (D2). Inflammatory markers were measured using a multiplex antibody bead kit. The postoperative levels of inflammatory markers were statistically analyzed using a linear mixed model. A P value <0.05 was considered statistically significant.

RESULTS

Twenty-nine patients randomized to ONF or LNF were included. Median age was 3.1 years (range 1.0-14.2) in the ONF group and 4.0 years (range 0.2-14.2) in the LNF group. Plasma levels of the anti-inflammatory cytokine interleukin (IL)-10 were significantly higher in the ONF group than in the LNF group postoperatively (P = 0.04). However, there were no significant differences between the groups in the levels of pro-inflammatory markers tumor necrosis factor-α, IL-6, IL-8, monocyte chemoattractant protein-1, white blood cell count, or C-reactive protein.

CONCLUSIONS

We did not find that laparoscopy induced a substantially less inflammatory response than laparotomy in children undergoing fundoplication.

Intraperitoneal wound in abdominal surgery

The intraperitoneal wound is often forgotten after transperitoneal surgery. This review is a on the peritoneum and the implications of peritoneal injury after surgery. This review will focus on the intraperitoneal wound response after surgical injury.

Thoracic epidural analgesia inhibits the neuro-hormonal but not the acute inflammatory stress response after radical retropubic prostatectomy

BACKGROUND

Epidural anaesthesia and analgesia has been shown to suppress the neuro-hormonal stress response, but its role in the inflammatory response is unclear. The primary aim was to assess whether the choice of analgesic technique influences these processes in patients undergoing radical retropubic prostatectomy.

METHODS

Twenty-six patients were randomized to Group P (systemic opioid-based analgesia) or Group E (thoracic epidural-based analgesia) perioperatively. Induction and maintenance of anaesthesia followed a standardized protocol. The following measurements were made perioperatively: plasma cortisol, glucose, insulin, C-reactive proteins, leucocyte count, plasma cytokines [interleukin (IL)-6, tumour necrosis factor (TNF)-α], and pokeweed mitogen-stimulated cytokines [interferon (IFN)-γ, IL-2, IL-12p70, IL-10, IL-4, and IL-17]. Other parameters recorded were pain, morphine consumption, and perioperative complications.

RESULTS

Plasma concentration of cortisol and glucose were significantly higher in Group P compared with Group E at the end of surgery, the mean difference was 232 nmol litre(-1) [95% confidence interval (CI) 84-381] (P=0.004) and 1.6 mmol litre(-1) (95% CI 0.6-2.5) (P=0.003), respectively. No significant differences were seen in IL-6 and TNF-α at 24 h (P=0.953 and 0.368, respectively) and at 72 h (P=0.931 and 0.691, respectively). IL-17 was higher in Group P compared with Group E, both at 24 h (P=0.001) and 72 h (P=0.018) after operation. Pain intensity was significantly greater in Group P compared with Group E (P<0.05) up to 24 h.

CONCLUSIONS

In this small prospective randomized study, thoracic epidural analgesia reduced the early postoperative stress response but not the acute inflammatory response after radical retrobupic prostatectomy, suggesting that other pathways are involved during the acute phase reaction.

Preoperative glucocorticoid use in major abdominal surgery: systematic review and meta-analysis of randomized trials

OBJECTIVE

To determine the clinical safety and efficacy of preoperative glucocorticoid (GC) administration in major abdominal surgery with regards to short term outcomes.

BACKGROUND

Previous randomized controlled trials (RCTs) in major abdominal surgery have displayed conflicting results regarding the short-term benefits of preoperative GC administration. Importantly, the safety of this intervention has not been conclusively determined.

METHODS

A systematic review and quantitative meta-analysis was conducted of all RCTs exploring preoperative GC administration in major abdominal surgery for the endpoints of complications, hospital length of stay (LOS) and serum IL-6 on postoperative day one. Subset analyses by procedure were planned "a priori."

RESULTS

Eleven RCTs of moderate quality, comprising 439 patients in total, were included in the final analysis. Preoperative GC use decreased complications (OR = 0.37; 95% CI, 0.21-0.64; P < 0.01), LOS (mean = 1.97 days; 95% CI, -3.33 to -0.61; P = 0.01), and serum IL-6 (mean: -55 pg/mL; 95% CI, -82.30 to -27.91; P < 0.01). Preoperative GCs decreased complications in hepatic resection (OR = 0.28; 95% CI, 0.14-0.55; P < 0.01) and mean LOS (mean LOS: -2.66; 95% CI, -5.01 to -0.32; P = 0.03). GCs reduced mean LOS in patients undergoing colorectal surgery (mean LOS: -0.98; 95% CI, -1.67 to -0.27; P = 0.01). There was no difference in complication rates (OR: 0.45; 95% CI, 0.16-1.32; P = 0.15) or anastomotic leaks specifically.

CONCLUSIONS

Preoperative administration of GCs decreases complications and LOS after major abdominal surgery as a likely consequence of attenuating the postsurgical inflammatory response. There is no evidence of increased complications in colorectal surgery.

Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial

BACKGROUND

Two wounds are created after abdominal surgery. The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions. In animal models vagotomy blunts the intraperitoneal response to induced inflammation. This is not feasible in humans. However a transient chemical afferentectomy after colectomy by using neuraxial blockade (epidural) and intraperitoneal blockade may be possible. We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic (IPLA) on recovery parameters after colectomy, in the setting of an established enhanced recovery after surgery (ERAS) program.

METHODS

Double blinded, randomized, placebo controlled design. The study group (IPLA) received instillation of intraperitoneal ropivacaine (75 mg) before dissection and postoperative infusion of 0.2% solution at 4 mL/hour for 3 days continuously. The placebo group (NS) was treated as above with 0.9% saline solution. All patients were cared for under ERAS standardized perioperative care. Epidural infusion was stopped on day 2. Patients were discharged from day 3 onwards once criteria met. Perioperative data, surgical recovery score (SRS), complications, and length of stay were recorded. Systemic cytokines response, neuroendocrine parameters, pain measures and opioid use data were collected. Patients were followed up for 60 days.

RESULTS

Sixty patients were recruited. Patients were equivalently matched at baseline. There were no local anesthetic related adverse events. The complication rate, including anastomotic leak rate, was equivalent between groups. IPLA group had better SRS scores for the duration of intraperitoneal infusion. Pain and opioid use was reduced in the IPLA group. Systemic cytokine and cortisol response was diminished in the IPLA group. IPLA group had consistently higher systemic ropivacaine levels than placebo group.

CONCLUSION

Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery. This was associated with a blunting of postsurgical systemic cytokines and cortisol. Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion. Therefore a transient chemical afferentectomy with clinical benefit is possible with this method. A longer IPLA infusion duration needs to be studied. This study is registered at clinicaltrials.gov and carries the ID number NCT00722709.