Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure?

BACKGROUND

Adhesions can result in serious clinical complications and make ileostomy closure, which is relatively simple procedure into a complicated and prolonged one. The use of sodium hyaluronate and carboxymethyl cellulose membrane (Seprafilm) was proven to significantly reduce the postoperative adhesions at the site of application. The aim of this study was to assess the incidence and severity of adhesions around a loop ileostomy and to analyze the length of time and morbidity for mobilization at the time of ileostomy closure with and without the use of Seprafilm.

METHODS

Twenty-nine surgeons from 15 institutions participated in this multicenter prospective randomized study. 191 patients with loop ileostomy construction were randomly assigned to either receive Seprafilm under the midline incision and around the stoma (Group I), only under the midline incision (Group II), or not to receive Seprafilm (Group III). At ileostomy closure, adhesions were quantified and graded; operative morbidity was also measured.

RESULTS

All 3 groups were comparable relative to gender, mean age and number of patients with prior operations (26, 25 and 19, respectively). Group II patients were significantly more likely to have pre-existing adhesions than Group III patients (30.6% vs. 14.1%, p = 0.025). At stoma mobilization, significantly more patients in Group III than in Group I had adhesions around the stoma (95.2% vs. 82.3%, p = 0.021). Mean operative times were 27, 25, and 28 minutes, respectively (p = 0.38), with significant differences among sites. There was no significant difference in the number of patients needing myotomy or enterotomy (29, 27 and 24 patients, respectively), nor in the number of postoperative complications (7, 9 and 7 patients, respectively).

CONCLUSIONS

When consistently applied, Seprafilm significantly decreased adhesion formation around the stoma but not operative times without any increase in the need for myotomy or enterotomy. These findings were not seen in the overall study population possibly due to the large number of surgeons using a variety of application techniques.

Differential changes in intestinal permeability following burn injury

Increased gut permeability (GP) following burn injury has been implicated in the predisposition to sepsis and multiple systems organ failure (MSOF). Since previous studies have identified only "global" alterations in GP, we examined the jejunum, ileum, and colon individually for GP using probes of two different sizes: fluorescein isothiocyanate-dextran-3 (FDEX, molecular weight 4387 d) and horseradish peroxidase (HRP, molecular weight 40,000 d). Animals were examined for GP at 1, 2, or 4 days following burn. The GP was significantly increased in all segments combined following burn injury to both the small probe (FDEX, p < 0.001) and the larger probe (HRP, p < 0.06) versus controls. The GP was significantly greater for FDEX versus HRP (p < 0.001). Jejunal permeability to FDEX and HRP increased most at 24 hours. Ileal and colonic GP to FDEX increased early also, but were higher at days 2 and 4. These results suggest that, following burn injury, there is differential GP that is size and site dependent, and that increased GP may last well beyond 24 hours postburn despite feeding.

Laparoscopic cholecystectomy: comparison of university and community experience

We compared the first year's experience in performing laparoscopic cholecystectomy in a university hospital and a community hospital to determine the impact of postgraduate surgical training on outcome. Laparoscopic cholecystectomy was attempted on 446 patients. The conversion rate to open cholecystectomy was 8.3% and did not differ between institutions. Surgical house staff performed 43% of the cases at the university hospital compared with 8% at the community hospital. The greater use of laser and cholangiograms resulted in significantly longer mean operative time at the university hospital (141 +/- 26 min) than at the community hospital (114 +/- 52 min). The overall complication rate did not differ significantly (p = 0.15). Complications included common duct injury (three cases), bile leak (five cases), bleeding or hematoma (six cases), epigastric artery hematoma (one case), and death (one case). Operative inexperience during this first year may be a major determinant for the complication rates at both hospitals. It is too early to determine the impact of graduate surgical education on complications. Intense education and supervised instruction is requisite to minimizing the morbidity associated with laparoscopic cholecystectomy regardless of whether it is performed at a university or community hospital.

Ranitidine does not alter adinazolam pharmacokinetics or pharmacodynamics

Adinazolam is a triazolobenzodiazepine with anxiolytic and antidepressant activity. Adinazolam is metabolized extensively; the major metabolite, N-desmethyladinazolam (NDMAD), possesses significant pharmacologic activity. NDMAD is eliminated predominantly by renal excretion. Ranitidine, a histamine H2-receptor antagonist, is also excreted renally and may compete with NDMAD for renal secretion. The purpose of this study was to examine the effect of ranitidine on the pharmacokinetics and pharmacodynamics of adinazolam and NDMAD. In a randomized, cross-over study, 12 healthy male volunteers received 300 mg of ranitidine orally followed by 30 mg of adinazolam 1 hour later (treatment A), or adinazolam alone (treatment B). Pharmacodynamic alterations were assessed using card sorting, digit-symbol substitution, and short-term memory tests. Venous blood samples were obtained over 24 hours for analysis of adinazolam and NDMAD by high-performance liquid chromatography. Urine samples also were collected and analyzed for NDMAD. No significant difference in adinazolam oral clearance (1,149 vs. 1,135 ml/hr/kg) was noted between treatments (A vs. B, respectively). Furthermore, the renal clearance of NDMAD (196 vs. 198 ml/min) and the cumulative urinary excretion of NDMAD (% dose; 61.2 vs. 62.3) were not significantly different. Repeated-measures analysis of variance indicated no significant differences in psychomotor performance or short-term memory between treatments. Results suggest that ranitidine has no effect on adinazolam disposition, NDMAD renal clearance, or the central nervous system effects mediated by the drug.

Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: an analysis of multiple intervention and outcome variables in 1,238 patients

OBJECTIVE

To assess the statistical association of the Acute Physiology and Chronic Health Evaluation (APACHE II) score with multiple intervention and outcome variables in surgical ICU patients.

DESIGN

Continuous data collection on every patient admitted to the surgical ICU for a 21-month period.

MATERIALS AND METHODS

For every admitted patient in the surgical ICU, APACHE II scores were calculated and the relationship between APACHE II score as an independent predictor of outcome was assessed with multiple outcome variables selected for study. The outcome and intervention variables tested included: treatment intervention measures such as days on ventilator; days with an arterial catheter, central venous catheter, triple lumen catheter, pulmonary artery catheter; days receiving total parenteral nutrition; days receiving tube feedings; number of transducers per days in the ICU; number of infusion pumps per ICU days, days in the hospital, number of complete blood counts; number of electrolyte determinations; number of blood gases; number of units of blood transfused; ICU and hospital mortality rates in the presence of complications, including: respiratory distress syndrome, renal failure, congestive heart failure, coma, requirement of cardiopulmonary resuscitation, and others.

RESULTS

The APACHE II score was statistically associated with each intervention and outcome variable tested. Unfortunately, the associations, although consistent, were weak with r2 values ranging from .03 to a maximum of .22 for Pearson's correlation coefficients.

CONCLUSION

The APACHE II score was statistically associated with all the variables examined in our surgical patients, but its predictive power for the individual surgical patient was limited. These findings suggest that the score may be useful for retrospective analyses of large cohorts of patients but should not be used as a triage tool or as a predictor of outcome for the individual patient. Triage decisions should continue to be based on the best available clinical judgment.

Continuous, graded steady-state muscle work in rats studied by in vivo 31P-NMR

Theoretical consideration and experimental findings of 31P nuclear magnetic resonance spectroscopy (NMR) studies of exercising human muscle suggest that a graded, steady-state work protocol is highly suitable for performance evaluation in health and disease. We describe a similar rat model for repeated 31P-NMR studies that follows many of the 31P-NMR features observed in normal human controls. Calf muscles of rats anesthetized with chloral hydrate were indirectly stimulated at four frequencies (0.25, 0.5, 1.0, and 2.0 Hz). It was found that 1) several steady states can be briefly maintained in this model; 2) work-induced phosphocreatine (PCr) fall and inorganic phosphate (Pi) rise is stoichiometric; 3) a linear relationship between stimulation rate and Pi/PCr was obtained, with a slope of 2.01 +/- 0.4 (+/- 2SD, n = 15); 4) no significant drop in ATP was observed, allowing the estimation of phosphorylation potential (PP) changes during this range of muscle work (PP at rest was 61,603 +/- 25,100 M-1 and fell to 6,700 +/- 900 M-1 at the end of exercise); and 5) poststimulation recovery was rapid, with a rate of 2.27 +/- 0.5 PCr/Pi U/min. This simple model can be used for prolonged studies of chronic animal muscle disorders.

Application of electromagnetic and sound waves in nutritional assessment

Four relatively new techniques that apply electromagnetic or sound waves promise to play a major role in the study of human body composition and in clinical nutritional assessment. Computerized axial tomography, nuclear magnetic resonance, infrared interactance, and ultrasonography provide capabilities for measuring the following: total body and regional fat volume; regional skeletal muscle volume; brain, liver, kidney, heart, spleen, and tumor volume; lean tissue content of triglyceride, iron, and high-energy intermediates; bone density; and cardiac function. Each method is reviewed with regard to basic principles, research and clinical applications, strengths, and limitations.