A.M. Lower

Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study

BACKGROUND Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures. METHODS We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people. FINDINGS 1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions. INTERPRETATION Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

Postoperative adhesions: Ten-year follow-up of 12,584 patients undergoing lower abdominal surgery

PURPOSE: Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million. METHODS: Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease. RESULTS: In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery—with 8.2 and 10.3 directly related to adhesions. CONCLUSIONS: There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study

Objective To investigate the epidemiology of, and the clinical burden related to, adhesions following gynaecological surgery.

Does pretreatment with progestogen or oral contraceptive pills in low responders followed by the GnRHa flare protocol improve the outcome of IVF-ET?

AbstractPurpose: Women undergoing in vitro fertilization with lowovarian reserve and poor response to controlled ovarianhyperstimulation (COH) present a management dilemma.In a retrospective observational study, we compared thepretreatment use of the gestogen medroxyprogesterone acetate(10 mg twice daily from day 15 of the cycle for aminimum of 2 weeks) with an oral contraceptive pill (onetablet daily from day 4 of the cycle for a minimum of 3 weeks). Methods: The criteria for inclusion in the study includedone or more of the following: abandoned cycles due topoor response, fewer than four oocytes retrieved followinga standard COH protocol, age >39 years, and elevatedbasal serum follicle-stimulating hormone (FSH).Thirty-eight women received pretreatment with gestogen, and asimilar number of women received pretreatment with thepill. The flare protocol was used in all treatment cyclescombined with an individualized dose of human menopausalgonadotropin (hMG) (4–8 ampoules/day of 75 units FSH/ampoule) depending on previous response, age, and earlyfollicular serum FSH level. Both groups were similar inmean age, duration of infertility, early follicular FSH levels,and the distribution of various aetiologies. Results: Twenty-nine cycles were abandoned before oocyteretrieval, 15 (39.5%) in the pill group and 14 (36.8%) inthe gestogen group, because of an inadequate ovarianresponse. The mean (±SD) number of ampoules (75 IUFSH/ampoule) of hMG used per cycle was similar in thepill and gestogen groups (59.7 ± 19.3 vs. 70.2 ± 29.4,respectively). There also was no difference seen in the numbersof oocytes retrieved (4.4 ± 2.3 vs. 4.2 ± 2.5), totalnumber of embryos (2.5 ± 2.4 vs. 2.2 ± 1.1), or the numberof embryos transferred (1.8 ± 1.2 vs. 2.1 ± 1.0) in the pilland gestogen groups, respectively. One pregnancy in eachgroup resulted following embryo transfer in 22 women inthe pill group and in 24 women in the gestogen group. Conclusions: We conclude that pre-IVF treatment with oralcontraceptive pill or gestogen combined with the flare protocolin women at high risk of or with a history of poor ovarianresponse, as defined in this study, did not appear to resultin an improvement in outcome of IVF-embryo transfer.

New directions in the prevention of adhesion in laparoscopic surgery.

The aim of this review is to appraise critically the literature over the past year with respect to new developments in adhesion prevention strategies. The majority of the work continues to be focused on animal models, and interest continues into the usage of heterologous barriers, which are increasingly derived from or related to hyaluronic acid. The recent trend has been to develop barriers that are not only effective but also technically easy to use for the laparoscopic surgeon--hence the development of barrier gels. It is only through the development of these user-friendly barriers that many laparoscopic surgeons will be willing to incorporate these important preventative measures into their busy daily practice. Routine usage of adhesion prevention measures will ultimately reduce patient morbidity and mortality and relieve the burden on health service provision.

Clinical evaluation of three different gonadotrophin-releasing hormone analogues in an IVF programme: a prospective study.

The efficacy and safety of short acting buserelin and nafarelin intranasal spray were compared to long acting leuprorelin depot intramuscular or subcutaneous injection in this prospective study of 157 women undergoing controlled ovarian hyperstimulation (COH) for in-vitro fertilisation (IVF). Patients were allocated to three groups to receive buserelin 150 microg nasal spray three times daily (Group B), nafarelin nasal spray 400 microg twice daily (Group N), or leuprorelin depot 3.75 mg once by intramuscular or subcutaneous injection (Group L) for pituitary desensitisation prior to commencing COH with human menopausal gonadotrophins (hMG) according to the Centres protocol. The mean (+/-S.D.) age (years) (32.6+/-3.8: Group B, 32.1+/-3.3: Group N versus 32.1+/-3.3: Group L); mean (+/-S.D.) total dosage of hMG (ampoules) (37.5+/-16.1: Group B, 39.8+/-14.2: Group N versus 41.9+/-12.6: Group L) and mean daily dosage of hMG (ampoules) (3.1: Group B, 2.8: Group N versus 3.0: Group L) seen were not statistically significantly different. The duration between starting the different gonadotrophin-releasing hormone (GnRHa) and the beginning of the next menstrual period was also not seen to be statistically significantly different between the three groups (Group B: 10+/-5.5, Group N: 9.1+/-4.1 versus Group L: 8.2+/-3, days). The number of abandoned cycles was higher in Group L (17% versus 11.8%: Group B and 11.3%: Group N) but this difference did not reach statistical significance. The clinical pregnancy rates per oocyte retrieval and per embryo transfer procedure were respectively, 31.1, 35% in Group B, 12.8, 14% in Group N versus 20.5, 23.7 in Group L and were not seen to be statistically significantly different even when ongoing pregnancy rates were compared. Apart from a statistically significantly greater incidence of allergic nasal reactions in the nafarelin group (P=0.001), all other side-effects were not shown to be statistically significantly different between the three groups. We conclude that a single dose of leuprorelin depot can be considered to be as an equally effective alternative to multiple doses of buserelin or nafarelin for pituitary desensitisation in women undergoing COH for IVF.

High concentrations of CA 125 in uterine flushings: influence of cause of infertility and menstrual cycle day

Uterine flushings were obtained under transvaginal ultrasonographic control from 132 women presenting for investigation and treatment of infertility. Levels of CA 125 were measured by radioimmunoassay and results expressed in relation to the total protein concentration of the same flushings. CA 125 was detected in uterine fluid at levels higher than those previously reported in peripheral blood. Uterine fluid CA 125 concentrations varied throughout the menstrual cycle, being highest in the mid-follicular phase (days 6 to 10). Uterine fluid CA 125 concentrations may reflect endometrial secretion of this protein more directly than serum levels. CA 125 concentrations did not vary according to the cause of infertility but further work in larger numbers of women is required.

Chromosome abnormalities detected in chorionic villus biopsies of failing pregnancies in a subfertile population

Objective— To determine the range and prevalence of chromosomal abnormal‐ities occurring in failing pregnancies in subfertile women.