Asgaut Viste

Long-term Prognosis After Operation for Adhesive Small Bowel Obstruction

Aim of Study:The objective of this study was to determine the pattern of recurrence after one or more episodes of adhesive small bowel obstruction (ASBO) during a follow-up period of up to 40 years. Furthermore, we wanted to analyze possible factors with an influence on the recurrence rate and to study the magnitude of “everyday” abdominal pain among these patients. Patients and Methods:Hospital records of 500 patients operated on for adhesive obstruction at Haukeland University Hospital from 1961 to 1995 were studied. The patients were followed until death, loss to follow-up, or end of study (February 2002), with a median follow-up of 10 years and a maximum follow-up time of 40 years. A questionnaire was sent to all living patients to obtain information on recurrences and abdominal complaints. Results:The cumulative recurrence rate for patients operated once for ASBO was 18% after 10 years and 29% at 30 years. For patients admitted several times for ASBO, the relative risk of recurrent ASBO increased with increasing number of prior ASBO episodes. The cumulative recurrence rate reached 81% for patients with 4 or more ASBO admissions. Other factors influencing the recurrence rate were the method of treatment of the last previous ASBO episode (conservative versus surgical) and the number of abdominal operations prior to the initial ASBO operation. Compared to results from the general populations, more ASBO patients suffer from abdominal pain at home. Women and patients having matted adhesions have significantly more complaints about abdominal pain than men and patients with band adhesions. Conclusion:The risk of recurrence increased with increasing number of ASBO episodes. Most recurrent ASBO episodes occur within 5 years after the previous one, but a considerable risk is still present 10 to 20 years after an ASBO episode. Surgical treatment decreased the risk of future admissions for ASBO, but the risk of new surgically treated ASBO episodes was the same regardless of the method of treatment. People treated for ASBO seem to be more prone to experiencing abdominal pain than the normal population, especially those having matted adhesions.

Postoperative complications and mortality after surgery for gastric cancer.

Complication rates and postoperative mortality were studied in 1010 consecutive patients entered into the Norwegian Stomach Cancer Trial. Twenty-eight per cent of the patients had one or more complications (31% of the men and 21% of the women). General complications (pneumonia, thromboembolic, and cardiac) were most frequent. The postoperative mortality rate for resected patients was 8.3% (63 of 763). Complication and mortality rates were highest for proximal resections (52% and 16%) followed by total gastrectomy (38% and 8%), subtotal resection (28% and 10%), and distal resection (19% and 7%). By logistic regression analysis it was found that age, sex, operative procedure, prophylactic antibiotics, and splenectomy were significantly related to postoperative complications. The odds ratio for complication for men versus women was 1.75: for no antibiotics versus antibiotic prophylaxis it was 2.5. Relative to distal resection the odds ratio for complications after subtotal resection was 2.2, for total gastrectomy was 3.9, and for proximal resection was 7.6. Age and sex were the only factors that affected operative mortality. The odds ratio for mortality for men versus women was 2.3. The odds ratio for operative mortality was 2.2 when the age of the patient increased with 10 years.

Complications and Death After Surgical Treatment of Small Bowel Obstruction: A 35-Year Institutional Experience

OBJECTIVE To study factors influencing complications and death after operations for small bowel obstruction (SBO) using multifactorial statistical methods. SUMMARY BACKGROUND DATA Death after surgery for SBO is believed to be influenced by factors such as old age, comorbidities, bowel gangrene, and delay in treatment. No studies have been reported in which adverse factors related to death and complications have been systematically investigated with modern statistical methods. METHODS The authors studied retrospectively 877 patients who underwent 1,007 operations for SBO from 1961 to 1995. Patients with paralytic ileus, intussusception, and abdominal cancer were excluded. Odds ratios for death, complications, postoperative hospital stay, and strangulation were calculated by means of logistic regression analyses. RESULTS Death and complication rates decreased during the study period. Old age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. The rate of nonviable strangulation increased markedly with patient age. Major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery. CONCLUSION Death and complication rates after SBO decreased from 1961 to 1995. Major factors influencing the rates were age, comorbidity, nonviable strangulation, and treatment delay. Nonviable strangulation was more common in old patients.

Gastroesophageal reflux in morbidly obese patients treated with gastric banding or vertical banded gastroplasty

OBJECTIVE To compare gastric banding (GB) and vertical banded gastroplasty (VBG) with respect to postsurgical gastroesophageal reflux (GER) and to investigate the role of preexisting hiatus hernia. SUMMARY BACKGROUND DATA GB and VBG have for a long time been used in the treatment of morbidly obese patients. The introduction of laparoscopic techniques has renewed the interest in these operations. The long-term results after GB have, however, been poor. VBG was suggested to have antireflux properties because it involves repositioning and retaining the gastroesophageal junction within the abdomen and constructing an elongated intraabdominal tube. METHODS Forty-three morbidly obese patients accepted for GB or VBG were evaluated for GER before and at regular intervals after surgery. All patients were questioned about adverse symptoms and need for antireflux medication. Both before and after surgery, 24-hour pH measurement and upper gastrointestinal endoscopies were performed. RESULTS The prevalence of heartburn and acid regurgitation among patients treated with GB increased from 14% and 13% to 63% and 69%, respectively. Heartburn and acid regurgitation were present before surgery in 32% and 23% of patients treated with VBG, percentages unchanged by the procedure. The 24-hour reflux time increased significantly from 6.4% to 30.9% in patients treated with GB but was essentially unchanged in patients treated with VBG. The prevalence of esophagitis after GB and VBG was 75% and 20%. Acid inhibitors were needed in 81% of patients after GB and 29% of patients after VBG. CONCLUSIONS The prevalence of GER was unchanged by VBG, but VBG did not demonstrate antireflux properties. The incidence of GER increased markedly after GB.

Acute pancreatitis in Bergen, Norway. A study on incidence, etiology and severity.

Background: Studies on the incidence and etiology of acute pancreatitis show large regional differences. This study was performed to establish incidence, etiology and severity of acute pancreatitis in the population of Bergen, Norway. Methods: A study of all patients with acute pancreatitis admitted to Haukeland University Hospital over a 10-year period was performed. Information was obtained about the number of patients with acute pancreatitis admitted to the Deaconess Hospital in Bergen. Results: A total of 978 admissions of acute pancreatitis were recorded in these two hospitals giving an incidence of 30.6 per 100 000. Haukeland University Hospital had 757 admissions of acute pancreatitis in 487 patients. Pancreatitis was severe in 20 % (96/ 487) of patients, more often in males (25 %) than in females (14 %). Mortality due to acute pancreatitis was 3 % (16/487). Gallstones were found to be an etiological factor in 48.5 % and alcohol consumption in 19 % of patients. The risk of recurrent pancreatitis was 47 % in alcohol induced and 17 % in gallstone induced pancreatitis. The last five years of the study period, endoscopic sphincterotomy of patients with gallstone pancreatitis, resulted in drop in relapse rate from 33 % to 1.6 %. Conclusion: The incidence of acute pancreatitis was found to be 30.6 per 100 000 with 48.5 % associated with gallstones and 17 % alcohol induced. Incidence of first attack was 20/100 000. Pancreatitis was classified as severe in 20 % of cases with a mortality of 3 %.

Early Operation or Conservative Management of Patients with Small Bowel Obstruction

OBJECTIVE To evaluate the outcome after initial non-operative treatment in patients with small bowel obstruction (SBO). DESIGN Prospective study. SETTING University hospital, Norway. PATIENTS One hundred and fifty-four patients with 166 episodes of SBO admitted during the period (1994-1995). Patients younger than 10 years as well as patients with large bowel obstruction, paralytic ileus, incarcerated hernia or SBO caused by cancer were excluded from the study. INTERVENTIONS Patients with signs of strangulation were operated on early. The rest were given a trial of conservative treatment. MAIN OUTCOME MEASURES Need of operative treatment. Incidence of bowel strangulation, complications and death. RESULTS There were 166 cases of SBO. Twenty patients were operated on early among whom bowel was strangulated in 9. Among the 146 patients initially treated conservatively 93 (64%) settled without operation, 9 (6%) had strangulated bowel and 3 (2%) died. Of the 91 patients with partial obstruction but no sign of strangulation, 72 (79%) resolved on conservative treatment. CONCLUSIONS Patients with partial obstruction with no sign of strangulation should initially be treated conservatively. When complete obstruction is present, it may settle on conservative management, but the use of supplementary diagnostic tools might be desirable to find the patients who will need early operative treatment.

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours.

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Early treatment of severe pancreatitis with imipenem: a prospective randomized clinical trial.

Objective. The main causes of death in severe pancreatitis are multiorgan failure and septic complications. Prophylactic treatment with effective antibiotics is therefore a tempting therapeutic option. However, there could be side effects such as selection of resistant microbes and fungi. The aim of the present study was to compare the rate of infectious complications, interventions, days in the intensive care unit (ICU), morbidity and mortality in patients with severe pancreatitis randomized to prophylactic therapy with imipenem compared with those receiving no treatment at all. Material and methods. Seventy-three patients with severe pancreatitis were included in a prospective, randomized, clinical study in seven Norwegian hospitals. The number of patients was limited to 73 because of slow patient accrual. Severe pancreatitis was defined as a C-reactive protein (CRP) level of >120 mg/l after 24 h or CRP >200 48 h after the start of symptoms. The patients were randomized to either early antibiotic treatment (imipenem 0.5 g×3 for 5–7 days) (imipenem group) (n=36) or no antibiotics (control group) (n=37). Results. The groups were similar in age, cause of pancreatitis, duration of symptoms and APACHE II score. Patients in the imipenem group experienced lower rates of complications (12 versus 22 patients) (p=0.035) and infections (5 versus16 patients) (p=0.009) than those in the control group. There was no difference in length of hospital stay (18 versus 22 days), need of intensive care (8 versus 7 patients), need of acute interventions (10 versus 13), nor for surgery (3 versus 3) or 30-day mortality rates (3 versus 4). Conclusions. The study, although underpowered, supports the use of early prophylactic treatment with imipenem in order to reduce the rate of septic complications in patients with severe pancreatitis.

Upper gastrointestinal contrast study in the management of small bowel obstruction--a prospective randomised study.

OBJECTIVE To find out whether contrast radiography helps to resolve small bowel obstruction. DESIGN Prospective randomised trial. SETTING University hospital, Norway. SUBJECTS 98 consecutive patients with symptoms of small bowel obstruction and a plain abdominal radiograph that confirmed the diagnosis. INTERVENTIONS The patients were randomly allocated to receive a mixture of barium and sodium diatrizoate (Gastrografin) (n = 48) or not (n = 50). Both groups were followed up clinically and by repeated abdominal films. MAIN OUTCOME MEASURES Non-operative resolution of small bowel obstruction; number of patients with strangulated bowel; bowel resections; mortality; complications; hospital stay; and time from admission to operation. RESULTS No significant differences were observed between the groups in the incidence of non-operative resolution (31/48 in contrast group, 35/50 in control group, OR: 0.89), strangulation obstruction (1/48 in contrast group, 4/50 in control group, OR: 0.24), bowel resection (3/48 in contrast group, 4/50 in control group, OR: 0.76), complications (8/48 in contrast group, 5/50 in control group, OR: 1.80), mortality (3/48 in contrast group, 1/50 in control group, OR: 3.26), and hospital stay (0-7 days: 34/48 in contrast group, 38/50 in control group, p = 0.95). The contrast group had a shorter interval between admission and operation than the control group (0-24 hours: 12/48 in contrast group, 3/50 in control group, p = 0.005). CONCLUSION The contrast examination did not contribute to the resolution of small bowel obstruction.

Effects of prolonged increased intra-abdominal pressure on gastrointestinal blood flow in pigs

BackgroundThe aim of the study was to investigate the effects of prolonged intra-abdominal pressure on systemic hemodynamics and gastrointestinal blood circulation.MethodsThe intra-abdominal pressure in anesthetized pigs was elevated to 20 mmHg (7 animals), 30 mmHg (7 animals), and 40 mmHg (4 animals), respectively. These pressures were maintained for 3 h by intra-abdominal infusion of Ringer’s solution. A control group of seven animals had normal intra-abdominal pressure (IAP). Transit time flowmetry and colored microspheres were used to measure blood flow.ResultsAn IAP of 20 mmHg did not cause significant changes in systemic hemodynamics or tissue blood flow. An IAP of 30 mmHg caused reduced blood flow in the portal vein, gastric mucosa, small bowel mucosa, pancreas, spleen, and liver. Serum lactate increased in animals with an IAP of 30 mmHg, but microscopy did not disclose mucosal damage in the stomach or small bowel. An IAP of 40 mmHg was followed by severe circulatory changes.ConclusionsProlonged IAP at 20 mmHg did not cause changes in general hemodynamics or gastrointestinal blood flow. Prolonged IAP at 30 mmHg caused reduced portal venous blood flow and reduced tissue flow in various abdominal organs, but no mucosal injury. A prolonged IAP of 40 mmHg represented a dangerous trauma to the animals.