Beatrice Pessia

Short- and Long-Term, 11–22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients

Background Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated. Methods Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m2), and patients with a BMI up to a maximum of 34.9. Results 201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI. Conclusions BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

Gut barrier function and systemic endotoxemia after laparotomy or laparoscopic resection for colon cancer: A prospective randomized study

Purpose: The gut barrier is altered in certain pathologic conditions (shock, trauma, or surgical stress), resulting in bacterial and/or endotoxin translocation from the gut lumen into the systemic circulation. In this prospective randomized study, we investigated the effect of surgery on intestinal permeability (IP) and endotoxemia in patients undergoing elective colectomy for colon cancer by comparing the laparoscopic with the open approach. Patients and Methods: A hundred twenty-three consecutive patients underwent colectomy for colon cancer: 61 cases were open resection (OR) and 62 cases were laparoscopic resection (LR). IP was measured preoperatively and at days 1 and 3 after surgery. Serial venous blood sample were taken at 0, 30, 60, 90, 120, and 180 min, and at 12, 24, and 48 h after surgery for endotoxin measurement. Results: IP was significantly increased in the open and closed group at day 1 compared with the preoperative level (P < 0.05), but no difference was found between laparoscopic and open surgery group. The concentration endotoxin systemic increased significantly in the both groups during the course of surgery and returned to baseline levels at the second day. No difference was found between laparoscopic and open surgery. A significant correlation was observed between the maximum systemic endotoxin concentration and IP measured at day 1 in the open group and in the laparoscopic group. Conclusion: An increase in IP, and systemic endotoxemia were observed during the open and laparoscopic resection for colon cancer, without significant statistically difference between the two groups.

Laparoscopic versus open colorectal surgery for colon cancer: the effect of surgical trauma on the bacterial translocation. A prospective randomized study

BACKGROUND Several studies suggest that surgical manipulation of the intestine and increased intra-abdominal pressure promotes bacterial translocation (BT). This prospective randomized study has investigated the effect of surgery on BT in patients undergoing elective colectomy for colon cancer by comparing the laparoscopic with the open approach. METHODS One hundred nineteen consecutive patients underwent colectomy for colon cancer: 59 cases underwent open resection and 60 cases underwent laparoscopic resection. For bacterial identification, tissue samples were taken from the liver, spleen, and mesenteric lymph nodes. RESULTS The incidence of BT increased in laparoscopic and open group after bowel mobilization (prior to ligation of the vascular pedicle), compared with the before mobilization (P < .05). There was not a statistically significant difference in BT value between the 2 groups. CONCLUSION BT increase was observed during the open and laparoscopic resection for colon cancer, without significant statistical difference between the 2 groups.

Thyroid Surgery: To Drain or Not to Drain, That Is the Problem - A Randomized Clinical Trial

Purpose: We conducted a prospective, randomized study to evaluate the necessity of drainage after thyroid surgery. Methods: The patients (n = 215) were randomly assigned to be treated with suction drains (group 1; n = 108) or not (group 2; n = 107). Results: The postoperative pain scores were significantly lower in the non-drained group than in the drained group of patients at postoperative days 0 and at 1. Hematomas, seromas, wound infections, transient biochemical hypoparathyroidism, and transient damage of the recurrent laryngeal nerve occurred more frequently in the drained group than in the non-drained group. The mean hospital stay was significantly shorter in the non-drained group than in the drained group. Conclusions: Routine drain emplacement after thyroidectomy is unnecessary.

Effects of low and standard intra-abdominal pressure on systemic inflammation and immune response in laparoscopic adrenalectomy: A prospective randomised study

Background: The advantages of laparoscopic adrenalectomy (LA) over open adrenalectomy are undeniable. Nevertheless, carbon dioxide (CO2) pneumoperitoneum may have an unfavourable effect on the local immune response. The aim of this study was to compare changes in the systemic inflammation and immune response in the early post-operative (p.o.) period after LA performed with standard and low-pressure CO2pneumoperitoneum. Materials and Methods: We studied, in a prospective randomised study, 51 patients consecutively with documented adrenal lesion who had undergone a LA: 26 using standard-pressure (12-14 mmHg) and 25 using low-pressure (6-8 mmHg) pneumoperitoneum. White blood cells (WBC), peripheral lymphocyte subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein (CRP) were investigated. Results: Significantly higher concentrations of neutrophil elastase, IL-6 and IL-1 and CRP were detected p.o. in the standard-pressure group of patients in comparison with the low-pressure group (P < 0.05). A statistically significant change in HLA-DR expression was recorded p.o. at 24 h, as a reduction of this antigen expressed on the monocyte surface in patients from the standard group; no changes were noted in low-pressure group patients (P < 0.05). Conclusions: This study demonstrated that reducing the pressure of the pneumoperitoneum to 6-8 mmHg during LA reduced p.o. inflammatory response and averted p.o. immunosuppression.

Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial

Background: A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF). Materials and Methods: Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated. Results: A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO2group patients in comparison with the 80% FiO2group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2group; no changes were noted in 80% FiO2group (P < 0.05). Conclusions: This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.

The Effects of High-concentration Oxygen on Inflammatory Markers in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

Background: This study assessed effect of administration of high-concentration supplemental perioperative oxygen on systemic inflammatory and immune response in patients undergoing elective laparoscopic cholecystectomy. Materials and Methods: One hundred seventy-seven patients were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n=88) or 80% (n=89). White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-1 and IL-6, and C-reactive protein were investigated. Results: Significantly higher concentration of neutrophil elastase, IL-1, IL-6 and C-reactive protein was detected postoperatively in the 30% FiO2 group patients in comparison with the 80% FiO2 group (P<0.05). Statistically significant change in human leukocyte antigen-DR expression was recorded postoperatively at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2 group. Conclusions: This study demonstrated that high-concentration (80%) supplemental perioperative oxygen can lead to a reduction in postoperative inflammatory response and avoid postoperative immunosuppression.

Septic Complications after Resection for Middle or Low Rectal Cancer: Role of Gut Barrier Function and Inflammatory Serum Markers

Background: The focus of this study was to understand the relationship between the failure of gut barrier function, inflammatory markers and septic complications after resection for extraperitoneal rectal cancer. Methods: One hundred seven patients were enrolled into this prospective observational study and underwent open colorectal resection for extraperitoneal cancer. All patients underwent an assessment of intestinal permeability (L/M ratio), endotoxemia, interleukin-1β (IL-1β), interleukin-6 (IL-6), C-reactive protein (CRP) and elastase levels before surgery and on postoperative days 1, 3, and 7. Results: Septic complications developed in 23.3% of patients. There were no significant differences in preoperative L/M ratio, endotoxine, CRP, interleukin-1 (IL-1), IL-6, and elastase levels between septic and non-septic groups. All patients showed a significant increase in intestinal permeability, endotoxemia, IL-1, IL-6, CRP, and elastase on the first postoperative day. At postoperative day 7, the septic group continued to demonstrate an increase in intestinal permeability, endotoxemia and elastase and significant difference was observed between the 2 groups (p < 0.05), whereas there was no significant difference in IL-1, IL-6, and CRP levels. Conclusion: The pattern of change in the postoperative period of intestinal permeability, systemic endotoxemia and elastase concentration is significantly higher in patients in whom sepsis develops, while the concentration of IL-1β, IL-6, and CRP does not permit to distinguish infection from inflammation.

Septic Complications After Pancreatoduodenectomy for Pancreatic Adenocarcinoma: Are Increased Gut Permeability and Inflammatory Serum Markers Responsible?

FIGURE 1. Correlation between systemic endotoxin concentration and intestinal permeability measured as lactulose/mannitol excretion ratio (L/M ratio) at day 7. (rs = 0.918; P = 0.001). To the Editor: A number of studies have investigated the relationship between failure of the gut barrier function and septic complications, although the data from these studies have been confusing, with some studies suggesting that gut barrier dysfunction was not associated with the development of sepsis, whereas others have not replicated these findings. The focus of this study was the relationship between the failure of gut barrier function, endotoxemia, inflammatory serum markers (interleukin [IL]-1β, IL-6, C-reactive protein [CRP], and elastase) and septic complications after pancreatoduodenectomy for adenocarcinoma in the head of the pancreas.