Mark Bremholm Ellebæk

The open abdomen: temporary closure with a modified negative pressure therapy technique

The most common indications for an open abdomen (OA) are abdominal compartment syndrome, damage control surgery, diffuse peritonitis and wound dehiscence, and often require a temporary abdominal closure (TAC). The different TAC methods that are currently available include skin closure techniques, mesh products and negative pressure therapy (NPT) systems. For this study, we retrospectively reviewed records of 115 OA patients treated with the commercially available NPT systems (V.A.C.® Abdominal Dressing System and ABThera™ Open Abdomen Negative Pressure Therapy System) using a new method of applying the system – the narrowing technique – over a 5‐year period. Endpoints included fascial closure and 30‐day mortality rates and presence of enteroatmospheric fistulas. Secondary closure of the fascia was obtained in 92% (106/115) of the patients with a mortality rate of 17% (20/115) and a fistula rate of 3·5% (4/115). The use of the narrowing technique to apply NPT may explain the high closure rates observed in the patient population of this study. Further studies are necessary to compare the different methods and to evaluate the long‐term outcomes.

Cytokine response in peripheral blood indicates different pathophysiological mechanisms behind anastomotic leakage after low anterior resection: a pilot study

BackgroundAnastomotic leakage (AL) after rectosigmoid resection is a serious complication associated with high morbidity and mortality. This case–control pilot study investigated the changes in blood concentration of 10 different cytokines and 2 complement factors in relation to symptomatic AL after low anterior resection for rectosigmoid cancer.MethodsFifty patients scheduled for resection of rectosigmoid cancer had blood samples taken the day before surgery and on post-operative days 1, 3 and 5. Four patients with symptomatic AL were identified. Twenty-two age- and disease-matched patients constituted the control group. The concentration of 10 cytokines (granulocyte macrophage colony-stimulating factor, interferon-γ, interleukin-1β, interleukin-2, interleukin-4, interleukin-5, interleukin-6, interleukin-8, interleukin-10 and tumour necrosis factor-α) and 2 complement factors (mannan-binding lectin and membrane attack complex) were measured.ResultsThe present study demonstrated that plasma concentration of interleukin-1β, interleukin-6, interleukin-8 and interleukin 10 within the first 5 post-operative days was increased in patients who developed early clinical AL, whereas there were no changes in patients with late-onset AL.ConclusionsThe demonstrated differences in the cytokine response in early and late AL may support the theory of different pathological mechanisms of AL.

Early detection and the prevention of serious complications of anastomotic leakage in rectal cancer surgery

Anastomotic leakage (AL) after low anterior resection for rectal cancer is a challenging complication in rectal cancer surgery. The reported frequency is 10–20 % in most publications, irrespective of the creation of a diverting stoma. AL has both immediate and long-term consequences that affect morbidity, mortality, functional and oncological outcome. The oncological impact of AL is still under discussion. Several studies have demonstrated an increase in local recurrence rate and a decreased overall survival, while other studies have failed to demonstrate this connection. A recent study showed that AL, which required reoperation, was associated with a significantly higher local recurrence and lower overall survival rate [1]. In most cases, the clinical presentation of AL is insidious with vague and uncharacteristic abdominal symptoms, which may be masked by the use of epidural analgesia. Some cases may present with extraintestinal manifestations such as atrial fibrillation or mental confusion. Thus, AL is typically not recognized until postoperative day 5–7, which in many cases means there is significant delay in diagnosis. Another explanation of delayed diagnosis might be the low diagnostic sensitivity and specificity of common clinical tests such as body temperature, C-reactive protein (CRP) concentration and leukocyte count in peripheral blood, which moreover may be obscured by other inflammatory conditions such as pneumonia, urinary tract infections and surgical site infections. The same may apply to other inflammatory parameters such as cytokines. A recent pilot study conducted by our group using a panel of 10 cytokines and 2 complement factors in patients with and without AL found that only combined changes in IL-4, IL-6 and IL-10 could accurately predict leak (submitted for publication). A study on postoperative CRP in elective abdominal surgery, published in the present issue, showed that patients with CRP \ 135 mg/L on postoperative day 3 were unlikely to develop AL. However, the sensitivity and specificity for AL of elevated values were dependent upon the duration of the elevation in the CRP concentration [2]. Regular computed tomography (CT) scan and endoscopy are other possible but less attractive investigations due to irradiation and the risk of iatrogenic anastomotic dehiscence. Early diagnosis of AL is important to reduce the negative effects on the patient’s health and to increase the success rate of treatment without reoperation. Therefore, new tests for early diagnosis of AL, before the development of overt symptoms, are warranted. The problem is that the complete pathophysiological background of AL is unknown. Several factors such as ischemia, inflammation, surgical techniques, comorbidity and preoperative radiochemotherapy may be involved. It is well documented that a diverting loop ileostomy reduces the risk of serious complications due to AL such as fecal peritonitis, reoperation, prolonged morbidity, permanent stoma and death. However, a diverting loop ileostomy is not without consequences and discomfort for the patient. In patients without AL, it has been demonstrated that a diverting stoma is associated with a higher long-term mortality rate than in patients without a stoma, due to stoma-related complications, missed adjuvant chemotherapy and complications of stoma closure. The use of ‘‘ghost’’ ileostomy, which allows selective loop ileostomy formation or early closure of the stoma before postoperative day 8–14, may be an alternative [3, 4]. The use of a transanal tube is dubious [5, 6]. Intraoperative laser M. Ellebaek (&) N. Qvist Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark e-mail: markep01@gmail.com

Postoperative complications following percutaneous endoscopic gastrostomy are common in children

Inserting a feeding tube using percutaneous endoscopic gastrostomy may be necessary to ensure that children with eating problems receive sufficient enteral nutrition. The aim of this study was to investigate the perioperative and postoperative complications of percutaneous endoscopic gastrostomy when the pull‐through method was the standard procedure.

Acute pancreatitis secondary to duodeno-duodenal intussusception caused by a duodenal membrane, in a patient with intestinal malrotation

Highlights • Intussusception is not always seen on ultrasonography but can revealed by a CT-scan.• Any child, and especially those with previous congenital disorders, must undergo upper GI- endoscopy at the presence of intermittent upper gastrointestinal symptoms as vomiting, abdominal pain and gastro-oesophageal reflux, to exclude upper GI anomaly.

Secondary anastomosis after preoperative botulinum type A toxin injection in a case with long gap oesophageal atresia.

The treatment of long gap oesophageal atresia is challenging. Primary gastric pull-up or secondary anastomosis, after awaiting the spontaneous growth of the upper and lower pouch or elongation techniques, are the most commonmethods.1,2 The gastric pull-up and colonic interposition may result in long-term functional problems and delayed primary anastomosis may be difficult or impossible due to insufficient elongation. We present a case where intramural botulinum type A toxin injection in the proximal and distal pouch resulted in an additional elongation making secondary anastomosis possible.

Intramural injection with botulinum toxin significantly elongates the pig esophagus

BACKGROUND/PURPOSE Surgical treatment of long-gap esophageal atresia (LGEA) is challenging. Methods which facilitate stretching of the esophageal pouches may allow primary anastomosis. Botulinum toxin type A (BTX-A) blocks acetylcholine release in neuromuscular junctions, thereby causing muscle relaxation. We hypothesized that intramural injections with BTX-A into the esophageal wall of piglets would significantly elongate the tissue upon stretch. METHODS Twenty-four piglets were randomized to receive BTX-A of placebo (saline). After one hour, the esophagus was removed en bloc and tested in a stretch-tension device. RESULTS The mean esophageal elongation was 84% (range 83-101) in the BTX-A-group and 65% (50-78) in the control group. The mean difference between the two groups was 18%, which was significant (p < 0.001). CONCLUSION Intramural injections with botulinum toxin type A elongate the esophagus significantly. Clinically, this could be a potential method to achieve primary anastomosis in LGEA. Additional clinical studies are necessary to evaluate the method before it can be generally recommended.

Intraperitoneal microdialysis in the postoperative surveillance of infants undergoing surgery for congenital abdominal wall defect: A pilot study

PURPOSE This study aims to investigate the safety and clinical implication of intraperitoneal microdialysis (MD) in newborns operated on for congenital abdominal wall defect. PATIENTS AND METHODS 13 infants underwent intraperitoneal microdialysis (9 with gastroschisis and 4 with omphalocele). MD samples were collected every four hours and the concentrations of lactate, glycerol, glucose and pyruvate were measured. The results of MD were compared between the group of infants with gastroschisis and the group with omphalocele. The duration of parenteral nutrition and tube feeding were compared for high and low levels of intraperitoneal lactate, glycerol, and glucose and lactate/pyruvate ratio respectively. High and low levels were defined as above or below the median value on day one. RESULTS Results from intraperitoneal MD showed a significantly higher mean lactate concentration in the group of infants with gastroschisis compared with the group of infants with omphalocele. The median values were 6.19 mmol/l and 2.19 mmol/l, respectively (P=0.006). The results from MD in the six infants in the gastroschisis group who underwent secondary closure after Silo treatment were similar to those who underwent primary closure. None of the infants with omphalocele received parenteral nutrition whereas all of the infants with gastroschisis did. There was no significant difference in duration of parenteral nutrition or tube feeding, respectively, when comparing the gastroschisis children with high versus low intraperitoneal lactate values. Placement of the MD catheter in the intraperitoneal cavity was feasible and without any major complications. CONCLUSION Intraperitoneal MD is a safe procedure and an applicable method in surveillance of inflammatory changes in the peritoneal cavity in infants after operation for congenital abdominal wall defect. The true clinical value in infants with congenital wall defect remains unknown.

Intramural Injection with Botulinum Toxin Type A in Piglet Esophagus. The Influencer on Maximum Load and Elongation: A Dose Response Study

Introduction The treatment of esophageal atresia (OA) is challenging. The main goal is to achieve primary anastomosis. We have previously demonstrated in a pig model that intramural injection of botulinum toxin type A (BTX-A) resulted in significant elongation of the esophagus during tensioning until bursting point. The objectives of the present study were to investigate the influence of different amounts of intramural BTX-A on the stretch-tension characteristics and histological changes of the esophagus in piglets. Materials and Methods A total of 52 piglets were randomized to four groups receiving 2, 4, or 8 units/kg of BTX-A or isotonic saline (placebo). After a 1-hour of rest the esophagus was harvested and subjected to a stretch-tension test and histological examination to assess changes in the density of presynaptic vesicles in the nerve cells. Results Overall, 9 of the 52 animals were excluded from analysis due to problems with the stretch-tension test or death from anesthesia. The maximum loads were higher in the BTX-A groups (2 units/kg: +2.1 N; 4 units/kg: +1.3 N; 8 units/kg: +1.9 N) than the placebo (p = 0.046). There were no significant differences in percentage elongation, or histology. Conclusions This study demonstrated that injection of 2 units/kg BTX-A into a nonanastomosed esophageal wall resulted in a modest increase in the maximum load achieved before bursting; this may be due to the muscle-relaxant effect of BTX-A. BTX-A injection produced no significant effects on elongation or esophageal histology. The clinical usefulness of BTX-A in treatment of OA is still unclear.

Full-thickness rectal biopsy in children suspicious for Hirschsprung's disease is safe and yields a low number of insufficient biopsies

INTRODUCTION The diagnosis of Hirschsprungs disease (HD) relies on the histological demonstration of aganglionosis in the bowel wall. Biopsies may be obtained by rectal suction biopsy (RSB) or by transanal full-thickness excision biopsy (FTB). The objective of the present study was to evaluate the frequency of complications and inconclusive biopsies after FTB in children referred with suspicion of HD. The secondary objective was to calculate the frequency of proven aganglionosis. METHODS A retrospective chart review was performed of all patients under the age of 16years who underwent transanal FTB during the time period of 2008-2014. RESULTS A total of 555 patients were included in the review. Inconclusive biopsies were found at the primary biopsy in 35 patients (5.9%). Aganglionosis was found in 12% of the cases. The complication rate was 6.6% (39 patients), 85% of which were classified as a Clavien-Dindo I-II and 15% were classified as Clavien-Dindo III. CONCLUSIONS In this retrospective evaluation of FTB for the diagnosis of HD, the frequency of inconclusive biopsies at primary attempt was low and the complication rate was relatively high. However, most were minor complications. LEVEL OF EVIDENCE III.