Peer Wille-Jørgensen

Risk Factors for Tissue and Wound Complications in Gastrointestinal Surgery

Background:Surgical site infections and disruption of sutured tissue are frequent complications following surgery. We aimed to assess risk factors predictive of tissue and wound complications in open gastrointestinal surgery. Methods:Data from 4855 unselected patients undergoing open gastrointestinal surgery from 1995 through 1998 were recorded in a clinical database and validated. The database embraced variables related to patient history, preoperative clinical condition, operative findings and severity, and the surgeons training. Variables predictive of surgical site infection and dehiscence of sutured tissue within 30 days after surgery were assessed by multiple logistic regression analysis. Results:Following elective operation, the incidence of tissue and wound complications was 6% compared with 16% in emergency surgery (P < 0.001). These complications resulted in prolonged hospitalization in 50% of the patients and a 3-fold higher risk of reoperation but not increased mortality. Factors associated with complications following elective operations were smoking, comorbidity, and perioperative blood loss. Following emergency operations, male gender, peritonitis, and multiple operations were predictors of complications. Irrespective of elective or emergency surgery, the type of operation was a predictor of complications. Conclusion:Factors known to affect the process of tissue and wound healing are independently associated with tissue and wound complications following gastrointestinal surgery.

Self-expanding metal stents for colonic obstruction: Experiences from 104 procedures in a single center

Purpose: In the past, colonic obstruction caused by malignancy most often resulted in high-risk operations, usually involving two-step procedures or leaving the patient with a stoma in case of disseminated disease. Methods: Between May 1997 and January 2003, 104 procedures with selfexpanding metal stents have been performed in 96 patients at our institution. The goals of the procedure were either postponement of emergency operation or definitive palliative treatment. Surgeons with combined endoscopic and fluoroscopic technique performed all procedures. In most cases no analgesia or only slight sedation was used. Seven types of stents were used, CHOO stents and Wallstents accounting for the majority. Results: A total of 96 patients were included, 44 men and 52 women, with a mean age of 78 (range, 41–100) years. Technical success was achieved in 92 percent; clinical success, in 82 percent. Thirty-eight patients presented with an acute obstruction and were treated with self-expanding metal stents. Seventeen patients later underwent an elective resection, 9 patients were not decompressed, and 12 patients had disseminated disease and were not treated further. Eight patients had benign strictures. These eight patients accounted for several of the reinterventions, and only three patients truly gained benefit from stenting. In the remaining patients disseminated disease was diagnosed and the acute stenting served as the definitive palliative treatment. Procedure-related complications were few: perforation occurred in three patients during stenting and in one instance 6 to 7 hours after. Other technical problems could mainly be overcome by introducing an additional stent. Complications seen in the group treated with self-expanding metal stents and subsequent resection [mortality N = 3 (18 percent)], anastomotic leakage [N = 3 (18 percent)], do not differ from the number of complications we usually see in our patients who undergo elective colorectal resection. Conclusions: The use of self-expanding metal stents in malignant colonic obstruction is a safe and effective procedure with a low mortality and morbidity. In our experience the stenting of benign strictures is ineffective and combined with a high rate of complications.

Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study.

INTRODUCTION The aim of this study was to investigate the incidence of deep vein thrombosis (DVT) in patients immobilized in plaster cast and the possible efficacy of prophylaxis with low molecular weight heparin (LMWH). MATERIAL AND METHODS The study was a randomized, assessor-blinded, open multicenter (three centers) study. All patients over 18 years of age with planned plaster cast on a lower extremity of at least 3 weeks were eligible for participation. Written informed consent was obtained from 300 patients and they were randomized to either 3.500 IU anti-Xa of tinzaparin (Innohep) subcutaneously once daily or no prophylaxis. On the day the cast was removed, ascending unilateral venography was performed. Two experienced radiologists, unaware of treatment, assessed the pictures independently. The radiologist had to obtain consensus as to whether DVT was present or not. RESULTS 300 patients were included (148 in the treatment group and 152 in the control group). Ninety-five were subsequently withdrawn. DVT was diagnosed in 10/99 patients in the treatment group and in 18/106 patients in the control group. This difference is not significant (P=.15, chi(2) test) and the odds ratio was 0.55 (95% confidence interval=0.34-1.26). CONCLUSION DVT in legs after plaster casting is a big problem, with an incidence of almost 20%. An effective prophylactic regime is required. Once-daily dose of 3.500 IU anti-Xa of tinzaparin was not sufficient.

Persisting Pain after Cholecystectomy: A Prospective Investigation

A prospective survey of the short-term outcome after cholecystectomy was carried out under circumstances in which the study itself did not influence preoperative decision making or surgical procedures. Of 122 consecutive patients, 115 were evaluable. In all cases gallstones were verified preoperatively either by oral cholecystography or by ultrasonography. Follow-up study was 6-12 months postoperatively. Ninety-one patients (79.1%) reported satisfactory outcome in terms of complete relief of preoperative symptoms. Age, sex, preoperative pain characteristics, history of disease, type of surgery, histology, and complications did not predict the surgical outcome. A test for psychic vulnerability was included among preoperative data items. Psychic vulnerability was significantly associated with persisting pain irrespective of the above-mentioned factors. This suggests that psychologic factors influence the outcome after cholecystectomy with regard to pain relief.

Asymptomatic postoperative deep vein thrombosis and the development of postthrombotic syndrome: A systematic review and meta-analysis

Perioperative antithrombotic clinical regimens have reduced the incidence of postoperative deep venous thrombosis (DVT). Long-term effects of asymptomatic postoperative DVT have been studied in a number of clinical trials and the present review describes the clinical significance of asymptomatic postoperative DVT regarding the possible development of postthrombotic syndrome (PTS). We performed a systematic review of reference databases focusing upon studies including patients suspected of having postoperative DVT and reporting subsequent cases of PTS at the end of a well-defined follow-up period. The included studies were stratified according to type of screening method and applied statistics. Over-all evaluation included meta-analyses based upon the Cochrane software package. The overall relative risk of developing PTS was 1.58 (95% confidence intervals: 1.24-2.02) in patients suffering from asymptomatic DVT as compared to patients without DVT (p<0.0005). In conclusion, asymptomatic postoperative DVT is associated with an increased risk of late development of PTS. The finding emphasizes that postoperative DVT, diagnosed by means of well-defined objective measures, remains the correct scientific endpoint in trials evaluating the efficacy of preoperative antithrombotic treatment regimens.

Staged or simultaneous resection of synchronous liver metastases from colorectal cancer – a systematic review

Objective  A systematic review of the literature was undertaken to estimate the differences in length of hospital stay, morbidity, mortality and long‐term survival between staged and simultaneous resection of synchronous liver metastases from colorectal cancer to determine the level of evidence for recommendations of a treatment strategy.

Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis

OBJECTIVE To study the incidence of late deep venous thrombosis (DVT), and to evaluate a regimen of prolonged thromboprophylaxis after general surgery. DESIGN Randomised, controlled, open trial, with blinded evaluation. SETTING University hospital, Denmark. SUBJECTS 176 consecutive patients undergoing major elective abdominal or non-cardiac thoracic operations, of whom 118 were eligible for evaluation. INTERVENTIONS Thromboprophylaxis with a low-molecular-weight heparin, tinzaparin, given for four weeks (n = 58), compared with one week (control group, n = 60). MAIN OUTCOME MEASURES Presence of DVT established by bilateral venography four weeks after the operation. RESULTS The incidence of late DVT in the control group was 6/60 (10%, 95% confidence interval (CI) 4% to 21%). In the prophylaxis group it was 3/58 (5.2%, 95% CI 1% to 14%) (p = 0.49). CONCLUSION Prolonged thromboprophylaxis had no significant effect on the incidence of DVT occurring late after general surgery.

Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 2: long-term outcome.

Objective  We reviewed recent literature to assess the impact of hospital caseload, surgeons caseload and education on long‐term outcome following colorectal cancer surgery.

Clinical Value of Preoperative Mechanical Bowel Cleansing in Elective Colorectal Surgery: A Systematic Review

AbstractPURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1) Overall anastomotic leakage —six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2) Peritonitis— three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3) Wound infection —six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.

Lumbar regional anaesthesia and prophylactic anticoagulant therapy : is the combination safe ?

A survey has been carried out in all Danish anaesthetic departments (n = 80) regarding the attitude towards the use of epidural/spinal lumbar analgesia in patients who were receiving prophylactic anticoagulant therapy for the prevention of thromboembolism. About 60% of the departments used the techniques in patients receiving low‐dose heparin and no side effects had been experienced. Spinal and epidural anaesthesia were in general regarded as being contraindicated in patients fully anticoagulated with vitamin K antagonists. In the world literature, the attitude towards the combination is conflicting. No randomised trial has been performed and complications are almost entirely confined to patients fully anticoagulated with vitamin K antagonists. Only one case of an epidural haematoma has been recorded when subcutaneous low‐dose heparin was used as thromboprophylaxis.