Ulf Petersson

Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction.

Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non‐trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum‐assisted wound closure and mesh‐mediated fascial traction (VAWCM) for long‐term OA treatment, and to describe complications.

Vacuum-assisted wound closure and mesh-mediated fascial traction - A novel technique for late closure of the open abdomen

BackgroundOpen abdomen (OA) treatment often results in difficulties in closing the abdomen. Highest closure rates are seen with the vacuum-assisted wound closure (VAWC) technique. However, we have experienced occasional failures with this technique in cases with severe visceral swelling needing longer treatment periods with open abdomen. Feasibility and short-term outcome of a novel combination of techniques for managing the open abdomen are presented.MethodsThe VAWC technique was combined with medial traction of the fasciae through a temporary mesh in seven consecutive patients. The VAWC-system was changed and the mesh tightened every 2–3 days.ResultsMedian (range) age in the 7 men was 65 (17–78) years. The diagnoses were ruptured abdominal aortic aneurysm (AAA) (3), operation for juxtarenal AAA (1), iatrogenic aortic lesion (1), trauma (1) and abdominal abscesses (1). Four patients were decompressed due to abdominal compartment syndrome (ACS) or intra-abdominal hypertension, and 3 could not be closed after laparotomy. Intra-abdominal pressure prior to OA treatment was 24 (17–36) mmHg. Maximal separation of the fasciae was 16 (7 –30) cm. Delayed primary closure was achieved in all patients after 32 (12–52) days with OA. No recurrent ACS was seen. No technique-specific complication was observed. Two small incisional hernias, one intra-abdominal abscess and one wound infection occurred in three patients.ConclusionsDelayed primary closure in cases with severe visceral swelling and long periods of OA seems feasible with this technique.

Randomized clinical trial of laparoscopic versus open appendicectomy for confirmed appendicitis.

Laparoscopy is safe for diagnostic and therapeutic purposes in patients with suspected acute appendicitis. This study compared recovery after laparoscopic (LA) and open appendicectomy (OA) for confirmed appendicitis, carried out by experienced surgeons in an educational setting.

Short-term Outcomes for Open and Laparoscopic Midline Incisional Hernia Repair: A Randomized Multicenter Controlled Trial: The ProLOVE (Prospective Randomized Trial on Open Versus Laparoscopic Operation of Ventral Eventrations) Trial.

Objective:The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. Background:Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. Methods:Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. Results:Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). Conclusions:Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537)

Quality-of-life and Surgical Outcome 1 Year After Open and Laparoscopic Incisional Hernia Repair: PROLOVE: A Randomized Controlled Trial.

Objective:Patients suffering from an incisional hernia after abdominal surgery have an impaired quality of life (QoL). Surgery aims to improve QoL with a minimum risk of further complications. The aim was to analyze QoL, predictors for outcome, including recurrence and reoperation rates during the first postoperative year. Methods:In a randomized controlled trial comparing laparoscopic and open mesh repair, 133 patients were assessed preoperatively and after 1 year with regard to QoL using the Short Form-36 (SF-36), visual analog scale (pain, movement limitation, and fatigue), and questions addressing abdominal wall complaints. Factors concerning recurrence, reoperations, satisfaction, and improved QoL were analyzed. Results:A total of 124 patients remained for analysis. All SF-36 scores except mental composite score increased, reaching and maintaining levels of the Swedish norm already after 8 weeks with no difference between groups. Event-free recovery was seen in 85% in the laparoscopic group and in 65% of the open cases (P < 0.010). Five recurrences occurred after laparoscopic surgery and 1 in the open group (P < 0.112). Overall, abdominal wall complaints decreased from 82% to 13% of the patients; and 92% were satisfied with the result after 1 year.In univariable logistic regression analyses laparoscopic surgery and male sex predicted an event-free recovery. Obesity (BMI > 30) predicted better outcome with regard to QoL. No predictors for recurrence or satisfaction were identified. Conclusions:Patients with incisional hernia benefit substantially from surgery concerning QoL, independent of surgical technique. An event-free recovery occurred frequently after laparoscopic surgery. SF-36 seems well suited for assessing surgical outcome in patients after incisional hernia repair.

Impact of Mesh Fixation on Chronic Pain in Total Extraperitoneal Inguinal Hernia Repair (TEP): A Nationwide Register-based Study.

Background:Mesh fixation is used to prevent recurrence at the potential risk for chronic pain in TEP. The aim was to compare the impact of permanent fixation (PF) with no fixation (NF)/nonpermanent fixation (NPF) of mesh on chronic pain after TEP repair for primary inguinal hernia. Methods:Men, 30 to 75 years old, consecutively registered in the Swedish Hernia Register for a TEP primary repair in 2005 to 2009, were included in a mail survey using SF-36 and the Inguinal Pain Questionnaire (IPQ). Primary endpoint was IPQ question “Did you have pain during past week that could not be ignored.” Risk factors for chronic pain and recurrent operations were analyzed. Results:A total of 1110 patients were included (325 PF, 785 NF/NPF) with 7.7% reporting pain at median 33 months follow-up. No difference regarding primary endpoint pain (P < 0.462), IPQ and SF-36 subscales were seen. Recurrent operation was carried out in 1.4% during 7.5 years follow-up with no difference between PF- and NF-groups including subgroups of medial hernias. All SF-36 subscale-scores were equal to or better than the Swedish norm. A postoperative complication was a risk factor for chronic pain (OR 2.44, 95% CI 1.23–5.25, P < 0.023). Conclusions:The TEP procedure for primary inguinal hernia repair in men is associated with a low frequency of chronic pain and recurrent operations, with no difference between permanent fixation and no/nonpermanent fixation of mesh in a nationwide population-based study. TEP without fixation reduces costs and is safe for all patients.

Different patterns in immunoreactive anionic and cationic trypsinogen in urine and serum in human acute pancreatitis

SummaryBackgroundAcute pancreatitis (AP) results in elevated concentrations of trypsinogen (T) isoenzymes in serum. Immunoreactive anionic trypsinogen in urin (irAT/u) is elevated in AP, and has recently been proposed as a rapid diagnostic instrument and severity predictor. These results have not been confirmed by other groups, and irAT/u has not been further characterized. The concentration of immunoreactive cationic trypsinogen in urine (irCT/u) and the serum irAT/irCT ratio in AP have not been extensively examined.MethodsLevels of irAT and irCT were studied in urine and serum from 50 AP patients and in urine from 41 non-AP patients. Severity was assessed according to the Atlanta classification. irAT/u was characterized by gel filtration.ResultsGel filtration revealed only AT in the urine. Highly significant differences in irAT/u were seen between AP/non-AP (p < 0.0001) and mild/severe disease (p = 0.0012). The irAT/irCT ratio in serum changed from normal 0.8 to 1.3 in AP.ConclusionsIrAT and only traces of irCT were found in the urine in AP. IrAT/u was higher in AP than in other acute abdominal disorders (non-AP) and also higher in severe than in mild AP. IrAT in serum (irAT/s) increased proportionally more than irCT/s in AP, but did not discriminate mild from severe forms. High levels of irAT/u in some non-AP cases and a wide range in AP cases make the clinical value of the test questionable.

An open access technique to create pneumoperitoneum in laparoscopic surgery.

Background: An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision. Aim: To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients. Methods: A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion. Results: Time for access was median 93 seconds. Entrance time in patients with BMI > 30 (n = 18) was 100 sec and with BMI < 30 it was 90 sec (p = 0,71). The median time for consultants was 88 sec and for residents 120 sec (p = 0,003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent. Conclusion: The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.

Enzyme leakage, trypsinogen activation, and inflammatory response in endoscopic retrograde cholangiopancreatography-induced pancreatitis.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP)–induced pancreatitis (EIP) provides an opportunity to study different pathophysiologic events early in the course of acute pancreatitis. Aims To investigate whether the leakage of pancreatic proenzymes (anionic trypsinogen), pancreatic protease activation (carboxypeptidase B activation peptide), cytokine response (interleukin [IL]–1 receptor antagonist, IL-6, and soluble tumor necrosis factor receptor-I) and neutrophil activation (neutrophil gelatinase–associated lipocalin and polymorphonuclear elastase) differ between patients with and without EIP. A second aim was to clarify the temporal relation between these different events. Methodology Ninety-nine nonconsecutive patients undergoing ERCP were investigated in the study. Results Fourteen of 99 patients undergoing ERCP developed mild EIP. Six hours after the investigation the concentration of anionic trypsinogen was significantly higher in patients with EIP than in patients without EIP. The day after ERCP, higher concentrations of anionic trypsinogen, carboxypeptidase B activation peptide, IL-6, and polymorphonuclear elastase were recorded in the EIP group. No significant differences in IL-1 receptor antagonist, soluble tumor necrosis factor receptor-I or neutrophil gelatinase–associated lipocalin were found between the groups in this study. Conclusion Mild EIP was accompanied by early leakage of proenzymes and later activation of trypsinogen/proteases. A significant cytokine response and neutrophil activation were recorded the day after ERCP, but further studies are needed to determine the temporal relation between these different pathophysiologic events.

Role of oxygen-derived free radicals in protease activation after pancreas transplantation in the pig.

The role of oxygen-derived free radicals in pancreatitis after pancreas transplantation was examined in a porcine pancreatic transplantation model. Trypsin activation, protease inhibitor consumption, kininogen consumption, and postoperative graft function were investigated in 24 pigs subjected to whole organ pancreaticoduodenal transplantation. The animals were divided into one control group and two groups treated with free radical scavengers. One group was given allopurinol, and one group was treated with superoxide dismutase in combination with catalase. In the early phase (within 1 hr) after reperfusion, no differences were seen between the groups as to protease activation. Neither trypsin-protease inhibitor imbalance nor any signs of kininogen consumption were seen. In a later phase (1-3 days after the transplantation), the trypsin activation, measured as high molecular weight immunoreactive cationic trypsin in plasma, was significantly less pronounced in allopurinol-treated animals. This finding indicates a less severe form of reperfusion pancreatitis in this group compared with the other groups. A tendency toward better function in the allopurinol-treated group was also seen. We conclude that oxygen-derived free radicals seem to be of importance in the development of reperfusion pancreatitis after pancreas transplantation in the pig. We also conclude that allopurinol, but not superoxide dismutase/catalase, possibly due to the administration regimens used in this series, is able to attenuate the trypsin activation and the development of pancreatitis in the later phase in this model.