The Necessity for Mechanical Bowel Preparation before Colonic Resection and Primary Anastomosis

BACKGROUND: The results of recent reports suggest that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary. To determine whether mechanical bowel preparation influences the incidence of postoperative complications following colorectal surgery, the records of patients who had undergone colonic or rectal resection were retrospectively reviewed. METHODS: Between March 1992 and October 1997, colonic resection and primary anastomosis without colostomy was performed on 56 patients. Among these, 27 patients had undergone mechanical bowel preparation (MBP) before surgery, and 29 patients had not. We compared the data from both groups with respect to wound infection, anastomotic leak, intra-abdominal sepsis and death. RESULTS: The postoperative complication and mortality rates were similar in the two groups. Wound infection occurred in seven patients (four with MBP, three without), and the incidence of wound infection was similar in the two groups (14.8% versus 10.3%, P=0.700). Wound disruption occurred in two patients (one with MBP, one without). Anastomotic leaks occurred in two patients who had undergone bowel preparation. The overall anastomotic leak rate was 3.6% (7.4% versus 0%), but the incidence of anastomotic leaks was not significantly different between the two groups (P=0.228). No intra-abdominal sepsis was clinically apparent in either group. There was one death, a patient who had undergone bowel preparation. The mortality rate was not significantly different between the two groups (P=0.482). CONCLUSIONS: We believe that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary, so routine MBP should be further scrutinized.

Laparoscopic Versus Open for Complicated Appendicitis

BACKGROUND: For complicated appendicitis, in contrast to simple appendicitis, laparoscopic appendectomy (LA) is considered a relative or absolute contraindication because of the higher postoperative complication rate than that of open appendectomy (OA), especially, high incidence of intra-abdominal abscess. The purpose of this article is to assess the feasibility of LA for complicated appendicitis. METHODS: A retrospective review of 35 LA and 128 OA for the cases of gangrenous, perforated appendicitis, and periappendiceal abscess between May 1995 and June 1997 was performed. Patients were identified through the hospital pathology registry. We compared data from both groups with respect to operative times, postoperative pain, duration of ileus, length of hospital stay, and complication rate, with special attention to the incidence of intra-abdominal abscess. RESULTS: 1) The male:female ratio of LA (1:1.2) was significantly lower than that of OA (1:0.45) (p0.05). But LA was associated with higher incidence of postoperative intra-abdominal abscess (3/35, 8.6%) than OA (3/128, 2.3%) (p=0.114). There was one serious intra-abdominal abscess in the LA, which required reoperation. The rest 2 cases in the LA and all 3 cases in the OA were treated conservatively. CONCLUSIONS: LA for complicated appendicitis could afford the merits of shorter hospital stay, reduced incidenceof wound infection, and comparable incidence of overall complication rate. To reduce the incidence of postoperative intra-abdominal abscess, copious irrigation and adequate drainage should be recommended.

A Study of iNOS Expression in the Alveolar and NO Concentrations in the Peritoneal Macrophage by Various Anesthetics in the Endotoxemic Rats / 대한마취과학회지

BACKGROUND: It is a well known phenomenon that alveolar and peritoneal macrophages exposed to bacterial lipopolysaccharide (LPS) induce a large output of nitric oxide (NO) and an inducible nitric oxide synthase (iNOS) m-RNA expression. The author elucidate the effects on NO production and iNOS m-RNA expression of various anesthetics, inhalational (halothane, enflurane, sevoflurane) and intravenous (ketamine, propofol), on endotoxemic rats. METHODS: To examine the production of NO in peritoneal macrophages, NO concentrations were measured from the rats following 2 hours exposure to LPS and 2 hours administration of various anesthetics, respectively. Culture supernatants were collected 24 hours after exposure to LPS and anesthetics and assayed by ELISA (Enzyme Linked Immunosorbent Assay) for production of NO. iNOS m-RNA expression was measured using PCR (Polymerase Chain Reaction) techniques and autoradiography. RESULTS: In the control group, the NO concentration was measured at 120 minutes after infusion of LPS to rats, and showed 12+/-4 micrometer. After insufullation of anesthetics to experimental animals, NO concentration increased in the halothane, enflurane, sevoflurane, propofol, and ketamine groups, 132+/-27 (P< 0.05), 49+/-19 (P< 0.05), 23+/-14 (P< 0.05), 37+/-11 (P< 0.05), and 17+/-2 micrometer respectively. The size and brightness of the iNOS m-RNA bands were large in halothane, enflurane, sevoflurane, propofol and ketamine, in order. CONCLUSIONS: Intravenous anesthetics showed more stability than inhalation anesthetics with regand to production of NO and iNOS m-RNA expression in sepsis on rats. The mechanism is not clear, but it is related to the strong stimulating effect to the airway tract in from inhalational anesthetics.

Revisit the Original Whitehead Hemorrhoidectomy The postoperative results of W-shaped circular incision & preservation of perianal skin

Since Whitehead had described a circular hemorrhoidectomy in 1882, many surgeons adopted it for decades for patients with protruding anal deformity. After a few decades of performing Whitehead operation, devastating complications such as anal stricture, fecal incontinence, and wet anus with mucosal eversion had been reported on the literatures and then it was buried as an abandoned procedure by surgeons for a long period. Recently, a few prominent anal surgeons reported that they could avoid such devastating complications by introducing diverse modifications of the original Whitehead's operation. The authors analyzed 22 patients who had undergone original Whitehead circular hemorrhoidectomy with the technique of preserving most of the perianal skin and W-shaped circular incision during the period from 1991 to 1996, with special regard to the com plications such as anal stricture and anal mucosal eversion which have been debated on so far and reviewed the articles about these issues. In immediate postoperative period, suture failure and resultant non-surgery requiring, mild anal stricture were documented in 3 of the 22 cases(13.6%). On long-term follow-up with the mean period of 44 months (18~79 months) in 14 cases, except those 8 cases that were lost, with phone-call questionaire, 13 patients(93%) had quite normal anal functions. The authors would like to suggest that the original Whitehead's circular hemorrhoidec tomy is a valuable surgical technique to manage the protruding anal deformity if surgeons can avoid well known complications such as anal stricture and anal mucosal eversion by choosing a correct location of initial W-shaped incision to preserve as much perianal skin as possible.

Experience of stapled Unbalanced Uncut Roux-Y Gastrojejunostomy

Roux-en-Y reconstruction is an occasional occurrence of Roux-Y stasis syndrome, characterized by chronic abdominal pain, persistent nausea, and intermittent vomiting. Construction of the Roux limb requires transection of the jejunum, which disturbs normal propagation of pacesetter potential and evokes development of ectopic pacemakers in the Roux limb. Ectopic pacemakers in the Roux limb generate pacesetter potentials, which with their associated orally propagating contractions, result in slower transit through the Roux limb.To prevent the Roux stasis syndrome, a new operation has been designed that is similar to the standard Roux-en-Y gastrojejunostomy construction but theoretically without inherent motor pathophysiology. The authors designed a new unbalanced " Uncut Roux-en-Y" procedure to avoid postoperative blind loop syndrome and performed the procedures with staple occlusion of the afferent loop in 11 patients who required gastric resection and reconstruction, during a period of 6 months from April 1995 to September 1995. Results were summarized as follows. 1) 9 of the 11 patients( 81%) had excellent results with stable or increased weight and no stasis syndrome. 2) 2 patients(19%) had poor results with alkaline reflux gastritis or esophagitis. Both had documented staple line dehiscence. One of them was operated on and converted to a standard Roux operation, but died. The other one continued to loose weight but maintained a normal dietary pattern. 3) Unbalanced Roux technique worked well without harmful complications. 4) Reinforcing serosal sutures on the staple line could prevent a possible jejunal leakage in the case of staple line dehiscence and might prevent dehiscence of staple lines.

Clinical Analysis of Actinomycosis: 66 Cases of Korean Experience

Abdominal actinomycosis is a rare entity which presents some difficulty in establishing a correct preoperative diagnosis. The diagnosis is usually based on histologic demonstration of sulfur granules in pus or surgically resected specimen. Treatment has consisted of longterm antibiotic therapy coupled with surgery in complicated cases. The authors analyzed 66 patients of proven abdominal actinomycosis, who consisted of 53 cases previously reported in Korean literatures since 1966 and 13 cases treated at the department of General Surgery, Sae Gang General Hospital since 1990. The results were as follows. 1) Females were more frequently involved. The male to female ratio of abdominal actinomycosis was 1:2.1 and the mean age was 40.3 years-old. 2) Clinical features were different with each involved organ. However, most of the clinical symptoms were nonspecific to suspect actinomycosis. 3) The frequently involved sites were mainly located in the lower abdomen, such as the appendix, omentum, uterus and adnexa, ileocecum, colon, rectum, and small bowel. 4) In 59% of the patients, predisposing factors were identifiable. Identified possible factors were previous appendectomy, IUD, abdominal trauma, abortion, and perforative disorders of the GIT. 5) The preoperative diagnoses were intra-abdominal tumors or abscesses in 67% of the patients. Correct pre-exploratory diagnoses were made in 15% of the patients by using fine needle aspiration cytologic study, culture of drained pus, or direct tissue biopsy. 6) Explorations were performed in 88% of the patients to afford a proper surgical treatment and a correct diagnosis. After operation, almost all patients were treated with oral antibiotics for long periods. The authors conclude that pre-exploratory cytologic or culture study in patients who show uncomplicated low abdominal tumors or abscesses may increase the rate of correct diagnosis and could eliminate unnecessary explorations.