Evaluation of Resorbable Materials for Preventing Surgical Adhesion on Rat Experiment

PURPOSE: Postsurgical adhesion formation is still a cause of postoperative morbidity because no satisfactory treatment or prophylaxis has yet been developed. Therefore, we have established an animal model for adhesion prevention, and evaluated the toxicity, inflammation and adhesion prevention effect of available water soluble materials as barriers against adhesion formation. METHODS: Four-week old female Sprague-Dawley rats (Sam: TacN(SD)BR, Smatako Co., Seoul Korea) were used. The 2 cm2 of cecal serosa and adjacent abdominal wall were abraded with bone burr, and the serosa of the cecum was sutured to the abdominal wall 1 cm apart from the injured site. The denuded cecum was covered with either sodium hyaluronate (HA), sodium alginate (Alg), sodium carboxymethyl cellulose (CMC), polyethylene glycol-polypropylene glycol-polyethylene glycol (PEG-PPG, Poloxamer), or polyethylene glycol (PEG) on both sides, or neither side (control group) and apposed to the abdominal wall. Two weeks after operation, the quality of adhesion was graded using a whole-number system of zero to five. RESULTS: Adhesion grades were highest in the control group (average 4.8), were a little lower in the PEG-PPG (aver. 4.6) and PEG (aver. 4.1) groups, and were significantly lower in the HA (aver. 3.1), Alg (aver. 3.3) and CMC (aver. 3.0) groups (all, P<0.05). However but inflammation was revealed in the Alg and CMC groups. CONCLUSION: In our animal model for adhesion prevention, a fairly good antiadhesion effect was attained with Alg, CMC and HA, whereas inflammation was revealed with Alg and CMC. In conclusion, HA is the best candidate for adhesion prevention.

Strategy of Early Diagnosis in Blunt Diaphragm Rupture

Diaphragm rupture often challenges the surgeon by it's subtle presentation in the face of more obvious injuries, equivocal chest roentgenography, and no obvious indication of celiotomy or thoracotomy. Delayed diagnosis is one variable implicated in increased morbidity and mortality. This retrospective study was performed to determine the diagnostic value of diaphragm rupture on initial evaluation and to present an algorithm for initial evaluation. We reviewed the hospital records and the radiographs of 37 patients with a blunt diaphragmatic rupture who were treated at Yongdong Severance Hospital during a period of 5 years. The blunt diaphragmatic ruptures in 14 (38.9%) of the thirty-seven patients were missed on initial admission. At admission, initial physical findings were diagnostic in 3 cases (8.1%), suspicious in 24 cases (64.9%) and normal in 10 cases (27%). On chest roentgenogram, findings were diagnostic in 6 cases (16.2%), suspicious in 28 cases (75.7%) and normal in 3 cases (8.1%). Chest CT scans were performed on 20 patients. Findings were diagnostic in 6 (30%) of these, suspicious in 11 (55%) and normal in 3 (15%). On the chest roentgenograms of the 15 cases with suspicious physical findings, which were diagnosed early, the findings were diagnostic in 4 cases (26.7%) and suspicious in 11 cases (73.3%). Chest CT scans were performed in 10 out of 15 cases with suspicious physical findings which were diagnosed early, and the findings were diagnostic in 3 cases (30%), suspicious in 6 cases (60%), normal in 1 case (10%). In 23 patients (61.1%), diagnosis was established within 48 hours. In 4 (17.4%) of these patients, the diaphragm rupture was detected at the time of the celiotomy performed for other injuries. In conclusion, a blunt diaphragm rupture can easily be missed in the absence of obvious indications for a celiotomy or a thoracotomy, because radiologic abnormalities are often interpreted as other injuries. In such cases, a high index of suspicion coupled with selective use of a CT scan, fluoroscopy, thoracoscopy, or laparoscopy may be necessary for early detection of the diaphragm rupture.

Management of Pancreatic Pseudocysts

A pancreatic pseudocyst is the most common cystic lesion in the pancreas encountered in the clinical practice. The management of pancreatic pseudocyst is a complex and prolonged problem for the general surgeon. Especially, considerable ambiguity exists regarding both the incidence for surgery and the timing of operative intervention in patients with pancreatic pseudocysts. The clinical courses of 50 patients with pancreatic pseudocysts were retrospectively reviewed in the Department of Surgery at Young Dong Severance Hospital during the period of 10 years from March 1985 to February 1995. The results were as follows: 1) The pancreatic pseudocysts were most prevalent in the 3rd and the 4th decade (58%) of age, and the male to female ratio was 3.5:1. 2) Alcoholic pancreatitis was the disease most frequently associated with pancreatic pseudocysts (44%). 3) The frequent symptoms or signs of patients of pancreatic pseudocyst were abdominal pain (84%), abdominal masses (24%), and nausea and vomiting (20%). 4) Valuable diagnostic radiologic methods were abdominal sonography (82%), abdominal CT (96%), and ERCP (80%). 5) The applied surgical methods were Roux-en-Y cystojejunostomy (37% of all surgical cases), pseudocyst resection or distal pancreatectomy (50%), and external drainage (13%).Surgical indications for the conservative management group were persistent symptoms and/ or increase in size in eleven patients (33%) and natural complications in six patients (18%). As the size of the pseudocyst increase, resolution rate tended to decrease and the complication rate tended to increase, but complete resolution occurred in 26% of the pseudocysts sized from 5 cm to 10 cm. Two pseudocysts greater than 10 cm in size were treated successfully with conservative management. We conclude that the cyst size and the cyst age are not absolute criteria for determining surgical indications.