Morbidity and mortality of inadvertent enterotomy during adhesiotomy.

BACKGROUND: Inadvertent enterotomy is a feared complication of adhesiotomy during abdominal reoperation. The nature and extent of this adhesion-associated problem are unknown. METHODS: The records of all patients who underwent reoperation between July 1995 and September 1997 were reviewed retrospectively for inadvertent enterotomy, risk factors were analysed using univariate and multivariate parameters, and postoperative morbidity and mortality rates were assessed. RESULTS: Inadvertent enterotomy occurred in 52 (19 per cent) of 270 reoperations. Dividing adhesions in the lower abdomen and pelvis, in particular, caused bowel injury. In univariate analysis body mass index was significantly higher in patients with inadvertent enterotomy (mean(s.d.) 25.5(4.6) kg/m2 ) than in those without enterotomy (21.9(4.3) kg/m2 ) (P < 0.03). Patient age and three or more previous laparotomies appeared to be independent parameters predicting inadvertent enterotomy (odds ratio (95 per cent confidence interval) 1.9 (1.3-2.7) and 10.4 (5.0-21.6) respectively; P < 0.001). Patients with inadvertent enterotomy had significantly more postoperative complications (P < 0.01) and urgent relaparotomies (P < 0.001), a higher rate of admission to the intensive care unit (P < 0.001) and parenteral nutrition usage (P < 0.001), and a longer postoperative hospital stay (P < 0.001). CONCLUSION: The incidence of inadvertent enterotomy during reoperation is high. This adhesion-related complication has an impact on postoperative morbidity

Recent clinical developments in pathophysiology, epidemiology, diagnosis and treatment of intra-abdominal adhesions.

Postsurgical intra-abdominal adhesions pose a significant medical problem in the Western world, and in the past decade progress has been made in understanding their pathophysiology. The early balance between fibrin formation and degradation in the peritoneal cavity during and after surgery seems to be a major determinant of adhesion formation. Postsurgical inhibition of fibrinolytic activity severely impairs fibrin breakdown. Adhesive small-bowel obstruction, inadvertent enterotomy at reoperation, prolonged operative time dividing adhesions, increased clinical workload and high financial costs are important adhesion-related problems discussed in this review. The cumulative risk of adhesive small-bowel obstruction after (sub)total colectomy is 11% within 1 year, increasing to 30% at 10 years. One of five patients undergoing reoperation suffers from inadvertent enterotomy, resulting in significant postoperative morbidity and mortality. Roughly 3% of all surgical admissions are associated with intra-abdominal adhesions. Clinical prospective trials have recently been designed to investigate the efficacy of barrier membranes and gels in the reduction of abdominal and pelvic adhesions and prevention of long-term morbidity, e.g., adhesive bowel obstruction and infertility in women. Early results are promising and contribute to the increased interest among clinicians in postsurgical adhesion formation and its consequences.

Effectiveness of isolated liver perfusion with mitomycin C in the treatment of liver tumours of rat colorectal cancer.

Dose limiting systemic toxicity prevents sufficient exploitation of the steep dose response relationship of most anticancer agents. In our rat liver tumour model (the CC531 colorectal carcinoma), isolated liver perfusion allows administration of higher doses of mitomycin C than hepatic artery infusion, while systemic toxicity remains minimal. To determine the temporal pattern of mitomycin C induced cytokinetic changes, we analysed flow cytometric DNA histograms of CC531 liver tumours from rats treated with high dose mitomycin C (3.2 mg kg-1) via hepatic artery infusion and sacrificed at different time intervals after treatment. Between 12 and 36 h after treatment, the fraction of cells in late S and G2/M phase had markedly increased. The effects of administration of the respective maximally tolerated doses of mitomycin C in isolated liver perfusion and via hepatic artery infusion on progression of tumour cells through the cell cycle and on gross tumour growth were compared. Isolated liver perfusion with mitomycin C resulted in a significant increase in the proportion of cells in mid and late S, and in some accumulation of cells in early S and G2/M phase at 24 and 48 h after treatment. In contrast, after hepatic artery infusion a significant increase of the fraction of cells in G2/M phase was observed at 24 h after treatment. Monitoring tumour growth after isolated liver perfusion five out of seven rats showed a complete tumour remission, while after hepatic artery infusion only a minimal growth delay was detected. This study demonstrates that isolated liver perfusion in the rat CC531 liver tumour model allows the administration of a well-tolerated dose of mitomycin C being high enough to induce a marked DNA synthesis inhibition and even complete tumour remission.