Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature.

INTRODUCTION: Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. METHODS: A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery". RESULTS: Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. CONCLUSIONS: The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients.

BACKGROUND: Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores. METHODS: From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration. RESULTS: The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively). CONCLUSION: The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Postoperative intraperitoneal adhesion pathophysiology.

Aside from the normal 'ad integrum' peritoneal regeneration, the postoperative intraperitoneal adhesion formation process may be considered as the pathological part of peritoneal healing following any injury, particularly a surgical one. Despite a large body of clinical and experimental studies, its pathophysiology remains controversial. Moreover, a better understanding of the pathophysiological events and of the medical and surgical factors involved in the adhesion formation process is pivotal in any attempt to control this very frequent phenomenon and its serious consequences.

Adhesions and colorectal surgery - call for action.

Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a 'call for action' to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process.

Use of icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL Registry.

INTRODUCTION: Intra-abdominal adhesions occur in many patients following major abdominal surgery and represent a serious burden to patients and healthcare providers. The multicentre ARIEL (Adept Registry for Clinical Evaluation) Registry was established to gather clinical experiences in the use of icodextrin 4% solution, an approved adhesion-reduction agent, during routine general surgery. PATIENTS AND METHODS: General surgeons from five European countries completed anonymised data collection forms for patients undergoing laparotomy or laparoscopy. Surgeons recorded patient demographics, use of icodextrin 4% solution and adverse events, and made subjective assessments of ease of use and patient acceptability with the agent. RESULTS: The general surgery registry included 1738 patients (1469 laparotomies, 269 laparoscopies). Leakage of fluid from the surgical site did not appear to be affected by icodextrin 4% solution and was classified as 'normal' or 'less than normal' in most patients (laparotomies 86%, laparoscopies 88%). Overall, satisfaction with ease of use was rated as 'good' or 'excellent' by the majority of surgeons (laparotomies 77%, laparoscopies 86%). Patient acceptability was also good, with ratings of 'as expected' or 'less than expected' in most cases for both abdominal distension (laparotomies 90%, laparoscopies 91%) and abdominal discomfort (laparotomies 91%, laparoscopies 93%). Adverse events occurred in 30.6% of laparotomy patients and 16.7% of laparoscopy patients; the most common events were septic/infective events (4.2% and 3.4% in the laparotomy and laparoscopy groups, respectively). Anastomotic wound-healing problems were reported in 7.6% of patients in the subset of laparoscopy patients undergoing anastomotic procedures (n = 66). DISCUSSION: Volumes of icodextrin 4% solution used as an irrigant and instillate were in line with recommendations. Surgeons considered the agent to be easy to use and acceptable to patients. The reported frequencies of adverse events were in line with those published in the literature for surgical procedures, supporting the good safety profile of this agent. CONCLUSIONS: Icodextrin 4% solution can be used in a wide range of surgical procedures. In combination with good surgical technique, it may play an important role in adhesion reduction.

[Digestive surgery in the elderly]. / Chirurgie digestive du grand âge.

The dramatic increase in digestive surgery among patients of advanced age is the logical consequence of the aging population demographics in developed countries. Surgery in the aged is not fundamentally different, but it demands precise and tailored assessment and management of surgical indications and surgical and anesthetic techniques. Advanced age is not a contraindication to even major digestive surgery, but every effort must be made to avoid urgent operations by attention to pre-existing symptoms which are all-too-often neglected in the aged. Intensive care may help to shorten the hospital stay which should ideally occupy only a minor portion of the numbered days of the patient (whose life expectancy may be significantly longer than one may intuitively foresee).

[Post-operative bowel obstruction. Part 1: Intraperitoneal bands and adhesions--causes and prevention]. / Pathologie occlusive postopératoire. 1. Les brides et adhérences intra-péritonéales, causes et moyens de prévention.

Postoperative peritoneal bands and adhesions are very common and may occur after any surgical procedure within the peritoneal cavity. Certain factors have been shown to contribute to their formation. The abdominal surgeon should take account of these factors in his daily practice; a reasoned and preventive surgical approach and the use of techniques and products with proven clinical efficacity are to be recommended. This should permit the surgeon to simplify and minimize post surgical work and to diminish the incidence and complications of adhesions in both the immediate and long-term post-operative periods such as post-surgical pain syndromes, mechanical bowel obstruction, and adhesive peritonitis complicating reinterventional surgery.

[Post-operative bowel obstruction. Part 2: Mechanical post-operative small bowel obstruction by bands and adhesions]. / Pathologie occlusive postopératoire. 2. Occlusions mécaniques postopératoires du grêle par brides ou adhérences.

Small Bowel obstruction due to post-operative adhesions is a common problem in a general surgical practice. Any laparotomy initiates the lifelong risk of this complication. Mortality rates have improved dramatically in the last three decades. The basic evaluation and treatment of small bowel obstruction is well defined but many individual strategies may result from the variety of clinical presentations and from techniques and equipment available to a local surgical practice. Recent advances in surgical techniques and preventive strategies may improve overall results. Results will remain linked to the continuous aging of the populations of Western countries.

[Gastrointestinal tract in the elderly]. / Radiologie digestive de la personne âgée.

Patient's age no longer is a major factor when discussing the diagnosis and treatment of hepatobiliary and gastrointestinal diseases. However, discussing with the physician in charge of the patient is the only adequate way to propose the quickest, least invasive and most comfortable imaging modality that will give a proper answer to the clinical problem. Cross sectional imaging, especially ultrasound, CT and in some cases MRI, plays an important role in the diagnosis of these diseases.

[Acute intestinal occlusions]. / Occlusions intestinales aiguës.

Acute intestinal obstruction comprises a vast clinical entity characterized by the items of the obstruction syndrome. It encompasses numerous etiologies, and in Western countries adhesions are currently the main cause. The work up of this urgent surgical condition must above all be clinical, even though new techniques will probably improve their diagnosis and treatment (CT scan, stent). These new technologies still have to be documented and validated. Likewise, the laparoscopic approach of acute intestinal obstruction has to be prudent. The overall mortality of this urgent condition is still high, more than 10% of the patients.

[Patients, surgeons and surgical gloves]. / Malades, chirurgiens et gants chirurgicaux.

Consumption of surgical gloves in progressing constantly. All proposed products do not have the same qualities in terms of protection, comfort, and safety for the surgeon, the surgical team and the patient. Latex is the basic material used to manufacture surgical gloves even if it does raise the problem of side-effects and requires use of starch powder for lubrification. The surgeon should be aware of the different products and participate in choosing this indispensable tool. There is a general and advisable trend to using non-powdered gloves.

Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. French Association for Surgical Research.

HYPOTHESIS: The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively. DESIGN: Retrospective review of cases of intestinal obstruction after laparoscopic surgery. SETTING: Sixteen surgical units performing laparoscopy in France. PATIENTS: Twenty-four patients with intestinal obstruction. MAIN OUTCOME MEASURES: Prevalence values and descriptive data. RESULTS: The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred. CONCLUSION: Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

[Pancreatectomy and diabetes]. / Pancréatectomie et diabète.

Post total pancreatectomy diabetes is a clearly defined form of unstable diabetes, requiring low doses of insulin, with frequent and severe hypoglycemic events. This is due to both deficiency of pancreatic glucagon, hormone of primary importance for hepatic gluconeogenesis and glycogenolysis, and exocrine failure. The management of this form of diabetes is difficult, involving exact correction of malabsorption and low doses of insulin. Whenever possible, partial pancreatectomy should therefore to be preferred. After partial pancreatectomy, the likelihood of diabetes depends on the volume of the remaining pancreas, the type of resection and above all the preexisting pancreatic status. Prevention of postoperative hyperglycemia could minimize the risk of long-term diabetes. Pancreatic cancer is a particular case: the onset of diabetes could be a manifestation of occult pancreatic cancer and glucose metabolism may improve after tumour excision with preservation of some pancreatic tissue.

Survey of the impact of randomised clinical trials on surgical practice in France. French Associations for Research in Surgery (AURC and ACAPEM). Association Universitaire de Recherche en Chirurgie. Association des Chirurgiens de l'Assistance Publique pour l'Evaluation Médicale.

OBJECTIVE: To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France. DESIGN: Telephone questionnaire. SETTING: Multicentre study, France. SUBJECTS: A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice. RESULTS: 148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results. CONCLUSIONS: French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

[Acute mesenteric ischemia: changes in 1985-1995. Surgical Research Associations]. / Ischémie mésentérique aiguë: ce qui a changé durant la décennie 1985-1995. Associations de recherche en chirurgie.

AIM OF THE STUDY: Acute mesenteric ischaemia (AMI) resulting in intestinal ischaemia and/or infarction is associated with an extremely serious prognosis and a mortality rate ranging from 40% to 100%. The aim of the study is to appreciate the epidemiological, therapeutic and prognostic changing aspects of the AMI over a decade. PATIENTS AND METHODS: Two retrospective and multicentric series (492 and 305 patients, respectively) identically collected between 1980-1985 and 1990-1995 by the French Associations of Surgical Research were compared. Comparisons concerned the patients' clinical features, the aetiology of AMI and the surgical management. The mortality was analysed taking into account the former items. RESULTS: The overall mortality rate decreased from 77% to 59% (P < 0.0001). The patients' preoperative clinical features improved but collapse remained the main serious factor. The rate of venous origin AMI increased significantly (P < 0.02) with a mortality decrease (51% to 19%, P < 0.0001). The mortality rate of thrombotic origin AMI decreased (83% to 63%, P < 0.0001). The results of surgical management improved, even though the frequency of angiographies, vascular and second-look procedures did not increase. CONCLUSION: Even though the prognosis of AMI remains extremely serious, a significant decrease of the overall mortality rate is observed. Two ways of progress can be recommended: the first, successfully initiated involving better management of the patients with a greater number of classical surgical procedures; the second, more aggressive treatment advocated by more specialised surgical teams.

Differential transferrin receptor density in human colorectal cancer: A potential probe for diagnosis and therapy.

Transferrin receptor density was investigated in human colorectal surgical specimens. Crude membranes were prepared from 23 cancer tumors (adenocarcinoma or malignant villous tumor) and 3 non-cancer tumors (polyadenoma or villous tumor) and 26 adjacent control mucosa. Contrary to non-cancer tumors, Scatchard analysis of 125I-transferrin binding data evidenced higher maximal transferrin binding capacity and lower dissociation constant in cancer tissues (Bmax cancer 1.828+/-0.320 nmol/g, Kd 24.1+/-4.7 nM), as compared to paired control colonic mucosa (Bmax contol 0.851+/-0.182 nmol/g, Kd 30.7+/-7.3 nM), paired t-tests: Bmax p<0.001, Kd p<0.05). As the cancer/control Bmax ratio was 2.6+/-0.4,transferrin carrier constructs should be proposed for cancer imaging or therapy.

[Preoperative skin preparation in abdominal surgery]. / Préparation cutanée mécanique pré-opératoire en chirurgie abdominale.

Mechanical skin preparation is a daily nursing procedure in abdominal surgery. Even though a single procedure has not yet been adopted, several evidence-based points can be found in the literature: non-shaving or depilation of the surgical field with and electric clipper give the lowest rate of wound infection. The same is true for shaving of the operative field just before the operation. The beneficial effects of depilatory cream have not been demonstrated. Finally, there are no current data dealing with the acceptability and the overall cost of depilation procedures.

Post-operative peritoneal adhesions and foreign bodies.

One of the proven causes of adhesions is foreign microbodies which are present in up to 93% of all re-operated patients in which adhesions are analysed for evidence of external contamination. Studies are described which show the changing nature of foreign microbodies with time, associated with the development of new surgical practices. This paper concludes that although foreign bodies found today may not be the same as those found 30 years ago, they remain prominent in the aetiology of adhesions--the main cause of postoperative intestinal obstruction. Every effort should be made to minimise tissue contamination during operations with particulate debris such as glove powder.