[Prolonged peridural analgesia (PDA) for postoperative pain therapy after major urologic interventions. Experiences with 172 adult patients]. / Prolongierte Periduralanalgesie (PDA) zur postoperativen Schmerztherapie nach grossen urologischen Eingriffen. Erfahrungen bei 172 erwachsenen Patienten.

UNLABELLED: The benefits of epidural analgesia are well known, but it is not well understood which types of urologic surgery benefit most from epidural analgesia. In this study, the effects and side effects of prolonged epidural analgesia are prospectively examined and analysed on 172 adult patients in three different operation groups. An epidural infusion of local anaesthetic combined with an opioid and adrenaline was given for a period of 5-7 days. There was no difference between the groups with respect to the effectiveness of the analgesia and patients' perception of the treatment. Mobilization differed, as expected, between the groups, however even after the most major surgery (e. g. cystectomy with bladder substitution), mobilization was impressively unproblematic. Retarded return of regular intestinal function after the transperitoneal operation and partly after lumbotomy compared with the extraperitoneal operation depended on which operation was performed and the amount of analgesia given. The side effects such as sedation, nausea and pruritus were conditional partly on the opiate and partly on the intervention. Up to 11 % showed slight muscular weakness of the lower limbs as a specific side effect of the local anaesthetic. COMPLICATIONS: One patient died of cerebral hypoxia due to an initially undetected subdural catheter placement complicated by severe pre-existent carotid stenosis. In four patients, the epidural analgesia had to be stopped because of catheter migration. There was no clinical evidence of hematoma, abscess or permanent neurological damage. Epidural analgesia works well in terms of analgesia, mobilization and patient satisfaction, bearing in mind the potential side effects and complications. It can be recommended for lumbotomy and long transperitoneal operations however not for extraperitoneal interventions in the lower abdomen such as radical prostatectomy.

Adding sodium bicarbonate to lidocaine enhances the depth of epidural blockade.

UNLABELLED: It is controversial whether adding CO2 or sodium bicarbonate to local anesthetics enhances the depth of epidural blockade. Repeated electrical stimulation is a reliable test for assessing epidural analgesia and evokes temporal summation. We used this test to investigate the analgesic effect of lidocaine, with or without CO2 or bicarbonate. Twenty-four patients undergoing epidural blockade with 20 mL lidocaine 2% at L2-3 were randomly divided into three groups: lidocaine hydrochloride, lidocaine CO2, and lidocaine plus 2 mL sodium bicarbonate 8.4%. Pain threshold after repeated electrical stimulation (five impulses at 2 Hz), pinprick, and cold test were performed at S1 and L4. Motor block was assessed. The addition of bicarbonate resulted in higher pain thresholds (P < 0.0001), faster onset of action (P = 0.009), and higher degree of motor block (P = 0.004) compared with lidocaine hydrochloride. We found no significant differences between lidocaine CO2 and hydrochloride. Most of these results were not confirmed by pinprick and cold tests. We conclude that the addition of sodium bicarbonate to lidocaine enhances the depth of epidural blockade, increases inhibition of temporal summation, and hastens the onset of block. Pinprick and cold are inadequate tests for comparing drugs for epidural anesthesia. IMPLICATIONS: We measured pain perception during epidural anesthesia by delivering electrical stimuli to the knee and foot. We found that the addition of sodium bicarbonate to the local anesthetic lidocaine enhances analgesia. We observed no effect of adding carbon dioxide to lidocaine.

Non-operative treatment of benign oesophageal strictures: results after endoscopic balloon dilatation and H2-antagonists.

OBJECTIVE: To evaluate the success of non-operative treatment of benign oesophageal strictures. DESIGN: Retrospective study. SETTING: University department of surgery. SUBJECTS: 27 consecutive patients with benign oesophageal strictures treated between 1984 and 1989. INTERVENTIONS: Repeated oesophageal dilatations as necessary together with cimetidine or ranitidine; 10 patients underwent 24 hour pH measurements. MAIN OUTCOME MEASURES: Resolution of dysphagia and gastro-oesophageal reflux. RESULTS: 125 dilatations were done for the 27 patients, 21 patients required four or less. The longer the stricture the larger the number of dilatations required. Median follow up time was 27 months (range 3-74), and during this period 11 patients died. None of the deaths was related either to the stricture or to its treatment. There were no complications of dilatation. Among the 10 patients who underwent 24 hour pH measurements the median percentage of time that the pH was less than 4 was 23, range 7-67. Non-operative treatment was successful in all but three patients, who required fundoplication. CONCLUSIONS: Non-operative treatment is successful for most patients with benign strictures, so it may be possible to restrict antireflux operations to young patients with strictures.

Effect of interrupted and continuous suturing on intestinal wound margin strength in rats.

Suture-holding capacity (breaking strength) of small bowel anastomoses made with interrupted or continuous sutures was assessed in two groups of rats. The tightness of the suture line was varied in a standardized manner in both groups. All types of anastomoses had similar strength immediately after surgery. After 72 h, suture-holding capacity had decreased by 50-55% (p < 0.001) in tightly sutured anastomoses and by 10-15% (p > 0.05) if sutures were loose. Changes in strength were similar regardless of whether interrupted or continuous sutures were used. Myeloperoxidase activity, reflecting tissue neutrophil accumulation, and hydroxyproline content were similar in all types of anastomoses after 72 h. Deterioration of early anastomotic strength is probably due to proteinase-mediated tissue degradation. It is speculated that tight sutures encourage proteolytic enzyme activity in the bowel wall by disturbing the local proteinase/proteinase inhibitor balance.

Effect of suture technique on early healing of intestinal anastomoses in rats.

OBJECTIVE: To see if the site and tension of sutures had any influence on early breaking strength in intestinal anastomoses. MATERIAL: 161 Male Wistar rats. INTERVENTIONS: First experiment: after laparotomy and division of the ileum an inverted end to end anastomosis was made in a single layer with 14 interrupted sutures of 7/0 polypropylene. All sutures were inserted 3 mm from the cut edges. The rats were randomly allocated to one of four groups according to the size of the loop of suture used: tight (n = 38), 0.4 mm (n = 22), 0.9 mm (n = 35), or 2.0 mm (n = 24). Second experiment: the method used was the same except that sutures were placed 1.5 mm from the cut edges and the rats were randomly allocated to one of two groups according to the size of loop of suture--tight (n = 20), or 0.9 mm (n = 22). MAIN OUTCOME MEASURES: Breaking strength measured in a tensiometer (both experiments); and myeloperoxidase activity/g tissue, hydroxyproline content and solubility/biopsy specimen (first experiment only). RESULTS: Breaking strength decreased proportionally the tighter the sutures were tied, and the differences were significantly greater when the sutures were placed closer to the cut edges. Anastomotic myeloperoxidase activity, hydroxyproline content, and soluble: total hydroxyproline ratio were similar in all groups. CONCLUSION: Tight sutures may promote proteolytic tissue degradation by reducing the local availability of circulating proteinase inhibitors.

Neutrophil-dependent decrease in early wound margin strength.

We evaluated the effect of neutropenia or administration of a serine proteinase inhibitor on the early suture-holding capacity of intestinal anastomoses in rats. One group of rats was treated with antineutrophil serum, and another group received the soybean trypsin inhibitor. Controls received inactivated serum or saline. Anastomotic suture-holding capacity (breaking strength), myeloperoxidase activity, and collagen were measured 0 and 72 hours after surgery. Suture-holding capacity decreased by 70% in controls and 35% in soybean trypsin inhibitor-treated rats, but remained on level with immediate postoperative strength in neutropenic rats, where low myeloperoxidase levels reflected effective wound margin neutropenia. Collagen content and solubility were similar in all groups. These findings indicate that reduction in early wound margin strength is neutrophil dependent, and that neutrophil serine proteinases are important mediators in that process.

Diathermy-induced inflammation does not affect suture holding capacity of intestinal anastomoses.

We compared the suture holding capacity of rat intestinal anastomoses after division of the bowel with scissors or diathermy. Two sets of experiments differing in suture technique were done. In one set the amount and solubility of anastomotic collagen were measured, and neutrophil accumulation quantified with a myeloperoxidase (MPO) assay. MPO activity 24 h after surgery was 60% higher (p less than 0.05) after division with diathermy than after division with scissors. Suture holding capacity (breaking strength) decreased by approximately 70% (p less than 0.001) in both groups when sutures were inserted near the bowel edges, while no decrease was noted when sutures were inserted at a farther distance, regardless of the mode of bowel division. After 7 days MPO levels approached baseline values in both groups and the bowel always ruptured outside the anastomosis. Collagen content was not adversely affected by diathermy. Although the reduction in early anastomotic strength may be mediated by local neutrophil activity, suture holding capacity was not influenced by the increased neutrophil accumulation elicited by diathermy.

Tension leads to increased neutrophil accumulation and decreased laparotomy wound strength.

Wound margin strength was measured immediately after and at 72 hours after median laparotomy in rats. The laparotomy wound was sutured with or without tension, and wound margin strength was measured as breaking strength with the sutures in situ. In wounds sutured without tension, no decrease in breaking strength was observed at 72 hours; in rats sutured with tension, breaking strength decreased by 77%, and in almost half of the animals the sutures cut through. There was markedly increased accumulation of neutrophil leukocytes around the sutures in the tension group, as indicated by increased tissue myeloperoxidase activity. The decrease in breaking strength was abolished by treatment with an inhibitor of the collagen-degrading proteinases of the neutrophils (the soybean trypsin inhibitor). Although the decrease in breaking strength should be due to collagenolysis, there were no changes in collagen content or solubility around the sutures, indicating that the changes in collagen were too delicate to be revealed by the methods used. We conclude that the decrease in breaking strength was caused by the neutrophils.

Esophageal and jejunal motor function after total gastrectomy and Roux-Y esophagojejunostomy.

Emptying and peristaltic activity of the esophagus and proximal jejunum were studied using scintigraphy and fluoroscopy documented on videotape in 11 patients after total gastrectomy and Roux-Y loop reconstruction. Impaired esophageal motor function, as judged by both methods, was seen in five patients who were all 50 years of age or older. This was in contrast to the findings in a group of healthy control subjects, all over 50 years of age, in whom esophageal function appeared normal on scintigraphy in five of seven. Disturbed jejunal function, as judged by radiography, was found in eight patients, whereas the emptying rate according to scintigraphy was judged normal in all but two patients. Five of the patients complained of various adverse alimentary tract symptoms, but the scintigraphic and radiographic findings did not correlate with these symptoms.

Neutrophil-induced decrease in wound margin strength after intestinal anastomosis--influence on collagen and mechanisms of granulocyte action.

A marked decrease in strength occurs early after surgery in tissues adjacent to an incisional wound. In this study measurement of collagen and a histological examination were carried out in a rat intestinal anastomosis. The decrease in tissue strength of the bowel wall did not correlate to the amount of collagen or to changes in collagen solubility. At histology the collagen layer was seen unaffected. Our previous studies showed that the decrease in strength was eliminated if the number of circulating neutrophils was reduced by antineutrophil serum. In addition, the decrease was counteracted by a proteinase inhibitor, the soybean trypsin inhibitor (STI), and the oxygen-free-radical scavengers superoxide dismutase (SOD) and catalase. To further examine the mechanisms of the decrease, neutrophil accumulation in the anastomosis was examined by myeloperoxidase (MPO) assay, and at histology, after treatment of the animals with the proteinase inhibitor, the scavengers or saline solution. MPO activity increased by 110% 24 h after the operation in saline-treated animals, but the increase was not influenced by STI or SOD and catalase. At the histological examination neutrophil accumulation was not seen affected by the drugs. Thus, the proteinase inhibitor and the scavengers counteract the decrease in strength in some other way than by reducing the number of neutrophils in the wound edges, for instance by local inhibition of neutrophil proteolytic enzymes and oxygen-free radicals.

Septic shock in the rat: activation of plasma proteolytic systems and effects of a kallikrein inhibitor/bradykinin antagonist (S-2441).

Septic shock was induced in rats by intraperitoneal injection of live Escherichia coli. Plasma prekallikrein, antithrombin III and plasminogen levels were studied with chromogenic peptide substrate assays. Decrease of all the studied plasma components occurred in all rats, but not until late in shock. S-2441, a kallikrein inhibitor/kinin antagonist, slightly delayed the fall in plasma prekallikrein, but no other effects were found. Rat survival was neither enhanced nor prolonged.

Cardiac output and its distribution in peritonitis. (Septic) shock in the rat.

Cardiac output and its distribution were studied in rats made septic by an i.p. injection of live E. coli bacteria and in controls given an equivalent amount of saline. The E. coli injection was followed by signs of severe shock in eight of 12 rats. Control animals all survived with only minor changes in cardiac output and peripheral hemodynamics. Blood flow in shocked animals was characterized by a reduction of cardiac output, while myocardial and cerebral flows were not reduced. The intact circulation to the brain and to the heart in the shocked rats was at the expense of kidney, spleen, and skin blood flows.

Mechanisms and prevention of decrease in wound margin strength in intestinal anastomoses and laparotomy wounds.

From the present investigation it can be summarized that breaking strength of an incisional wound, measured with the sutures in situ, decreased markedly early after the operation in all tissues investigated if the sutures were inserted 1.5 mm from the incision; that the decrease was also found if new sutures, placed between and substituting the old, were inserted before measuring breaking strength, indicating that the decrease in strength occurs all along the wound; that breaking strength did not decrease if the sutures were inserted 3 mm from the incision; that breaking strength decreased markedly in the wounds sutured under stretching, even if the sutures were inserted 4 mm from the incision; that collagen content and solubility, and the histological appearance of the submucosal collagen layer, were only insignificantly changed in the early period after the operation; that the decrease in breaking strength was eliminated in animals made neutropenic by anti-neutrophil serum; that the decrease in breaking strength was reduced, but not eliminated, by oxygen free radical scavengers; that the decrease in breaking strength was eliminated by a group-specific serine proteinase inhibitor and was reduced, but not eliminated, by proposed collagenase inhibitors; that the serine proteinase inhibitor and the oxygen free radical scavengers did not reduce the increase in myeoloperoxidase activity in the anastomotic segment and did not, at histological examination, reduce the accumulation of neutrophils there, and that the serine proteinase inhibitor did not impair the subsequent gain in breaking strength, measured after removal of the sutures, during the fibroplasia period. From these findings it can be concluded that there is a narrow zone of decrease in tissue strength adjacent to an incisional wound; that measurement of collagen content and solubility, and histology, are methods too crude to reveal the collagen changes that should be responsible for the decrease; that the neutrophils seem to be responsible for the decrease; that the mechanisms are probably a combined effect of neutral proteinases and oxygen free radicals, and that drug therapy modifying neutrophil function may be of value as prophylaxis against intestinal anastomotic dehiscence and burst abdomen.

Neutropenia prevents decrease in strength of rat intestinal anastomosis: partial effect of oxygen free radical scavengers and allopurinol.

A marked decrease in strength, probably due to local collagenolysis, occurs early after surgery in tissues adjacent to an incisional wound. To examine the role of the neutrophils, antineutrophil serum (ANS) was given to rats before and after a standardized end-to-end ileoileal anastomosis. Preimmune serum (PIS) was given to control rats. The decrease in anastomotic breaking strength, amounting to 55% in the PIS group, did not occur in ANS-treated rats, in which there was a decrease by more than 95% in the number of circulating polymorphonuclear cells. The decrease in tissue strength seems to be partly from oxygen free radicals, since the free radical scavengers superoxygen dismutase (SOD) and catalase prevented approximately 50% of the decrease. The xanthine oxidase inhibitor, allopurinol, prevented approximately 30% of the decrease. This is consistent with oxygen free radicals being partly generated by the neutrophils and partly generated after conversion of tissue xanthine dehydrogenase to xanthine oxidase. In contrast to ANS, SOD and catalase were unable to fully prevent the decrease in breaking strength. Therefore some other factor in addition to oxygen free radicals should be involved. One such factor may be the release of collagenolytic proteinases, e.g., elastase and cathepsin G, from the neutrophils.

A technique for endoscopic balloon dilatation of pyloric stenoses.

A technique facilitating the endoscopic dilatation of pyloric stenoses due to peptic ulcer disease is described. By means of a Dormia basket placed in the 3rd part of the duodenum a guide wire is obtained with the aid of which the balloon catheter can be positioned. Four patients thus treated are described. Short-term follow-up has been uneventful.

Beneficial effect on intestinal anastomoses of S-2441, a synthetic kallikrein-kinin antagonist. Experimental studies in the rat.

The effects of two protease inhibitors on breaking strength of an intestinal anastomosis were studied. The inhibitors tested were aprotinin and S-2441, a synthetic triple-peptide kallikrein-kinin antagonist. Rats were subjected to an end-to-end anastomosis in the small intestine. The breaking strength, or suture-holding capacity, was measured immediately after suture and after 24 hours. The loss of mechanical strength found in untreated rats was substantially, but not fully, prevented by S-2441. Aprotinin in the dose given was not effective.

Plasma fibronectin in relation to surgical trauma.

Plasma concentrations of fibronectin, alpha 2-macroglobulin and orosomucoid were monitored immunochemically in 20 patients before, during and after surgery. At 2 h after the induction of anaesthesia fibronectin concentrations were lowered 31 +/- 6% (SEM) compared to values obtained 1-3 d preoperatively. However, the fibronectin concentration decreased 17 +/- 5% (SEM) compared to preoperative values at the beginning of surgery. Most of the decline was thus not caused by the operative trauma. The perioperative changes in fibronectin concentrations did not differ from those found in alpha 2-macroglobulin and, up to 2 h postoperatively, orosomucoid.

Primary gastric lymphoma versus gastric cancer. An endoscopic and radiographic study of differential diagnostic possibilities.

Eighteen patients with primary gastric malignant lymphoma were compared retrospectively with an age- and sex-matched group of patients with gastric cancer. It was found that a correct preoperative diagnosis was established in 8 out of 18 lymphoma patients (44%). Of the remaining patients eight were preoperatively diagnosed as cancers and two as benign ulcers. Malignancy was not suggested by biopsy or cytology in a total of six lymphoma patients. There was no difference as regards the size of the gastric lesion between the groups. A diffuse involvement of the stomach was found only in lymphoma patients. Furthermore, lymphoma patients often showed superficial stellate ulcers and a sharp margin between the lesion and the normal mucosa. It is suggested that these findings should make the investigator aware of the possibility of a gastric lymphoma. When this diagnosis is considered, great importance should be attached to obtaining large biopsies which possibly allow a correct preoperative diagnosis more often.

Influence of intraperitoneal Escherichia coli with septicemia on the healing of colonic anastomoses and skin wounds. An experimental study in the rat.

In rats a standardized left colonic resection was performed and colonic continuity restored by an end-to-end anastomosis in one layer. The rats were subjected to an LD50 septic challenge by intraperitoneal injection of live Escherichia coli pre- or postoperatively. Controls received saline in a corresponding manner. Groups of animals were sacrificed on the 3rd or 7th postoperative day. The breaking strengths of the anastomosis and of the skin wound were measured. The collagen content of the anastomotic segments was analyzed. There were no differences in anastomotic or skin wound strength between septic animals and controls. Collagen content was unaffected. Wound healing was not influenced by sepsis in this model.