Perioperative fluid infusion and its influence on anastomotic leakage after rectal cancer surgery: implications for prevention strategies.

AIM: This study aimed to identify modifiable risk factors for anastomotic leakage during the postoperative period to recognize areas of clinical practice that could be improved. METHOD: Medical charts of patients who underwent elective open anterior resection for rectal cancer over a 5-year period were reviewed retrospectively. RESULTS: One hundred and twenty-four patients [64 men, mean age (± SD) 68.0 ± 9.0 years] underwent an anterior resection for rectal cancer during the study period. Twenty-two (17.7%) patients had anastomotic leakage. Patients who were given more than 8000 ml of intravenous fluid during the 72-h perioperative period had a statistically significant increased risk of developing anastomotic leakage [odds ratio (OR) 3.20, 95% confidence interval (CI) 1.10-9.31, P = 0.049] and the risk increased further when patients were given more than 8500 ml of intravenous fluid (OR 3.86, 95% CI 1.29-11.5, P = 0.019). The incidence of anastomotic leakage was not influenced by baseline comorbidity or tumour stage. CONCLUSION: Perioperative intravenous fluid of more than 8000 ml was associated with increased occurrence of anastomotic leakage. Vigorous monitoring of intravenous fluid use in the perioperative period may minimize this complication.

Late outcome of bleeding gastric ulcer. Five to eight years' follow-up.

BACKGROUND: Gastric ulcer haemorrhage is associated with a high immediate mortality, but few data exist on the late prognosis of these patients. The aim of this study was to determine the long-term recurrence rate and late outcome in patients with gastric ulcer complicated with bleeding. METHODS: In a prospective follow-up study 90 consecutive patients with a bleeding gastric ulcer discharged after non-operative treatment (bleeding controlled by endoscopic electrocoagulation or ceased spontaneously) were followed up once every year for 5-8 years (median, 6.5 years). RESULTS: Recurrent ulcer was seen in 17 patients, repeat haemorrhage being the presenting symptom in 13 of them. The estimated cumulative recurrence rate after 2, 5, and 8 years was 10%, 19% and 33%, respectively. Recurrence rate was unaffected by sex, complicating disease, and non-steroidal anti-inflammatory drugs (NSAIDs) ingestion before and after the index bleeding episode. The recurrence rate of patients with a history of ulcer before the index bleeding episode did not differ from that of patients with no previous ulcer history. A significantly increased risk of recurrence was seen in patients with previous bleed as opposed to patients with previous non-bleeding ulcer (p < 0.05). The cumulative survival rate was significantly reduced compared with the expected survival rate of the sex- and age-matched background population (p < 0.01), primarily because of diseases not related to the ulcer disease. CONCLUSION: Bleeding gastric ulcer is associated with a relatively low long-term recurrence rate, except in a few patients with a history of previous bleeding ulcer, who have an increased risk of recurrence. Patients with bleeding gastric ulcer have an excess mortality not related to the ulcer disease.

General surgery in patients aged 80 years and older.

This study reviews 594 surgical admissions, of patients aged 80 years and older, to departments of general surgery during 1 year. Half of the patients were admitted as emergencies and 60 per cent underwent surgery. The operative mortality rate was 8 per cent and the overall mortality rate for all admissions 9 per cent. The number of complications and the mortality rate after surgery increased in emergency cases and in patients with coexisting disease. Of all admissions, 72 per cent were uncomplicated and in 70 per cent patients could be discharged directly home; such patients do not generally take up beds and are discharged as soon as medical care is no longer indicated. The number of admissions of patients over 80 years of age will increase by about 30 per cent during this decade and, unless additional resources are provided to meet this challenge, new standards must be considered for the distribution of resources and of indications for surgery in both young and old.

Herniorrhaphy in patients aged 80 years or more. A prospective analysis of morbidity and mortality.

OBJECTIVE: To find out the morbidity and mortality after repair of groin hernias in patients aged 80 years or more, and to identify factors that add to the risk of hernia repair. DESIGN: Prospective open study. SETTING: All general surgical departments in Ringkøbing County, Denmark. SUBJECTS: All 39 patients aged 80 years and over who were admitted with hernias during a one year period (1990). OUTCOME MEASURES: Morbidity and mortality. RESULTS: Three patients refused operation, and of the remaining 36, 15 (42%) were admitted as emergencies (5 of whom were already waiting for elective repair of their hernias). The median age was 84 years (range 80-90) and 23 (64%) were men, 31 patients had inguinal hernias, 4 had femoral hernias, and one an obturator hernia. There were six major and two minor complications after 14 emergency operations (57%), and one minor complication after 22 elective operations (5%, p = 0.0007). Two patients died, both after emergency operations (14%). CONCLUSION: Elective hernia repair can be carried out safely even in the presence of serious coexisting disease, and emergency hernia repair carries a high risk of complications even in the absence of coexisting disease.

Cefoxitin for one day vs. ampicillin and metronidazole for three days in elective colorectal surgery. A prospective, randomized, multicenter study.

In a multicenter study the prophylactic efficacy of two antibiotic regimens was tested against postoperative septic complications following elective colorectal surgery. The study was conducted in a prospective block-randomized design. Patients were preoperatively allocated to either ampicillin, 1 gm, four times daily, and metronidazole, 0.5 gm, three times daily, for 72 hours, or to cefoxitin, 2 gm, given three times in a period of 10 hours. Both regimens were initiated immediately before surgery. Forty-five patients were withdrawn from the study after randomization. Three hundred fifty two patients (175 receiving ampicillin and metronidazole and 177 receiving cefoxitin) completed the study and were followed for one month postoperatively. The frequency of septic and nonseptic complications was not statistically significant different between the two regimens. About one third of all septic complications appeared more than two weeks after surgery. It is concluded that short-term treatment with cefoxitin is at least as efficient as a three-day treatment with ampicillin and metronidazole.

Dihydroergotamine and the thromboprophylactic effect of dextran 70 in emergency hip surgery.

In a prospective randomized controlled trial treatment with a combination of dextran 70 and dihydroergotamine (DHE) was compared with the administration of dextran 70 alone as prophylaxis against postoperative thrombo-embolic complications in emergency hip surgery. Forty-five consecutive patients with a fractured hip entered the study. Twenty-one were randomized to prophylactic treatment with dextran 70 (group 1) and twenty-four patients received dextran 70 and DHE (group 2). Both regimens were initiated pre-operatively and the surgical and postoperative procedures were the same in the two groups. On the first and fourth postoperative day, Tc-plasmin scintigraphy of the lower extremities and pulmonary ventilation/perfusion scintigraphy were performed to detect any deep vein thrombosis (DVT) and/or pulmonary emboli. A total of 19 per cent of group 1 patients developed DVT and so did 25 per cent in group 2; this difference was not statistically significant. Of the detected DVT, 60 per cent were subclinical, and 7 per cent of the patients had minor pulmonary emboli, all of which were symptomless. No therapeutic difference could be demonstrated between the two regimens. A recent report claiming that adding DHE to the prophylactic administration of dextran 70 considerably reduces the incidence of postoperative DVT in emergency hip surgery is questioned.

Muscle blood flow after amputation. Increased flow with medullary plugging.

At below-knee amputation for arterial insufficiency in 31 patients, the muscle blood flow of quadriceps and triceps surae was measured by clearance of 99mTc pertechnetate pre- and postoperatively. In 15 patients, myoplastic amputation was performed and in 16 patients the medullary cavity of the tibial stump was plugged with cortex of the removed bone as well. Plugging caused a two-third increase in muscle blood flow.