Monday, January 31, 2011

Adhesion Awareness: A National Survey of Surgeons.

Schreinemacher MH, ten Broek RP, et al: World J Surg; 2010;34 (December): 2805-2812

Objective: To report on a survey of Dutch surgeons, hypothesizing that lack of knowledge about adhesions and their consequences is related to surgeon practice and adhesion-related complications.

Design: Survey.

Participants: 1455 surgeons and trainees.

Methods: Initial survey questions were developed by a group of surgeons with a particular interest in adhesions. Questions were then edited by researchers with expertise in survey design and construction of multiple choice questions. Resultant survey was pilot-tested with 5 practicing surgeons and 3 surgical trainees. Final survey contained 55 multiple-choice questions, 4 open-ended questions, and 4 optional questions. Survey was sent to all members of the Dutch Association for Surgery, as well as to all registered surgical trainees. A reminder was sent electronically 1 week after the initial email if no response was obtained. Data from surveys with <80% p ="0.032).">Conclusions: The magnitude of the problem of postoperative adhesions is underestimated.
Reviewer's Comments: None of the agents that have been proposed as the magic bullet to prevent adhesions has lived up to expectations (or hopes), although certain products are effective in certain high-risk operations and populations. Even if adhesions are viewed as an inevitable result, it does make sense to include this in the preoperative discussion with patients, particularly those in high-risk groups. It appears that hopes and expectations will continue to rest on a future magic bullet.(Reviewer–Karen J. Brasel, MD, MPH).
© 2010, Oakstone Medical Publishing
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Friday, January 28, 2011

Will liver scar tissue hurt my chances for a natural birth?

Asked by Inga Johnson, Lake Mary, Florida

"I had a liver resection in late December 2008 because of a cavernous hemangioma (an abnormal buildup of blood vessels). I now have about a 10-inch scar from about center of my rib cage following along to the outer ribcage. Are there known complications of scar tissue like this? I am eight weeks pregnant and have started to wonder if the scar tissue may be an issue for natural birth and if there may be other issues that I should be aware of."

Conditions Expert
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society

Expert answer
Of course, I encourage you to discuss your concerns with your obstetrician. Perhaps I can give you some information to help in that discussion.

First let me explain that a hepatic hemangioma (also referred to as cavernous hemangioma) is a very common benign liver tumor. It is not known why these tumors occur. They are found in men and women of all ages. They usually have no symptoms and are frequently found when CT scans and ultrasounds are done for unrelated reasons.

Small asymptomatic hemangiomas are usually watched. Larger (greater than 5 centimeter in diameter) and symptomatic hemangiomas are treated.

The most common treatment is surgical removal. When a hemangioma is successfully removed, the overwhelming majority of patients do very well. Some patients will have multiple hemangiomas and only the largest one or the one causing symptoms is removed.

For women who have a known moderate to large hemangioma, there is concern that the high estrogenic levels found in women who are pregnant or taking oral contraceptives may encourage the growth of these hemangiomas. This is a concern and not a certainty.

As a result, controversy exists as to whether patients with known hemangiomas should be advised against pregnancy. For patients with hepatic hemangioma, full-term pregnancy without complication is the norm, but there have been a small number of women with hemangiomas that rupture and bleed during pregnancy. Some of these ruptured hemangiomas can be carefully watched and some need surgical resection.

In answer to your question, all surgeries in which the abdomen is entered carry a risk of postoperative adhesions, or the bowel sticking to itself. This is true for an appendectomy, a gallbladder surgery or a liver surgery. The risk is greatest for open surgeries and lower for laparoscopic surgery.

In general, a healthy pregnant woman with a history of a hemangioma resection should do well with the pregnancy. The risk of complications in delivery, be it by natural childbirth or by cesarean section delivery, are similar to that of a woman having had any successful abdominal surgery.

Adhesions are the result of tissue trauma and subsequent healing. They can cause abdominal pain, infertility, bowel obstruction, and they can increase the difficulty of subsequent surgical procedures. Bowel obstruction is the most common concern. In one large study, 3 of every 100 patients having an open abdominal surgery were diagnosed with symptomatic adhesions. Most are diagnosed within the first year after surgery.

To understand adhesions and obstruction, picture the gastrointestinal tract. It is a long tubular structure running from the mouth to the anus. The large and small intestine is a part of that tract and runs more than 25 feet long in the average adult. Imagine the large and small intestine like a garden hose coiled up in the abdominal cavity. It is possible for some of the bowel to have folds stuck to itself that can at times, due to shifting and movement, impede the flow of bowel content.

Acute bowel obstruction due to adhesions usually manifests itself with abdominal pain, nausea and vomiting. It is usually treated with hydration and bowel rest and can resolve with no further ill effects. Severe obstruction and especially recurring obstruction may be treated with surgical removal of the blockage.


Tuesday, January 25, 2011

Acute kidney injury due to osmotic nephrosis following intraoperative placement of an intraperitoneal antiadhesive barrier.

Am J Kidney Dis. 2011 Feb;57(2):304-7.

Acute kidney injury due to osmotic nephrosis following intraoperative placement of an intraperitoneal antiadhesive barrier.
Economidou D, Stavrinou E, Giamalis P, Dimitriadis C, Economou S, Memmos D.

Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.

In recent years, a common strategy for the prevention of postsurgical intra-abdominal adhesions has been intrasurgical placement of adhesion barriers into the peritoneal cavity. Osmotic agents, such as various polysaccharides, frequently are used as antiadhesive materials. The effects of these materials on kidney function have not yet been studied. We report a case of an individual with pre-existing chronic kidney disease who developed acute kidney injury after surgical placement of an antiadhesive barrier of macromolecular polysaccharides. A kidney biopsy, performed because of persistent kidney failure, showed tubular cell lesions compatible with osmotic nephrosis lesions. This case suggests that use of polysaccharide-containing antiadhesive barriers can induce severe kidney damage. Such barriers should be used with caution in patients with abnormal kidney function to prevent irreversible damage.

Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
PMID: 21251542 [PubMed - in process]

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