A comparative study of the effects of thrombin and electrodesiccation used for haemostasis on inflammation and adhesion formation

Electrodesiccation or chemical agents, such as thrombin and fibrin sealant, may be used to control oozing in the peritoneal cavity. Electrodesiccation is time consuming and associated with adjacent thermal damage. Adhesion formation remains a concern with the use of thrombin and fibrin sealant. In this study, adhesion formation and various histological parameters of inflammation were evaluated following haemostasis with electromicrodesiccation or thrombin in the rabbit model (n = 36). Following laparotomy, the right uterine horn was subjected to a measured injury producing sufficient oozing. After the injury was effected, the animals were randomized to haemostasis with electromicrodesiccation (n = 18) or thrombin (n = 18). In the first phase of the study, the histological parameters of acute injury and haemostasis with either modality were evaluated in two animals in each group. In the second phase, one, two and 10 animals, in each group, were submitted to second-look laparotomy on post-operative days 2, 7, and 15, respectively and the type and extent of adhesions were quantified. Histological parameters of inflammation as well as the type and extent of adhesions were comparable between the two groups. We conclude that local application of thrombin is not associated with a statistically greater degree of post-operative adhesions when compared to electromicrodesiccation.     

Adhesions: pathogenesis and prevention-panel discussion and summary

This article summarizes the discussions of the faculty and chairpersons on four major topics on postsurgical adhesions examined at the symposium, "Adhesions: Pathogenesis and Prevention". These topics are: 1) clinical significance; 2) pathogenesis; 3) research status and directions; and 4) recommendations for reduction or prevention. Abdominal postsurgical adhesions develop following trauma to the mesothelium, which is damaged often by surgical handling and instrument contact, foreign materials such as sutures and glove dusting powder, desiccation, and overheating. Postoperative adhesions occur after most surgical procedures and can result in serious complications, including intestinal obstruction, infertility, and pain. A long-term and unpredictable problem, postoperative adhesions impact the surgical workload and hospital resources, resulting in considerable health care expenditures. Although understanding of the pathogenesis of adhesions has improved recently, the molecular mechanisms involved continue to be delineated. Adhesions result from the normal peritoneal wound healing response and develop in the first five to seven days after injury. Adhesion formation and adhesion-free re-epithelialization are alternative pathways, both of which begin with coagulation which initiates a cascade of events resulting in the buildup of fibrin gel matrix. If not removed, the fibrin gel matrix serves as the progenitor to adhesions by forming a band or bridge when two peritoneal surfaces coated with it are apposed. The band or bridge becomes the basis for the organization of an adhesion. Protective fibrinolytic enzyme systems of the peritoneum, such as the plasmin system, can remove the fibrin gel matrix. However, surgery dramatically diminishes fibrinolytic activity. The pivotal events determining whether the pathway taken is adhesion formation or re-epithelialization are therefore the apposition of two damaged surfaces and the extent of fibrinolysis. Research in postsurgical adhesion formation and prevention abounds in a variety of avenues of investigation, including: 1) identification on a molecular level of the components involved in adhesiogenesis and their interactions; 2) clarification of the role of fibrin and fibrinolysis in adhesion formation; 3) standardization of design in preclinical and clinical studies of adhesion formation and prevention; 4) delineation of the relationship between adhesion formation and adhesive complications; and 5) elucidation of efficient, site-specific methods of prophylactic drug delivery. Currently, it seems logical to focus preventive research on development of barriers, fibrinolytic drugs, and selected agents such as phospholipids. The major strategies for adhesion prevention or reduction are adjusting surgical practice and applying adjuvants. Surgeons should adjust their major practices by: 1) becoming aware of the potential adhesive complications of a procedure; 2) minimizing the invasiveness of surgery; and 3) minimizing surgical trauma, ischemia, exposure to intestinal contents, introduction of foreign material into the body, and the use of talc- or starch-containing gloves. Available adjuvants include a newly developed by hyaluronic acid-phosphate-buffered saline solution applied intraoperatively to protect peritoneal surfaces from indirect surgical trauma and three mechanical barriers. One of these, a bioresorbable membrane consisting of hyaluronic acid and carboxymethylcellulose, has demonstrated efficacy and safety in both general and gynecological surgery. The other two barriers, one made of expanded polytetrafluoroethylene and one developed from oxidized regenerated cellulose, are indicated only for use in gynecological surgery.     

Tissue markers as predictors of postoperative adhesions

BACKGROUND: Postoperative adhesion formation has been associated with a decreased capacity to degrade intra-abdominally deposited fibrin. Adhesions, once lysed, have a high propensity for reformation. This study tested the hypothesis that patients with a high propensity for adhesion formation as well as adhesion tissue had a reduced fibrinolytic capacity. METHODS: Peritoneal biopsies were taken during abdominal surgery from 21 patients who had previously undergone operation; previously formed adhesion tissue was sampled from ten of these patients. Adhesion formation was scored. The fibrinolytic capacity of peritoneum was determined in tissue extracts. RESULTS: At the time of opening of the abdominal cavity, levels of plasminogen activator inhibitor (PAI) type 1 (P = 0.009) and tissue-type plasminogen activator (tPA)/PAI complex (P = 0.008) were increased in peritoneal samples from patients with severe adhesions compared with those in samples from patients with less severe adhesions. Adhesion tissue similarly had reduced fibrinolytic capacity as judged by a decrease in tPA activity (P = 0.005) and an increase in PAI-1 level (P = 0.01), reflected in an increased level of tPA/PAI complex (P = 0.008) compared with unaffected peritoneum. CONCLUSION: These observations demonstrate reduced fibrinolytic capacity in peritoneal tissue in patients with a greater propensity for development of adhesions and likewise in adhesion tissue. This suggests that components of the fibrinolytic system may be used as markers of an increased risk of adhesion development.     

Peritoneal healing after fibrin glue application: a comparative study in a rat model

The influence of fibrin glue on adhesion formation and peritoneal healing is evaluated in a prospective, randomized, controlled study. In all, 20 Wistar rats underwent microsurgical suturing of two silicone sheets, one covered with a fibrin glue barrier, to the anterior peritoneum. Each animal thus served as its own control. After 10 days, adhesions and peritoneal healing were evaluated by a blinded observer through a second-look laparotomy. Adhesions were scored using a modification of the classification of Diamond. Tissue around the silicone sheet was examined histologically and by scanning electron microscopy to evaluate the inflammatory reaction and peritoneal healing (ingrowth of blood vessels and quality of peritoneal cells). Adhesion scores for treated and control sides were (mean +/- SD) 2.89 +/- 4.68 and 6.79 +/- 9.09 (P = 0.181) respectively, and the percentage of the sheet covered by peritoneum was 26.25 +/- 31.50 and 29.21 +/- 40.21 (P = 0.226) respectively. Using the paired Wilcoxon rank test, the P values for the ingrowth of blood vessels and peritoneal healing evaluated by histology and scanning electron microscopy were 0.842, 0.692 and 0.695 respectively. We conclude that although the mean adhesion score was reduced by > 50% by fibrin glue, there is no statistically significant difference concerning adhesion formation or peritoneal healing with the use of fibrin glue.     

Comparative study of biological glues: cryoprecipitate glue, two-component fibrin sealant, and "French" glue

BACKGROUND: Although biological glues have been used clinically in cardiovascular operations, there are no comprehensive comparative studies to help clinicians select one glue over another. In this study we determined the efficacy in controlling suture line and surface bleeding and the biophysical properties of cryoprecipitate glue, two-component fibrin sealant, and "French" glue containing gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG). METHODS: Twenty-four dogs underwent a standardized atriotomy and aortotomy; the incisions were closed with interrupted 3-0 polypropylene sutures placed 3 mm apart. All dogs had a 3- by 3-cm area of the anterior wall of the right ventricle abraded until bleeding occurred. The animals were randomly allocated into four groups: in group 1 (n = 6) bleeding from the suture lines and from the epicardium was treated with cryoprecipitate glue; in group 2 (n = 6) bleeding was treated with two-component fibrin sealant; group 3 (n = 6) was treated with GRFG glue; group 4 (n = 6) was the untreated control group. The glues were also evaluated with regard to histomorphology, tensile strength, and virology. RESULTS: The cryoprecipitate glue and the two-component fibrin sealant glue were equally effective in controlling bleeding from the aortic and atrial suture lines. Although the GRFG glue slowed bleeding significantly at both sites compared to baseline, it did not provide total control. The control group required additional sutures to control bleeding. The cryoprecipitate glue and the two-component fibrin sealant provided a satisfactory clot in 3 to 4 seconds on the epicardium, whereas the GRFG glue generated a poor clot. There were minimal adhesions in the subpericardial space in the cryoprecipitate and the two-component fibrin sealant groups, whereas moderate-to-dense adhesions were present in the GRFG glue group at 6 weeks. The two-component fibrin sealant was completely reabsorbed by 10 days, but cryoprecipitate and GRFG glues were still present. On histologic examination, both fibrin glues exhibited minimal tissue reaction; in contrast, extensive fibroblastic proliferation was caused by the GRFG glue. The two-component and GRFG glues had outstanding adhesive property; in contrast, the cryoprecipitate glue did not show any adhesive power. The GRFG glue had a significantly greater tensile strength than the two-component fibrin sealant. Random samples from both cryoprecipitate and the two-component fibrin glue were free of hepatitis and retrovirus. CONCLUSIONS: The GRFG glue should be used as a tissue reinforcer; the two-component fibrin sealer is preferable when hemostatic action must be accompanied with mechanical barrier; and finally, the cryoprecipitate glue can be used when hemostatic action is the only requirement.     

Construction and characterisation of a Yersinia enterocolitica O:8 ompR mutant

OBJECTIVE: To test whether a barrier of chemically cross-linked pure hyaluronic acid reduces postoperative adhesion formation. DESIGN: The material was evaluated in the murine uterine horn model using excision and electrocautery injuries and in animals who had amounts of material inserted into the abdomen to evaluate toxicity. SETTING: Academic medical center. SUBJECT(S): Mice. INTERVENTION(S): Insertion of the barrier between uterine horns and into the peritoneal cavity. MAIN OUTCOME MEASURE(S): Adhesion formation at 14 days; the histology of the peritoneum, liver, and spleen at 42 days; and the number, differential count, morphology, and flow cytometry of peritoneal leukocytes 3 days postoperatively. RESULT(S): Fewer adhesions were present when excision injuries were separated by the barrier (12 of 28 sites [43%] versus 23 of 26 control sites [88%]), whereas the number of adhesions was unchanged after electrocautery injuries (14 of 26 sites [54%] versus 17 of 26 control sites [65%]). The uterine horn sites covered by the barrier were histologically indistinguishable from controls. No adverse impact on the peritoneum and peritoneal fluid leukocyte population was observed with barrier insertion. CONCLUSION(S): The use of a barrier composed of a chemically cross-linked hyaluronic acid derivative (Incert, Anika Therapeutics, Inc., Woburn, MA) reduced postoperative adhesion formation in this model without any adverse impact on the peritoneum and peritoneal leukocyte population. This barrier material shows promise in preventing postoperative adhesions and deserves clinical evaluation.     

The role of neutrophils in peritoneal adhesion formation

The most common cause of intraperitoneal adhesions is previous abdominal surgery. Postoperative adhesion formation results from a fibroproliferative inflammatory reaction that begins with an influx of polymorphonuclear leukocytes (PMNs) into the peritoneal cavity. Adherence of the PMNs to the endothelial cells (EC) is necessary for PMN migration into the tissue in response to a stimulus. Several receptor-counterreceptor pairs of ligands such as CD11/CD18 on the PMN and ICAM-1 (CD54) on EC have been identified. Monoclonal antibody against CD11/CD18 (R15.7) inhibits PMN adherence and migration and consequently protects against PMN-induced tissue injuries. We therefore studied the effect of preventing PMN-EC adherence, using anti-CD18 monoclonal antibody, on postoperative adhesion formation in rabbits. Group 1 was a control receiving physiologic saline, and group 2 received anti-CD18 antibody (R15.7, 2 mg/kg). The treatment was administered iv at the end of surgery and repeated on the first and second postoperative days. Peritoneal adhesions were induced at laparotomy by repairing two peritoneal defects, by oversewing the defect (model 1), and by resuturing the removed parietal peritoneum in its place as an ischemic graft (model 2). Adhesions were evaluated blindly at 10 days after operation by measuring the percentage of the suture line covered with adhesions (model 1) or by a scoring system (model 2). All control animals developed intraperitoneal adhesions and the percentage of the suture line covered with adhesions was 25 +/- 5.9% (mean +/- SEM) and the mean score in model 2 was 0.9 +/- 0.2. Anti-CD18 antibody, R15.7, increased the degree of postoperative adhesion formation in both models, but the results were significant only in model 2. Also, anti-CD18 antibody significantly decreased peritoneal neutrophils from 11.1 x 10(7) +/- 1.8 x 10(7) to 2.2 x 10(7) +/- 0.4 x 10(7) (P < 0.001) on the first postoperative day. It is concluded that inhibition of PMN-EC adherence does influence the postoperative adhesion formation. These results might suggest that PMNs have a role in modulating postoperative adhesion formation.     

Clinical evaluation of 0.5% ferric hyaluronate adhesion prevention gel for the reduction of adhesions following peritoneal cavity surgery: open-label pilot study

The objective of this study was to assess the safety and to make a preliminary assessment of the efficacy of 0.5% ferric hyaluronate adhesion prevention gel in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy. The study was a randomized, open-label, placebo-controlled, parallel-group design in patients desirous of fertility at the Women's and Children's Hospital, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California. Female patients aged 24 to 41 years received 300 ml 0.5% ferric hyaluronate adhesion prevention gel or lactated Ringer's solution as an intraperitoneal instillate at the completion of the laparotomy procedure. At second-look laparoscopy 4-12 weeks after the laparotomy, the presence of adhesions was evaluated. Haematology and serum chemistry were determined throughout the study interval. All patients tolerated the procedures well and did not manifest any serious adverse events. At second-look laparoscopy, patients treated with 0.5% ferric hyaluronate adhesion prevention gel had significantly fewer adhesions than control patients. When adhesions did form, they were significantly less extensive and less severe in patients who received 0.5% ferric hyaluronate adhesion prevention gel. In conclusion, 0.5% ferric hyaluronate adhesion prevention gel was safe and highly efficacious in the reduction of the number, severity and extent of adhesions throughout the entire abdomen following peritoneal cavity surgery.     

Serum levels of interleukin 1 and tumor necrosis factor alpha correlate with peritoneal adhesion grades in humans after major abdominal surgery

Peritoneal adhesions are a leading cause of potential morbidity and mortality. We undertook this prospective study to determine the clinical relevance of interleukin 1 (IL-1) and tumor necrosis factor alpha (TNF-alpha) levels as biological markers for peritoneal adhesion formation in humans. Fifteen patients who had previous colectomies and were undergoing re-exploration for an elective vascular procedure were studied. Blood samples were collected from each patient preoperatively and 30 minutes after the abdominal incision was made. Serum levels of IL-1 and TNF-alpha were determined using enzyme-linked immunosorbent assay kits. Adhesions were graded using an adhesion scale of 0 (none), 1 (mild), 2 (moderate), and 3 (extensive, dense). Preoperative levels of IL-1 and TNF-alpha did not differ significantly among all patients (IL-1 level was 60 +/- 14 pg/mL, and TNF-alpha level was 45 +/- 11 pg/mL; mean +/- standard deviation). Significant correlation was observed between grades of adhesions and early intraoperative levels of IL-1 [101 +/- 36 pg/mL for grade 1 (n = 8) vs 298 +/- 73 pg/mL for grade 3 (n = 6); P < 0.01] and TNF-alpha (88 +/- 23 pg/mL for grade 1 vs 261 +/- 88 mL for grade 3; P < 0.02). We conclude that early elevations of IL-1 and TNF-alpha are reliable biological markers for postoperative adhesions in humans. Studies utilizing cytokines antibodies to these markers may further elucidate the efficacy of this method for prevention of peritoneal adhesions.     

Protein kinase C modulates estrogen receptors in differentiated osteoblastic cells in vitro

Ventriculo-peritoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. Abdominal complications of VPS are now a rare event; however, their frequency varies from 5% to 47% according to reports. Anything that causes an obstruction or impediment of the VP derivation system will lead to intracranial hypertension, which requires immediate surgery. From 1985 to 1995 at the Division of Pediatric Surgery of the Federico II University of Naples, ten laparoscopies were performed in ten children with VPS complications. Cerebrospinal fluid pseudocysts were found in four infants. There was one case of abdominal wall perforation by the tip of the catheter at the umbilical level, two bowel obstructions, and one catheter was lost in the abdominal cavity. Finally, two children had malfunctioning of the peritoneal limb of the catheter. The laparoscopic technique was curative in all ten cases, thus avoiding a conventional laparotomy and the consequent risk of adhesions, which could cause further complications.     

The gynecologic contribution to intestinal obstruction in females

This study was done to identify the cause of intestinal obstruction with particular emphasis on the gynecologic and perioperative related causes. All medical records from females with the discharge diagnosis "intestinal obstruction" from 1988 to 1991 at Columbia Presbyterian Medical Center were requested. The patient series consisted of the first 100 completed charts received. Forty-eight percent of those patients with intestinal obstruction had experienced a previous gynecologic or obstetric event that could account for the obstruction. Primarily, the gynecologist managed more than 20 percent of all female patients with intestinal obstruction. The most common causative factors contributing to intestinal obstruction were postoperative adhesions (59 percent) and tumor (17 percent). Fifty-six percent of the patients with intestinal obstruction associated with postoperative adhesions had a history of previous gynecologic and obstetric operation. Hysterectomy was the most common previously performed operation. In this series, cesarean section was less likely and myomectomy was more likely to cause subsequent intestinal obstruction than expected. Of 59 female patients with postoperative adhesions associated with intestinal obstruction, 31 had the original operative reports available for analysis. Eleven of these patients were taken to the operating room for management of the obstruction. In the nine patients who had surgical peritoneal closure in the original operation, the adhesions causing the obstruction were always to the site of reperitonealization. In the two patients in whom the peritoneum was left open, the adhesions causing obstruction were remote from the site of spontaneous reperitonealization. In an unselected patient series of intestinal obstruction, a history of previous gynecologic pathology is a significant factor contributing to the total number of instances of intestinal obstruction in females. Also, surgical peritoneal closure may result in an increase in the incidence of intestinal obstruction.     

A steady-state template model that describes the kinetics of fibrin-stimulated [Glu1]- and [Lys78]plasminogen activation by native tissue-type plasminogen activator and variants that lack either the finger or kringle-2 domain

The kinetics of activation of both [Glu1]- and [Lys78]Plg(S741C-fluorescein by native (recombinant) tissue-type plasminogen activator and its deletion variants lacking either the finger or kringle-2 domain were measured by fluorescence within fully polymerized fibrin clots. The kinetics conform to the Michaelis-Menten equation at any fixed fibrin concentration so long as the plasminogen concentration is expressed as either the free or fibrin-bound, but not the total. The apparent kcat and Km values both vary systematically with the concentration of fibrin. Competition kinetics disclosed an active site-dependent interaction between t-Pa and [Glu1]Plg(S741C-fluorescein) in the presence, but not the absence, of fibrin. A steady-state template model having the rate equation v/[A]o = kcat(app).[Plg]/(Km(app) + [Plg]) was derived and used to interpret the data. The model indicates that catalytic efficiency is determined by the stability of the ternary activator-fibrin-plasminogen complex rather than the binding of the activator or plasminogen to fibrin. This implies that efforts to improve the enzymatic properties of t-PA might be more fruitfully directed at enhancing the stability of the ternary complex rather than fibrin binding.     

Stimulation of monocyte tissue factor expression in an in vitro model of bacterial endocarditis

The coagulation system plays a major role in the formation of the infected endocardial vegetation in bacterial endocarditis. Since monocytes can express tissue factor (TF) on their surfaces, they are thought to be responsible for the extrinsic activation of the coagulation cascade during this disease. The present study used an in vitro model in which fibrin plates, isolated adherent monocytes, and Streptococcus sanguis were used as an analog for endocardial vegetations. Adherence to fibrin by itself was found to stimulate TF expression on the monocytes, but stimulation by S. sanguis significantly increased TF expression, which was found to be maximal at a bacterium-to-monocyte ratio of 9 or more.     

Optimization of photopolymerized bioerodible hydrogel properties for adhesion prevention

The aim of this study was to optimize the properties of a lubricious bioerodible hydrogel barrier for the prevention of postoperative adhesions. Water-soluble macromers based on block copolymers of poly(ethylene glycol) (PEG) and poly(lactic acid) or poly(glycolic acid) with terminal acrylate groups were used, and these macromers were gelled in vivo by exposure to long wavelength ultraviolet light. The precursor was photopolymerized from buffered saline solution while in contact with the tissues. This resulted in the conformal coating of the tissue with an adherent hydrogel film, while forming a nonadhesive barrier at the free surface, on the treated wound site. The hydrogels were evaluated in two animal models of postsurgical adhesions, first in a rat cecum abrasion model and then in a rabbit uterine horn ischemia model. In the rat cecum model, six of seven animals treated with a hydrogel, with glycolide in the precursor as the comonomer, showed no adhesions; untreated animals and animals treated with precursor, but not gelled with light, showed consistent dense adhesions. In the rabbit uterine horn ischemia model, using hydrogels with lactide in the precursor as the comonomer, and PEG of molecular weight from 6,000 to 18,500 Da, adhesions were dramatically reduced, with occurrence in none of seven animals treated with a gel containing PEG 10,000. By contrast, the seven animals in the control group demonstrated a mean of 35% involvement of the horn length in dense, fibrous adhesions. These materials, photopolymerized in vivo in direct contact with the tissues, appear to form an adherent hydrogel barrier that is highly effective in reducing postoperative adhesions in the models used.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experimental assay of a Dual Mesh polytetrafluoroethylene prosthesis (non-porous on one side) in the repair of abdominal wall defects

The porosity of the prosthetic biomaterials used to repair defects in the abdominal wall seems to influence the tissue repair process insofar as tissue integration of the prosthetic material and the formation of adhesions with abdominal viscera are concerned. We studied the behaviour of a new type of polytetrafluoroethylene prosthesis used for the repair of abdominal wall defects. Dual Mesh (DM), which has two different faces; one face has a porosity between 30 and 60 microns, while the other is non-porous. In 20 New Zealand White rabbits, a full-thickness (except skin) 7 cm x 5 cm defect was created in the anterior abdominal wall that was repaired with DM. At 14, 30, 60 and 90 days, samples were obtained and studied by light and scanning electron microscopy. An immunohistochemical study was made with antibody anti-rabbit macrophages (RAM-11). Tensile strength was measured with an Instron tensiometer using 2-cm-wide strips obtained parallel to the shorter axis of the implant. DM induced little tissue adhesion to the material on the visceral peritoneum interface and was surrounded by organized repair tissue. The biomaterial was integrated in the repair tissue on the subcutaneous interface, but not on the peritoneal interface. The macrophage response decreased between days 14 and 90 (P < 0.001). Tensile strength increased significantly (P < 0.05) at every study period. We conclude that the DM prosthesis has little tendency to formation of visceral adhesions, the DM prosthesis was well tolerated by the receptor organism and the tensile strength of the prosthesis/receptor tissue interface increased with time.     

Results with collagen fleece coated with fibrin glue (TachoComb). A macroscopical and histological experimental study

Diffuse bleeding from parenchymatous organs at conventional surgery is eliminated with the usual methods coagulation tamponade or styches. We performed experimental series at 9 dogs. After resection of spleen, liver, pancreas and kidney, the bleeding surface was covered by collagen fleece coated with fibrin glue (TachoComb). Postoperatively 7 days, 10 days, 14 days and 28 days we made a relaparotomy. Then the results were analyzed macroscopically and microscopically. In the abdominal cavity neither significant quantity of blood nor greater adhesions were detected. At all cases the fibrin glue was found on place were it was put before. Histologically a perfect wound healing experienced. The fibrin glue (TachoComb) using at diffuse parenchymatous organs' bleeding give a very good results when the wound area is at least 1 cm beyond the immediate wound margin and the fibrin glue is applied onto the wound and pressed on it for 4-5 minutes.     

Talc pleurodesis: talc slurry versus thoracoscopic talc insufflation in a porcine model

BACKGROUND: Pleurodesis using both talc slurry and thoracoscopic talc insufflation has been shown to be clinically effective. This study compares these two modalities of pleural talc instillation in an animal model. METHODS: Eleven immature pigs underwent general endotracheal anesthesia. On one side, a slurry of 5 g sterile United States Pharmacopeia talc in 50 mL of saline solution was instilled through a thoracostomy tube. On the other side, the lung was deflated and 5 g of dry talc was insufflated under thoracoscopic visualization. The animals were sacrificed 30 days later, and the quality of pleural adhesions was graded from 0 to 2 (0 = absent; 1 = light; 2 = dense) in each of six regions of each hemithorax. The distribution of adhesions on each side was graded from 0 to 6, according to the number of areas that contained adhesions. RESULTS: One animal died of anesthetic complications. Among the survivors, adhesions produced by both methods were dense and diffuse in 8 of 10 animals, and light and diffuse in 1 animal. One animal had light or absent adhesions on the talc slurry side, and dense and diffuse adhesions on the thoracoscopic talc insufflation side. There was no difference between the techniques for density of adhesion scores (talc slurry, 9.9 +/- 2.2; thoracoscopic talc insufflation, 10.0 +/- 2.5) or distribution of adhesion scores (talc slurry, 5.5 +/- 1.0; thoracoscopic talc insufflation, 5.8 +/- 0.4) (p > 0.1). CONCLUSIONS: Effective pleurodesis in a porcine model can be obtained with either talc slurry or thoracoscopic talc insufflation.     

Effect of fibrin sealant on the integrity of colonic anastomoses in rats with faecal peritonitis

OBJECTIVE: To assess the influence of fibrin adhesive on the healing of colonic anastomoses in rats with and without faecal peritonitis. DESIGN: Controlled study. SETTING: Laboratory for experimental surgery, Erasmus University Rotterdam, The Netherlands. MATERIAL: 120 male Wag/Rij rats. INTERVENTIONS: All rats had a single layer end-to-end anastomosis fashioned with 7/0 polypropylene. Faecal peritonitis was then induced in half of the rats by placement of 200 mg powdered autoclaved rat faeces in the peritoneal cavity near the anastomosis. Rats were allocated to one of four groups (n = 30 in each): 1--control; 2--additional sealing with fibrin glue; 3--peritonitis alone; and 4--peritonitis with fibrin glue. MAIN OUTCOME MEASURES: Body weight, adhesion formation, anastomotic bursting pressure and collagen concentration around the anastomosis on days 2, 4, and 7 in 10 rats from each group. RESULTS: 11 rats died of peritonitis before the experiment was completed. Peritonitis caused increased formation of adhesions and abscesses, with or without fibrin sealant. Bursting pressure at the anastomosis was significantly reduced in peritonitis compared with controls on days 4 and 7, and this was not prevented by fibrin. Sealing of anastomoses resulted in lower bursting pressures on day 4 in control animals. Collagen concentration was significantly reduced in peritonitis with or without fibrin sealant on days 4 and 7, and after fibrin sealing of control anastomoses. CONCLUSION: Faecal peritonitis reduced mechanical strength and collagen concentration of colonic anastomoses, and this was not prevented by additional sealing of the anastomosis with fibrin sealant.     

Acute intestinal obstruction in an elderly patient

The correct diagnosis of an acute abdomen in the aged is difficult, because of its varying presentation. Intestinal obstruction as a cause of acute abdomen is five times more common in the elderly as compared to younger patients. Acute intestinal obstruction in elderly patients may be due to intestinal or gynaecologic malignancies, or more frequently to incancerated hernias, peritoneal adhesions or faecal impaction. This case report describes a 90-year old female patient with intestinal obstruction, due to a bilateral torsion of benign ovarian cysts. Urgent surgery was life-saving. This case demonstrates that early decision for adequate therapy can reduce morbidity and mortality, also in very old patients.     

Decrease in contents of pancreatic carboxyl ester lipase, phospholipase A2, and lingual lipase in rats with streptozotocin-induced diabetes

Fibrin glue has been used as a protective seal in normal and high-risk anastomoses to prevent leakage. The influence of fibrin adhesive on the healing colonic anastomosis in a control and high-risk model was tested. Resection and anastomosis of the left colon was performed in rats. In group Ia an end-to-end anastomosis was constructed with 12 7-O polypropylene sutures; in group Ib the anastomosis was sealed with fibrin adhesive. In group II an incomplete anastomosis was constructed with only 4 sutures at 90 degrees, therefore potentially leaking. In group IIb additional sealing with fibrin glue was performed. On Days 2, 4, and 7 body weight, adhesion formation, anastomotic bursting pressure, and collagen concentration were measured. The results showed increased adhesion formation after fibrin sealing. The anastomotic bursting pressure of incomplete anastomoses showed a significant increase after sealing on Day 2 only; on Day 4 and 7 no differences were found. Sealing of control anastomoses caused lower bursting pressures on Day 4. Collagen concentration is significantly reduced after fibrin sealing of normal anastomoses. We conclude that fibrin sealing of control anastomoses inhibits wound healing. Incomplete anastomoses are temporarily protected by fibrin glue sealing. Finally, fibrin sealing of the colon wound does not prevent adhesion formation.