Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults

BACKGROUND: Postoperative adynamic bowel atony interferes with recovery following abdominal surgery. Prokinetic pharmacologic drugs are widely used to accelerate postoperative recovery. OBJECTIVES: To evaluate the benefits and harms of systemic acting prokinetic drugs to treat postoperative adynamic ileus in patients undergoing abdominal surgery. SEARCH STRATEGY: Trials were identified by computerised searches of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and the Cochrane Colorectal Cancer Group specialised register. The reference lists of included trials and review articles were tracked and authors contacted. SELECTION CRITERIA: Randomised controlled parallel-group trials (RCT) comparing the effect of systemically acting prokinetic drugs against placebo or no intervention. DATA COLLECTION AND ANALYSIS: Four reviewers independently extracted the data and assessed trial quality. Trial authors were contacted for additional information if needed. MAIN RESULTS: Thirty-nine RCTs met the inclusion criteria contributing a total of 4615 participants. Most trials enrolled a small number of patients and showed moderate to poor (reporting of) methodological quality, in particular regarding allocation concealment and intention-to-treat analysis. Fifteen systemic acting prokinetic drugs were investigated and ten comparisons could be summarized. Six RCTs support the effect of Alvimopan, a novel peripheral mu receptor antagonist. However, the trials do not meet reporting guidelines and the drug is still in an investigational stage. Erythromycin showed homogenous and consistent absence of effect across all included trials and outcomes. The evidence is insufficient to recommend the use of cholecystokinin-like drugs, cisapride, dopamine-antagonists, propranolol or vasopressin. Effects are either inconsistent across outcomes, or trials are too small and often of poor methodological quality. Cisapride has been withdrawn from the market due to adverse cardiac events in many countries. Intravenous lidocaine and neostigmine might show a potential effect, but more evidence on clinically relevant outcomes is needed. Heterogeneity among included trials was seen in 10 comparisons. No major adverse drug effects were evident. AUTHORS' CONCLUSIONS: Alvimopan may prove to be beneficial but proper judgement needs adherence to reporting standards. Further trials are needed on intravenous lidocaine and neostigmine. The remaining drugs can not be recommended due to lack of evidence or absence of effect.

Peri-operative adrenocortical response to low-dose (1 microg) ACTH and relation to postoperative complications in patients undergoing elective abdominal surgery

BACKGROUND: To test the hypothesis that reduced responsiveness to adrenocorticotropin (ACTH) stimulation before elective major abdominal surgery is associated with an increased incidence of postoperative complications. METHODS: A low-dose (1 microg) ACTH test was performed the day before surgery, during the operation, on the first postoperative day, and before discharge from the hospital in 77 patients undergoing major abdominal surgery (age 62 [47;69] yrs [median, quartiles]; 30 female). Thirty-one patients undergoing minor, non-abdominal surgery (mostly inguinal hernia repair) (age 57 [40;66] yrs; 14 female) served as controls with minor surgical stress. A stimulated plasma cortisol concentration >or=500 nmol/l or an increment of >or=200 nmol/l in response to 1 microg ACTH was defined as normal. Scores for surgical stress and comprehensive risk, postoperative complications, and length of hospital stay (LOS) were assessed. RESULTS: On the day before major abdominal surgery, basal and stimulated plasma cortisol were 242 (165;299) nmol/l and 497 (404;568) nmol/l, respectively. Eighteen (23%) patients had an abnormal ACTH test, and 7 of these (39%) had complications versus 25 (42%) of the 59 patients with normal ACTH tests (P = .992). Surgical stress, comprehensive risk, and intra- and postoperative basal cortisol levels were higher and the response to ACTH stimulation smaller in patients with major abdominal compared to minor surgery. The peri-operative course of ACTH responses was not associated with complications or LOS in abdominal surgery patients. CONCLUSION: In patients scheduled for abdominal surgery, pre-operatively reduced adrenal response to stimulation with 1 microg ACTH is common but not associated with postoperative complications.

Three hundred and eighty-four laparotomies for various diseases, with tables showing the results of the operations and the subsequent history of the patients. A resumé of the writer's experience in abdominal surgery during the last fifteen years.

Includes tables.

Abdominal surgery;

Mode of access: Internet.

Local analgesia: abdominal surgery,

Mode of access: Internet.

Surgical risk tests related to cardiopulmonary postoperative complications: comparison between upper abdominal and thoracic surgery

PURPOSE: To investigate if tests used in the preoperative period of upper abdominal or thoracic surgeries are able to differentiate the patients that presented cardiopulmonary postoperative complications. METHODS: Seventy eight patients, 30 submitted to upper abdominal surgery and 48 to thoracic surgery were evaluated. Spirometry, respirometry, manovacuometry, six-minute walk test and stair-climbing test were performed. Complications from immediate postoperative to discharge from hospital were registered. RESULTS: The postoperative complications rate was 17% in upper abdominal surgery and 10% in thoracic surgery. In the univariate regression, the only variable that kept the correlation with postoperative complications in the upper abdominal surgery was maximal expiratory pressure. In thoracic surgery, the maximal voluntary ventilation, six-minute walk test and time in stair-climbing test presented correlation with postoperative complications. After multiple regression only stair-climbing test continued as an important risk predictor in thoracic surgery. CONCLUSION: The respiratory pressure could differentiate patients with complications in upper abdominal surgery, whereas in thoracic surgery, only spirometric values and exercise tests could differentiate them.

Nutritional status and its impact on time and relocation in postoperative complications of abdominal patients undergoing surgery

Introduction: The nutritional state is the independent factor that most influences the post-operational results in elective surgeries. Objective: to evaluate the influence of the nutritional state on the hospitalization period and on the post-operative complications of patients submitted to abdominal surgery. Methods: prospective study with 99 surgical patients over 18 years of age, submitted to abdominal surgeries in the period from April to October of 2013, in the Instituto de Medicina Integral Professor Fernando Figueira (IMIP). All patients were submitted to anthropometric nutritional evaluations through the body mass Index (BMI), arm circumference (AC) and triceps skinfold thickness (TEST). The biochemical evaluation was carried out from the leukogram and serum albumin results. The identification of candidate patients to nutritional therapy (NT) was carried out through the nutritional risk (NR) evaluation by using the BMI, loss of weight and hypoalbuminemia. The information about post-operational complications, hospitalization period and clinical diagnosis was collected from the medical records. Program SPSS version 13.0 and significance level of 5% were used for the statistical analysis. Results: The malnutrition diagnosed by the AC showed significant positive association with the presence of post-operative complications (p=0.02) and with hospitalization period (p=0.02). The presence of NR was greater when evaluated by hypoalbuminemia (28.9%), however, only 4% of the sample carried out the NT in the pre-operational period. The hospitalization period was greater for patients with malignant neoplasia (p<0.01). Conclusion: The malnutrition diagnosis of patients submitted to abdominal surgeries is associated to greater risk of post-operational complications and longer hospitalization permanence.

A dor no período pós-cirúrgico abdominal em doentes geriátricos

A dor é uma das principais causas do sofrimento humano, comprometendo a qualidade de vida dos indivíduos, em especial o idoso que, devido aos problemas cognitivos e à elevada medicação os torna mais suscetíveis aos efeitos adversos dos medicamentos utilizados para o alívio da dor. Neste contexto, o objetivo deste estudo é avaliar a dor na pós-cirurgia abdominal em doentes geriátricos; identificar a localização e a intensidade dolorosa utilizando a Escala Numérica; analisar a dor nas dimensões sensorial, afetiva e cognitiva, utilizando o Questionário para Dor de McGill; relacionar o processo álgico com a idade, sexo, religião e tipo de abordagem cirúrgica; saber se as intervenções autónomas de enfermagem contribuem para o alívio da dor pós-operatória. Trata-se de um estudo descritivo correlacional longitudinal, com abordagem quantitativa, desenvolvido entre 14 de fevereiro e 30 de março de 2012 num Hospital no Serviço de Cirurgia Geral. A amostra constou de 30 pacientes submetidos a cirurgias abdominais. Os dados que serviram de base a este estudo foram recolhidos através da aplicação da Escala Numérica e do Questionário de Dor de McGill. Os resultados mostraram que 60% eram homens, 50% dos doentes tinham 65 e 69 anos e todos (100%), eram católicos romanos. Na primeira avaliação, 60% apresentaram dor pós-operatória moderada, 30% severa e 10% leve. Os descritores escolhidos com maior frequência foram: fisgada (90%); fina, agulhada e pontada (70%); beliscão (60%); sensível (50%); cansativa (60%) e que incomoda (50%). Nas três avaliações seguintes houve diminuição da dor severa e moderada que, aos 180 minutos era de 0% e 3% respetivamente, aumentando a percentagem de pacientes com dor leve (7%). Não encontramos relação significativa entre a variável dor pós-operatória e o sexo mas, pelo contrário, a intensidade da dor pós-operatória e a idade. O índice de dor total e sensitiva é influenciado pelo sexo. A localização da dor é influenciada pelo tipo de cirurgia, pela idade e pelo sexo. A dor pós-operatória era, principalmente, de intensidade moderada. Mesmo nos doentes a quem não foi administrado fármaco (50%), a dor foi aliviada ao longo das quatro avaliações. Desta forma, podemos inferir que as que as intervenções autónomas de enfermagem contribuem para o alívio da dor. A informação/atualização permanente dos profissionais de saúde é indispensável para que seja possível evitar ou minimizar a ocorrência de dor.

Biological materials in colorectal surgery: current applications and potential for the future.

Biological materials are increasingly used in abdominal surgery for ventral, pelvic and perineal reconstructions, especially in contaminated fields. Future applications are multi-fold and include prevention and one-step closure of infected areas. This includes prevention of abdominal, parastomal and pelvic hernia, but could also include prevention of separation of multiple anastomoses, suture- or staple-lines. Further indications could be a containment of infected and/or inflammatory areas and protection of vital implants such as vascular grafts. Reinforcement patches of high-risk anastomoses or unresectable perforation sites are possibilities at least. Current applications are based mostly on case series and better data is urgently needed. Clinical benefits need to be assessed in prospective studies to provide reliable proof of efficacy with a sufficient follow-up. Only superior results compared with standard treatment will justify the higher costs of these materials. To date, the use of biological materials is not standard and applications should be limited to case-by-case decision.

Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery

Study Objectives: To evaluate the effects of intraoperative skin-surface warming with and without 1 hour of preoperative warming, in preventing intraoperative hypothermia, and postoperative hypothermia, and shivering, and in offering good conditions to early tracheal extubation. Design: Prospective, randomized, blind study. Setting: Teaching hospital. Patients: 30 ASA physical status I and II female patients scheduled for elective abdominal surgery. Interventions: Patients received standard general anesthesia. In 10 patients, no special precautions were taken to avoid hypothermia. Ten patients were submitted to preoperative and intraoperative active warming. Ten patients were only warmed intraoperatively. Measurements and Main Results: Temperatures were recorded at 15-minute intervals. The patients who were warmed preoperatively and intraoperatively had core temperatures significantly more elevated than the other patients during the first two hours of anesthesia. All patients warmed intraoperatively were normothermic only at the end of the surgery. The majority of the patients warmed preoperatively and intraoperatively or intraoperatively only were extubated early, and none had shivering. In contrast, five unwarmed patients shivered. Conclusions: One hour of preoperative warning combined with intraoperative skin-surface warming, not simply intraoperative warming alone, avoided hypothermia caused by general anesthesia during the first two hours of surgery. Both methods prevented postoperative hypothermia and shivering and offered good conditions for early tracheal extubation. © 2003 by Elsevier B.V.

Testes de risco cirúrgico relacionados às complicações cardiopulmonares: comparação entre a cirurgia abdominal supra-umbilical e a torácica

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Pressão intra-abdominal como preditor de lesão renal aguda no pós-operatório de cirurgias abdominais

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Análise da pressão intra-abdominal em pacientes submetidos à cirurgia abdominal oncológica internados em Unidade de Terapia Intensiva

Pós-graduação em Pesquisa e Desenvolvimento (Biotecnologia Médica) - FMB