April 2000

6877

ETIOLOGY AND OUTCOME OF READMISSION FOR SMALLBOWEL OBSTRUCTION IN THE EARLY POST·OPERATIVE PE·RIOD.G. Miller, 1. Bowman, I. Shier, Philip H. Gordon, Sir Mortimer B Davis­Jewish Gen Hosp, Montreal, Canada.

Purpose: Goals of the study were to determine the frequency for readmis­sion for early post-operative small bowel obstruction, highlight factors thatmay predispose to this entity, and define the risks of strangulation. Finally,we compare the immediate as well as long-term risks and benefits ofoperative versus non-operative treatment. Methods: The medical records ofall patients admitted to the Sir Mortimor B. Davis - Jewish GeneralHospital (Montreal, Quebec) between 1986 and 1996 with the diagnosis ofsmall bowel obstruction were reviewed retrospectively. Patients who pre­sented for admission within 50 days of a previous laparotomy wereselected for this review. All patients whose symptoms began during thesame admission as the initial laparotomy or in whom bowel function hadnot clearly returned were excluded. Results: Of the 1001 admissions forsmall bowel obstruction, 3% occurred within 50 days of a previous lapa­rotomy. In the majority of cases adhesions were the cause of the obstruc­tion (24 cases). Other etiologies were Crohn's Disease (2), hernia (I),malignant neoplasm (I), and a combination of adhesions and malignancy(2). 43% of procedures preceding the obstruction were primary smallbowel operations. Overall, 23% of patients were treated operatively. Therewas only one episode of strangulated bowel. A comparison of individualsigns and symptoms reveals no significant difference between the operativeand non-operative groups. However, patients with more positive signs orsymptoms had a greater tendency to be treated by operation. For patientstreated operatively the recurrence rate was 71% compared to a readmissionrate of 48% for those treated non-operatively. The median time to recur­rence was O. I years (mean= 1.3) post surgical treatment compared to 0.7years (mean = 1.2) post non-surgical treatment. The median length of stayfor operated patients was 12 days (mean = 11.1) compared to 6 days(mean = 8) for those not undergoing operation. Conclusions: Readmissionfor small bowel obstruction within 50 days of a previous laparotomyrepresents a small percentage of all cases of small bowel obstruction. Thesefrequently follow small bowel operations. Cases of strangulation are nomore common than in general cases of small bowel obstruction. Patientstreated non-operatively had a lower recurrence rate, longer time interval toreadmission and a shorter hospital stay.

6878

RADICAL RESECTION FOR COLORECTAL LIVER METASTA·SES ACCOMPANIED BY EXTRAHEPATIC LESIONS.Masami Minagawa, Masatoshi Makuuchi, Tadatoshi Takayama, GraduateSch of Medicine, Univ of Tokyo, Tokyo, Japan.

Objective: The aim of this study was to elucidate the operative indicationfor colorectalliver metastases accompanied by extrahepatic disease. Back­ground: Hepatectomy for colorectal liver metastases is a first choicetherapy when the metastases are restricted in the liver, but the operativeindications for the hepatic metastases accompanied by extrahepatic dis­eases are still controversial. Material and Methods: Between 1980 to1998, 251 patients underwent curative hepatic resection for metastaticcolorectal cancer. Among them 40 patients had extrahepatic metastases atthe initial hepatectomy; 6 had local recurrence where the colorectal cancerwere removed, 10 had lung metastases, 6 had localized peritoneal dissem­ination, 2 had bone metastasis, 16 had extrahepaic invasion and 6 hadlymph nodes metastasis. All of them were radically removed at the hepa­tectomy. The long-term results of those patients were retrospectivelyanalyzed. Result: The median survival of 40 patients with extrahepaticdisease was 2.84 years, although that of 211 cases without extrahepaticlocations was 3.39 years (P=0.038). The local recurrence, lung metastases,localized peritoneal dissemination and extrahepaic invasion were not sta­tistically significant prognostic factors (P>0.05), the median survival timeof those cases were 2.89 years, 1.48 years, 3.17 years and 3.32 yearsrespectively. Bone metastasis and lymph nodes metastasis were significantpoor prognostic factors (P=O.OOOI, 0.0001), the median survival time were0.63 years and 1.24 years respectively. 16 patients with synchronous andmetachronous lung metastases underwent radical resection, the mediansurvival time was 3.67 years, which were not statistically different fromthat of cases without lung metastases. Conclusion: The survival time ofpatients with bone metastasis or lymph nodes metastasis was not beimproved by radical resection. Patients with local recurrence, localizedperitoneal dissemination, extrahepatic invasion and lung metastasis willobtain survival benefit if complete removal can be accomplished.

SSATA1523

6879

REDUCTION OF TROCAR·RELATED LAPAROSCOPIC COM­PLICATIONS USING THE STEp™ RADIALLY EXPANDING AC­CESS SYSTEM - A REVIEW OF 3461 STEP CANNULA PLACE·MENTS.Carlos R. Miranda, Manuel E. Castro-Arreola, Bruce J. Applebaum, ElPaso Surg Assoc, P A, EI Paso, TX.

Study Objective. To review the safety of a new radially expanding accessdevice compared to known published complication rates from the use ofsharp laparoscopic trocars. Design. Retrospective review of laparosopicpatients over a thirty-six (36) month time frame. Setting. Hospital-basedsurgery centers. Patients. One thousand thirty-six (1036) male and female,general surgery patients undergoing various laparoscopic procedures. In­terventions. Three thousand four hundred sixty-one (3461) radially dilatingaccess (Step) devices were used exclusivelyu for laparoscopic abdominalwall access. Measurements and Main Results. There were no occurrencesof major vascular injury, abdominal wall bleeding, intestinal injury, blad­der injury or any other complication associated with the use of the Stepdevice. Further, there are no incisional hernias reported to date despite thefact that the fascial defects were not routinely closed. Conclusions. Radi­ally dilating abdominal access devices significantly reduce laparoscopiccomplications.

6880

THE EFFECTS OF PROKINETICS ON THE INTESTINAL PA·RALYSIS IMMEDIATELY AFTER ABDOMINAL SURGERIES.Masahiko Miyachi, Yoshihisa Nagata, Yuji Nimura, Aichi Med Univ,Aichi-pref, Japan; Nagoya Univ, Nagoya.

The intestinal paralysis immediately after abdominal surgery is wellknown. However, the mechanism and treatment of it hasn't established. Westudied the mechanism of postoperative intestinal paralysis and effects ofprokinetics on it after abdominal surgeries. We measured gastric andduodenal motilities, which are good parameters to indicate the recovery ofgastrointestinal function after the operation as we had reported previously,for 48 hours immediately after open cholecystectomy (CC, n= 8), gastrec­tomy with Billroth I maneuver (GR, n=8), colectomy (CL, n=5) byinfused catheter method through a naso-gastro-duodenal tube with threelumens which we designed newly. Moreover, we gave neostigmine (NT)0.5mg intramuscularly, prostaglandinF2a(PG) 0.5mg/kg/2 hours intrave­nously, cisapride (CP) 5mg to the duodenum at 12 and 24 hours after CC(n=5), GR (n=5), CL (n=5). Gastric motility in patients undergoing CC,CL appeared at 21:'::.7 hours, 25:'::.4 hours respectively. Duodenal strongcontraction after CC, CL, GR appeared 20:'::.5 hours, 25:'::.4 hours, 44±6hours, respectively. NT, PG and CP given at 24 hours after operationsstimulated significantly both gastric and duodenal motilities in patientsundergoing CC, CL, and GR. However, effects of them given after oper­ations were weaker. After GR, effects of prokinetics weaker than after CC,or CL. The recovery mechanism of gastrointestinal motility, and efficacy ofprokinetics after CC or CL were different from that after GR. We suggestthat the vagus nerve system influences these differences.

6881

ENTERIC TYPHOID PERFORATION IN GUATEMALAN PEO·PLE.J. C. Morales Linares, J. C. del Cid, F. Mendizabal, J. Braham, J. D.Maldonado, San Carlos Univ, Guatemala, Guatemala.

Purpose: Document our experience with patients with enteric typhoidperforation in our institution. Methods: A retrospective review of medicalrecords of 67 patients with enteric typhoid perforation was done. Theperiod covered by this study was II years (January 1988 to December1998). Data related to clinical features, as gastrointestinal signs and symp­toms which caused urgent hospitalization and management were analyzed.We emphasized progress of disease from the onset of symptoms to defin­itive surgical treatment as: second look, reintervention, perforation's num­ber, severe abdominal contamination, reperforation, morbidity and mortal­ity. Outcomes were statistically analyzed by Chi Square and Fisher ExactTest, Odds Ratio, with p<0.05. Results: There were 46 males and 33females an age range 13-30 years. The most common clinical findingswere: fever, abdominal distension and pain. Severe contamination wasassociated with mortality (p<0.05). Surgical reintervention for abdominalperforations was also associated with greater likelihood of death fromoverwhelming sepsis, (p=O.04) and the morbidity was also increased(p=O.OOOI). Postoperative morbidity and mortality was 36% and 12%respectively. Conclusions: disease evolution after the onset of signs andsymptoms, perforation's number, severe abdominal contamination andreperforation could be important factors related with postopersative mor­bidity and mortality. Abdominal studies have on patient outcome and hostquality of life.