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Morbidity and mortality following traditional surgical treatment of gastric outlet obstruction is high. The aim of this work was to identify risk factors predictive of postoperative complications and mortality following gastroenterostomy.One-hundred sixty-five consecutive patients subjected to open gastroenterostomy from January 1996 through July 2003 were included. Data on vital signs and operative variables were retrieved from medical records and recorded retrospectively. Risk factors for postoperative complications and mortality within 30 days after operation were analyzed with multiple logistic regression.The 30-day complication and death rates were higher after emergency operations (80% and 60%) than after elective operations (32% and 25%). A multivariate analysis disclosed that hypoalbuminemia (or = 32 g/l), comorbidity, high age, and hyponatremia (135 micromol/l) were significantly associated with postoperative death, whereas hypoalbuminemia, comorbidity, high age, and emergency operation were predictors of postoperative complications.Complications and mortality after gastroenterostomy due to gastric outlet obstruction are associated with modifiable and non-modifiable risk factors. Prior to surgery means should be taken to correct low albumin and sodium levels to prevent complications. In addition, the surgeon should consider alternative treatment modalities including laparoscopic gastroenterostomy, self-expanding metallic stents, or tube gastrostomy to relieve or palliate gastric outlet obstruction.

Predictors of a poor surgical outcome are numerous, of which some are well-defined. We aimed to assess risk factors predictive of poor surgical outcome across different gastrointestinal operations related to the patient, the disease, the treatment, and the organization of care. Data from 5,255 unselected patients undergoing open gastrointestinal surgery from 1995 through 1998 was prospectively recorded in a clinical database and validated. The database embraced variables related to patient history, preoperative clinical condition, operative findings and complexity, and the surgeon’s training. Variables predictive of mortality and complications occurring within 30 days after surgery were assessed by multiple logistic regression analysis. After elective operation, the 30-day mortality was 2.8% and major complications occurred in 11.5% of the patients. The corresponding figures in emergency surgery were 13.8% and 30.1%. Independent of elective or emergency surgery, dependent functional status, and type of operation were associated with postoperative mortality. Comorbidity, type of operation, blood loss, and reoperation were predictors of complications regardless of elective or emergency operation. In elective surgery, predictors of poor surgical outcome were high age, comorbidity, malignancy, and the surgeons training, whereas abnormal vital signs values and peritonitis were predictors of poor outcome after emergency surgery. Premorbid factors, characteristics of the disease, the patients’ preoperative condition, operative factors, and the surgeon’s training are all associated with surgical outcome across different gastrointestinal operations and should be assessed when auditing surgical outcome.

To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses.The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB.All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy.Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.

The purpose of this randomized, double-blind, placebo-controlled multicenter trial was to compare topical zinc oxide with placebo mesh on secondary healing pilonidal wounds. Sixty-four (53 men) consecutive patients, aged 17-60 years, were centrally randomized to either treatment with 3% zinc oxide (n = 33) or placebo (n = 31) by concealed allocation. Patients were followed with strict recording of beneficial and harmful effects including masked assessment of time to complete wound closure. Analysis was carried out on an intention-to-treat basis. Median healing times were 54 days (interquartile range 42-71 days) for the zinc and 62 days (55-82 days) for the placebo group (p = 0.32). Topical zinc oxide increased (p < 0.001) wound fluid zinc levels to 1,540 (1,035-2,265) microM and decreased (p < 0.05) the occurrence of Staphylococcus aureus in wounds. Fewer zinc oxide (n = 3) than placebo-treated patients (n = 12) were prescribed postoperative antibiotics (p = 0.005). Serum-zinc levels increased (p < 0.001) postoperatively in both groups but did not differ significantly between the two groups on day 7. Zinc oxide was not associated with increased pain by the visual analog scale, cellular abnormalities by histopathological examination of wound biopsies, or other harmful effects. Larger clinical trials will be required to show definitive effects of topical zinc oxide on wound healing and infection.

Surgical site infections and disruption of sutured tissue are frequent complications following surgery. We aimed to assess risk factors predictive of tissue and wound complications in open gastrointestinal surgery.Data from 4855 unselected patients undergoing open gastrointestinal surgery from 1995 through 1998 were recorded in a clinical database and validated. The database embraced variables related to patient history, preoperative clinical condition, operative findings and severity, and the surgeon's training. Variables predictive of surgical site infection and dehiscence of sutured tissue within 30 days after surgery were assessed by multiple logistic regression analysis.Following elective operation, the incidence of tissue and wound complications was 6% compared with 16% in emergency surgery (P0.001). These complications resulted in prolonged hospitalization in 50% of the patients and a 3-fold higher risk of reoperation but not increased mortality. Factors associated with complications following elective operations were smoking, comorbidity, and perioperative blood loss. Following emergency operations, male gender, peritonitis, and multiple operations were predictors of complications. Irrespective of elective or emergency surgery, the type of operation was a predictor of complications.Factors known to affect the process of tissue and wound healing are independently associated with tissue and wound complications following gastrointestinal surgery.

Little information is currently available concerning the relationship between results obtained in humans from surgical test wounds and results from wound models. Therefore, to evaluate human wound healing parameters, tubings of expanded polytetrafluoroethylene were implanted in a subcutaneous test wound in the arm of 47 volunteers and 20 patients undergoing hernia repair. The surgical patients also had implants left in the surgical wound cavity. After 10 days the deposition of collagen in the tubings as expressed by hydroxyproline content was 30% higher in the surgical wound than in the test wound, p < 0.05. The amount of collagen deposited in the tubing within the surgical wound did not correlate with measurements in the test wound, whereas a significant correlation of proline levels was found between the two sites, p < 0.05. Deposition of proline and total protein in the model was equivalent. In both wound types age negatively correlated with levels of protein, but not collagen. The variability of the results was 40% lower in the subcutaneous test wound than in the surgical wound. There was no significant difference in hydroxyproline deposition between the volunteers and the patients undergoing hernia repair. In patients undergoing minor surgery without signs of compromised healing the expanded polytetrafluoroethylene test wound in the arm reflects the deposition of non-collagenous protein, but not collagen, within the surgical wound.

OBJECTIVES:The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB.METHODS:All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality.RESULTS:A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010-2011 vs. 89% in 2004-2006, relative risk (RR) 1.06 (95% confidence intervals 1.04-1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10-1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59-0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66-0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78-1.00)).CONCLUSIONS:QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.Am J Gastroenterol advance online publication, 4 June 2013; doi:10.1038/ajg.2013.162.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a multipotent cytokine with a molecular weight ranging from 15 to 35 Kd. GM-CSF primarily stimulates proliferation and differentiation of hematopoietic progenitor cells in the myeloid and erythroid lineages into neutrophils, eosinophils, and macrophages. Therapeutically, the beneficial effects of GM-CSF are well documented in myelodepressive states associated with radiation therapy, chemotherapy, and bone marrow transplantation. It has also been proposed to use GM-CSF perioperatively to improve immune functions in conjunction with colorectal surgery. 1 Mediators released during the acute inflammatory response coordinate the early connective tissue repair response after injury. The early inflammatory reaction precedes the deposition of granulation tissue composed mainly of macrophages, active fibroblasts, and new vessels in a provisional extracellular matrix. 2 The macrophage plays an essential directory role in tissue repair, demonstrated by the use of antimacrophage serum or radiation-induced monocytopenia in rodents, by releasing a plethora of cytokines. 3–5 The neutrophil granulocyte mainly phagocytoses microorganisms but apart from that is only secondary in tissue repair. 6 GM-CSF regulates several biologic functions of the inflammatory cells and those of macrophages in particular. 7 Apart from modulating the nonspecific inflammatory processes, it has been reported that GM-CSF is chemotactic and mitogenic for fibroblasts and endothelial cells in vitro. 8,9 These effector cells are also stimulated indirectly or synergistically by GM-CSF in an autocrine or paracrine fashion by other cytokines such as interleukin-1 (IL-1), IL-6, IL-8, and tumor necrosis factor-α (TNF-α). 7,8,10 There is experimental evidence of a profibrotic effect of GM-CSF in the subcutaneous tissue and skin of rats. GM-CSF delivered continuously from osmotic minipumps implanted subcutaneously elicited a collagenous capsule around the devices and even a stronger one than that of transforming growth factor-β (TGF-β) and platelet-derived growth factor (PDGF). 11 This effect appeared to be indirectly mediated by the accumulation of macrophages that stimulated α-SM actin synthesis by myofibroblasts. 11,12 In rat skin, GM-CSF delivered continuously over several days by gene transfer induced a dermal inflammatory fibrotic response. 13 A stimulatory effect on fibroplasia and collagen deposition by GM-CSF administered locally was also suggested by the increased mechanical strength of incisional wounds in normal and immunosuppressed rats. In contrast, no effect was found following systemic GM-CSF treatment. 14 Furthermore, granulocyte colony-stimulating factor (G-CSF), which acts mainly on neutrophils, did not enhance wound repair, reemphasizing the crucial role of macrophages in tissue repair. However, human studies on the influence of either endogenous or exogenous cytokines and specifically GM-CSF on tissue fibrosis and repair are scarce. 15 Because the mechanical strength of wounds correlates with the amount of collagen in the early fibroplastic phase, we investigated whether GM-CSF possesses a fibrogenic effect in humans. The deposition of connective tissue with different doses of recombinant human GM-CSF was assessed in a minimally invasive implantable subcutaneous tissue repair model. 16,17

From a post hoc analysis a hypothesis was generated that women deposit more collagen in a surrogate test wound than men. The purpose of this study has been to verify this hypothesis prospectively in a controlled study.Post hoc analyses were done on 37 volunteers (study A). The prospective trial included 47 smoking volunteers (study B). Outcome measures were deposition levels of collagen (hydroxyproline) and protein during a period of 10 days in subcutaneously implanted tubes of expanded polytetrafluoroethylene.The mean increments of collagen deposition levels in women as compared with men were 56% (P.01) in study A and 74% (P.001) in study B. The mean increase in the ratio collagen/total protein was 74% (P.001) and 69% (P.001), indicating that the increase was specific for collagen.The studies show that deposition in a miniature subcutaneous test wound of collagen, but not noncollagenous protein, is promoted in women as compared to men. These findings may relate to the observation in some reports indicating higher rates of compromised postoperative wound healing in men.

Background: An association between smoking and impaired wound healing has been reported in retrospective studies. The smoking status of a surgical patient may be confounded by social and medical parameters. We have evaluated the effect of smoking in a test wound in volunteers, with special reference to a reliable scientific match between smokers and nonsmokers. Methods: In a prospective open study with blinded assessment, 19 smoking (20 cigarettes/day) and 18 nonsmoking healthy volunteers were matched with respect to baseline characteristics. The deposition of total protein and mature collagen (expressed as hydroxyproline) was assessed in an expanded polytetrafluoroethylene wound healing model implanted subcutaneously for 10 days. Results: The nonsmokers had a 1.8 times higher median amount of hydroxyproline than the smokers (p < 0.01). The deposition of hydroxyproline was negatively correlated with the consumption of tobacco both before (r = –0.44; p < 0.01) and during the study (r = –0.48; p < 0.005). The impairment was specific for the production of collagenous proteins and not other proteins. Conclusions: The synthesis of subcutaneous collagen in smokers is specifically impeded, indicating an impaired wound-healing process. Because mature collagen is the main determinator of strength of an operative wound, the results support the view that patients should be advised to stop smoking before an operation. (Surgery 1998;123:450-5.)

Purpose This study measured the effect of hyperbaric oxygen (HBO) treatment on transmucosal oxygen tension in irradiated human oral mucosa. Patients and Methods Ten patients received 30 dives of HBO as part of their treatment for mandibular osteoradionecrosis. A noninvasive, nonheated oxygen electrode was used to measure the tissue surface transmucosal oxygen tension directly on the attached gingiva. Measurements were done before, during, and after HBO treatment. The normal level of gingival surface transmucosal oxygen tension was measured in five healthy volunteers. Results During HBO treatment, the transmucosal oxygen tension increased significantly after five dives of HBO (P < .05). After 30 dives, the increases were from a mean of 50% to a mean of 86% of the transmucosal oxygen tension of normal healthy gingiva. Conclusion An increase in the transmucosal oxygen tension is based on neo-angiogenesis. Patients with subischemic tissues, such as the study population with postirradiation mucosal and osseous necrosis, therefore may benefit from treatment with HBO.

The preoperative and postoperative wound-healing capacity of 23 patients undergoing elective major abdominal, thoracic or urological surgery was tested objectively by the subcutaneous accumulation of hydroxyproline and proline in an expanded polytetrafluoroethylene (ePTFE) tube. Before scheduled surgery two ePTFE tubes were implanted for removal after 5 and 10days. This was repeated for each patient immediately after surgery. After 10 days a higher amount of hydroxyproline was measured before than after operation median 2·91 (range 0·37–14·45) versus 1·45 (range 0·26–6·94) pglcm, P = 0·01. This decline was significantly higher in the six patients who had a postoperative infection (median 3·02 (range −0·06 to 6·14) versus 0·36 (range −1·56 to 12·60) μg/cm, P = 0·02). This study shows that major surgery is associated with impairment of subcutaneous collagen accumulation in a test wound, suggesting diminished systemic woundhealing capacity in such patients.

Hypothesis A number of risk factors for incisional hernia have been identified, but the pathogenesis remains unclear. Based on previous findings of smoking as a risk factor for wound complications and recurrence of groin hernia, we studied whether smoking is associated with incisional hernia. Design Cohort study. Clinical follow-up study for incisional hernia 33 to 57 months following laparotomy for gastrointestinal disease. Variables predictive for incisional hernia were assessed by multiple regression analysis. Setting Department of Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark. Patients All 916 patients undergoing laparotomy from 1997 through 1998. Surgeons performed clinical examination in 310 patients; patients who failed to meet for examination, died, or were lost to follow-up were excluded. Main Outcome Measures Thirty-four variables related to patient history, preoperative clinical condition, operative severity and findings, and the surgeon’s training. Results The incidence of incisional hernia was 26% (81/310). Smokers had a 4-fold higher risk of incisional hernia (odds ratio [OR], 3.93 [95% confidence interval (CI), 1.82-8.49]) independent of other risk factors and confounders. Relaparotomy was the strongest factor associated with hernia (OR, 5.89 [95% CI, 1.78-19.48]). Other risk factors were postoperative wound complications (OR, 3.91 [95% CI, 1.99-7.66]), age (OR, 1.04 [95% CI, 1.02-1.06]), and male sex (OR, 2.17 [95% CI, 1.21-3.91]). Conclusion Smoking is a significant risk factor for incisional hernia in line with relaparotomy, postoperative wound complications, older age, and male sex.