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Experimental studies on Damage Control Surgery and Intraabdominal Hypertension
Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Surgery in Östergötland.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Damage control surgery (DCS) offers an alternative to the traditional surgical management of complex or multiple injuries in critically injured patients. If a patient survives the initial phase of DCS, complications may occur, one of these being intraabdominal hypertension (IAH) and it´s potential development into the abdominal compartment syndrome.

The indications for DCS have been widened and DCS principles can be applied in situations where time and resources are essential factors. The DCS principles of rapidly controlling intestinal spillage have not been evaluated. The aim of the studies in Papers I and II was to evaluate the principles of spillage control of intestinal contents according to the DCS concept and more specifically the effects of early rapid control of multiple bowel perforations on cardiovascular and pulmonary function compared with conventional small bowel resections in an animal model with abdominal trauma. In Paper I the animal model using anaesthetised pigs included a gunshot wound to the abdomen which caused multiple small bowel injuries. Haemorrhagic shock was combined with the gunshot wound in Paper II. The results presented in Paper I showed a significant reduction in rise in systemic vascular resistance and pulmonary vascular resistance, and a trend towards higher cardiac output and lower oxygen consumption in the bowel ligation group. In Paper II the results show a longer persistence of lactic acidaemia in the bowel ligation group. The aim of the study in Paper III was to assess visceral (intestinal, gastric and renal) microcirculation parallel with central haemodynamics and respiratory function during stepwise increases in intraabdominal pressure. In Paper IV we studied mucosal barrier function and morphology in the small bowel and colon of the pigs which were subjected to IAH. The IAP in anaesthetised pigs was increased stepwise using CO2 inflation, by 10 mm Hg at 10-minute intervals up to 50 mm Hg, and followed by exsufflation (Paper III). The microcirculation was selectively studied using a 4-channel laser Doppler flowmeter (Periflex 5000, Perimed, Sweden). The mucosal tissues were mounted in modified Ussing chambers for assessment of barrier function (E.coli K12 uptake and 51Cr-EDTA permeability) (Paper IV). The results showed that the microcirculation of the small bowel mucosa and colon mucosa was significantly less affected compared to the seromuscular layers. The microcirculation of gastric mucosa, renal cortex and the seromuscular layer of small bowel and colon were significantly reduced with each increase. Cardiac output (CO) decreased significantly at IAP levels above 10 mm Hg and the respiratory function data showed an increasing airway pressure and a concomitant reduction in thoracic compliance. Transmucosal passage of E. coli was increased three-fold in the small bowel after ACS with a significant correlation to the degree of mucosal microcirculatory reperfusion after exsufflation. 51Cr-EDTA permeability was unaffected. Bacterial passage in the colon was unchanged, whereas 51Cr-EDTA permeability after ACS increased by up to 181% of baseline and was correlated to significant histopathological changes in the mucosa.

In Paper I we have demonstrated that early rapid control of multiple bowel perforations in a model with moderate shock resulted in less impairment of SVR and PVR than conventional resection and anastomosis. The use of DCS principles, however, had no beneficial effect on cardiovascular function when haemorrhagic shock was combined with abdominal missile trauma (Paper II), on the contrary bowel ligation was followed by more prolonged lactic acidosis than conventional repair. The studies in Paper III and IV indicate that the microcirculation of intestinal mucosa and especially small bowel mucosa seem better preserved in response to intraabdominal hypertension caused by CO2 insufflation than other intraabdominal microvascular beds. The short term ACS in this model caused morphological changes in the intestinal mucosa, and mucosal barrier dysfunction. The response pattern concerning barrier function changes after CO2 insufflation differs between small bowel and colonic mucosa. The small bowel mucosa showed increased bacterial passage, and the colonic mucosa an increase in paracellular permeability and secretory response.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2008. , 73 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1085
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-17796ISBN: 978-91-7393-775-7 (print)OAI: oai:DiVA.org:liu-17796DiVA: diva2:212097
Public defence
2008-11-14, Katastrofmedicinskt Centrum, Campus US, Linköpings Universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2009-04-21 Created: 2009-04-21 Last updated: 2012-05-09Bibliographically approved
List of papers
1. The effects of early rapid control of multiple bowel perforations after high-energy trauma to the abdomen: implications for damage control surgery
Open this publication in new window or tab >>The effects of early rapid control of multiple bowel perforations after high-energy trauma to the abdomen: implications for damage control surgery
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2006 (English)In: Journal of Trauma, ISSN 0022-5282, E-ISSN 1529-8809, Vol. 61, no 1, 185-191 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: This study evaluates the effects of early rapid control of multiple bowel perforations on cardiovascular and pulmonary function in high-energy traumatic shock compared with conventional small bowel resection anastomosis.

METHODS: Fifteen anesthetized pigs, 10 to 12 weeks old, were exposed to a reproducible high-energy trauma and were divided into two groups. In the first group, the resection anastomosis group (RA, n = 8), small-bowel injuries were treated with resection and anastomosis; in the second group, the multiple bowel ligation group (BL, n = 7), small-bowel injuries were treated by resection and ligation. Repeated measurement analysis of variance was used to study the within group change overtime, the between group difference, and the interaction between them. Mean outcome measures were intravascular pressures, cardiac output, vascular resistance, lactic acid, and blood gases.

RESULTS: The high-energy injuries caused traumatic shock in both groups with reduced cardiac output (p < 0.001) and lactic acidemia (p < 0.001). The BL group had a trend for higher cardiac output (p = 0.06). The rise in systemic and pulmonary vascular resistance was significantly reduced in the BL group compared with the RA group (p < 0.05). The BL group had a strong trend for higher oxygen extraction ratio (p = 0.06). There was a trend for less oxygen consumption in the BL group (p = 0.07). There was no difference in the lactic acidemia between the two groups.

CONCLUSIONS: Early rapid control of multiple bowel perforations after high-energy trauma resulted in less impairment of cardiovascular function than conventional resection anastomosis of the bowel.

Keyword
Bowel ligation, Damage control, Traumatic shock, Lactic acidemia, Cardiac output, Vascular resistance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17794 (URN)10.1097/01.ta.0000221807.69844.63 (DOI)16832269 (PubMedID)
Available from: 2009-04-21 Created: 2009-04-21 Last updated: 2017-12-13Bibliographically approved
2. Multipel Small Bowel Ligation Compared to Conventional Primary Repair after Abdominal Gunshot Wound with Haemorrhagic Shock
Open this publication in new window or tab >>Multipel Small Bowel Ligation Compared to Conventional Primary Repair after Abdominal Gunshot Wound with Haemorrhagic Shock
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2009 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 98, no 1, 41-47 p.Article in journal (Refereed) Published
Abstract [en]

Aims: The aim of this study was to evaluate the effects of early rapid control of multiple bowel perforations on cardiovascular function in combined abdominal missile trauma and haernorrhagic shock compared with conventional surgery.

Methods: Eighteen anesthetised pigs were injured with a standardised abdominal missile trauma. The animals were bled to a mean arterial pressure of 50 mm Hg for 30 minutes, after which they were resuscitated and had laparotomy. They were divided into conventional surgery group (n=9) with primary resection and anastomosis of bowel injuries and early rapid multiple bowel ligation group (n=9). Repeated measurement analysis of variance was used for analysis.

Results: There was profound hypotension, reduced cardiac output, increased vascular resistance and lactic acidaemia in both groups. Lactic acidaemia persisted longer in the early rapid multiple bowel ligation group. There were no significant differences in mean arterial pressure, cardiac output, stroke volume or systemic vascular resistance between the groups. The mean operation time was significantly shorter in the early rapid multiple bowel ligation group (13.3 (1.5) (SEM) minutes, compared with 116.4 (1.74) (SEM) minutes in the conventional surgery group, p = <0.001).

Conclusions: Damage control principles have shortened the operating time in our model but did not improve the cardiovascular function and caused more lactic acidaemia than conventional repair.

Keyword
Animal model, bowel injuries, damage control surgery, haemorrhage, shock, trauma
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17604 (URN)
Available from: 2009-04-06 Created: 2009-04-06 Last updated: 2017-12-13Bibliographically approved
3. Gastrointestinal microcirculation and cardiopulmonary function during experimentally increased intra-abdominal pressure
Open this publication in new window or tab >>Gastrointestinal microcirculation and cardiopulmonary function during experimentally increased intra-abdominal pressure
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2009 (English)In: Critical Care Medicine, ISSN 0090-3493, Vol. 37, no 1, 230-239 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: The aim of this study was to assess gastric, intestinal, and renal cortex microcirculation parallel with central hemodynamics and respiratory function during stepwise increase of intra-abdominal pressure (IAP).

Design: Prospective, controlled animal study.

Setting: Research laboratory, University Hospital.

Subjects: Twenty-six anesthetized and mechanically ventilated pigs.

Interventions: Following baseline registrations, CO2 peritoneum was inflated (n = 20) and IAP increased stepwise by 10 mm Hg at 10 mins intervals up to 50 mm Hg and subsequently exsufflated. Control animals (n = 6) were not insufflated with CO2.

Measurements and Main Results: The microcirculation of gastric mucosa, small bowel mucosa, small bowel seromuscular layer, colon mucosa, colon seromuscular layer, and renal cortex were selectively studied at all pressure levels and after exsufflation using a four-channel laser Doppler flowmeter (Periflex 5000, Perimed). Central hemodynamic and respiratory function data were registered at each level and after exsufflation. Cardiac output decreased significantly at IAP levels above 10 mm Hg. The microcirculation of gastric mucosa, renal cortex and the seromuscular layer of small bowel and colon was significantly reduced with each increase of IAP. The microcirculation of the small bowel mucosa and colon mucosa was significantly less affected compared with the serosa (p < 0.01).

Conclusions: Our animal model of low and high IAP by intraperitoneal CO2-insufflation worked well for studies of microcirculation, hemodynamics, and pulmonary function. During stepwise increases of pressure there were marked effects on global hemodynamics, respiratory function, and microcirculation. The results indicate that intestinal mucosal flow, especially small bowel mucosal flow, although reduced, seems better preserved in response to intra-abdominal hypertension caused by CO2-insufflation than other intra-abdominal microvascular beds.

Keyword
intra-abdominal hypertension, gastrointestinal microcirculation, cardiopulmonary function
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-16533 (URN)10.1097/CCM.0b013e318192ff51 (DOI)
Available from: 2009-01-30 Created: 2009-01-30 Last updated: 2009-08-20Bibliographically approved
4. Increased transmucosal uptake of E. coli K12 in porcine small bowel following experimental short term abdominal compartment syndrome
Open this publication in new window or tab >>Increased transmucosal uptake of E. coli K12 in porcine small bowel following experimental short term abdominal compartment syndrome
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2009 (English)Article in journal (Other academic) Submitted
Abstract [en]

Background: Abdominal compartment syndrome (ACS) may lead to bacterial translocation and possibly be of importance for development of multiorgan failure. However, the underlying mechanisms have not been fully elucidated. In a porcine model we recently demonstrated preserved intestinal mucosal blood flow during experimental short duration ACS. In the present study we used the same model to determine mucosal barrier function and morphology in the small bowel and colon of pigs before and after short term ACS.

Methods: The study comprised 12 anaesthetized pigs exposed to experimental ACS and 6 control animals. Via laparotomy, samples of small bowel and colon were taken out for studies before short term ACS, where the abdomen was inflated with CO2 and IAP was increased stepwise by 10 mm Hg at 10-minute intervals up to 50 mm Hg, and again 10 minutes after exsufflation. Mucosal microcirculation was measured by laser Doppler flowmetry, and mucosal tissues were mounted in modified Ussing chambers for assessment of barrier function (E. coli K12 uptake and 51Cr-EDTA permeability). Specimens were also fixed in formaldehyde, stained with eosin-hematoxylin and evaluated blindly using an 8-grade scale for assessment of mucosal damage.

Results: Transmucosal passage of E. coli was three-fold increased in the small bowel after ACS (22.6 [18.2 – 54.4] units) vs. baseline (8.1 [2.0 – 13.9]; P< 0.050) with a significant correlation to alterations of mucosal microcirculation. In the colon bacterial passage was unchanged, whereas 51Cr-EDTA permeability after ACS increased to 181% of baseline (P<0.05) and was correlated to significant mucosal histopathological changes (P<0.03).

Conclusion: Short term ACS with reperfusion induced significant dysfunction of the intestinal mucosal barrier. The response patterns concerning barrier dysfunction differed between small bowel and colonic mucosa, with increased bacterial passage and paracellular permeability, respectively.

Keyword
Short term ACS, intestinal barrier function, animal model, Ussing chamber
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17795 (URN)
Available from: 2009-04-21 Created: 2009-04-21 Last updated: 2010-04-23Bibliographically approved

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