Which children could benefit from additional diagnostic tools in case of suspected appendicitis?

BACKGROUND

New diagnostic tools such as ultrasound scan, computed tomography (CT) scan, and diagnostic laparoscopy, have become available for children with suspected appendicitis but should be reserved for equivocal cases. The aim of this study was to develop a scoring system to identify this subgroup of children.

METHODS

Patients from 2 different periods (period 1, 99 consecutive children [group 1] and period 2, 62 consecutive children [group 2] with suspected appendicitis) were prospectively evaluated. Variables predicting appendicitis were obtained from group 1. By means of a regression analysis, a scoring system was created and applied to the patients of group 2. Missed appendicitis and negative appendectomy rates obtained by clinical practice were compared with the results that would have been accomplished based on the scoring system. Thereafter, the scoring system was externally validated in a group of children presented at another hospital (group 3, n = 114).

RESULTS

The variables, leukocyte count > or = 10.10(9)/L (2 points); rebound tenderness (2 points); and temperature > or = 38 degrees C (1 point) correlated significantly with appendicitis. The scoring system was used to categorize patients into 3 groups: appendicitis unlikely, doubtful appendicitis, and suspected appendicitis. The specificity and sensitivity of the scoring system were, respectively, 85% and 89%. Applying the scoring system would lead to comparable negative appendectomy rates of 8% versus 6% using clinical judgement and a comparable number of performed laparoscopies (26% v 31%). However, it could lead to a lower missed appendicitis rate (1% v 6%) and a lower perforation rate (0% v 11%). External validation showed comparable performed laparoscopies (32%) and missed appendicitis (2%) rates but a higher negative appendectomy rate (19%), probably owing to a lower percentage of appendicitis in hospital (2, 47%) compared with hospital (1, 71%).

CONCLUSIONS

Children can be observed if leukocyte count is less than 10.10(9)/L and rebound tenderness is absent; a diagnostic laparoscopy should be performed if one of these is present, and if both are present one could perform an appendectomy.

Surgical palliation in pancreatic cancer

The prognosis of patients with pancreatic carcinoma is poor. At the time of diagnosis, approximately 80% of patients are found to have an unresectable tumour, because of local spread or metastatic disease. Therefore, most patients will undergo palliative treatment, which is aimed at the improvement of the quality of life and the prevention of symptoms. The most important symptoms which are associated with advanced pancreatic cancer are pain, obstructive jaundice and gastric outlet obstruction. Controversy remains on the question whether these symptoms should be treated surgically or non-surgically. This review describes the best evidence (if possible randomised controlled trials) in recent literature on the palliation of most important symptoms and focuses on surgical palliative treatment options.

Preoperative assessment of liver function: a comparison of 99mTc-Mebrofenin scintigraphy with indocyanine green clearance test

BACKGROUND/AIMS

The indocyanine green (ICG) clearance test is the most frequently used test for preoperative assessment of liver parenchymal function but has its limitations. The aim of this study was to investigate the correlation between ICG clearance test and the liver uptake of 99-Technetium-labelled (99mTc)-Mebrofenin (99mTc-Mebrofenin) as measured with hepatobiliary scintigraphy.

METHODS

Fifty-four patients were diagnosed as hepatocellular carcinoma (n=9), hilar tumours (n=20) and 25 patients with non-parenchymal tumours including colorectal metastasis (n=15) and miscellaneous tumours (n=10). One day prior to operation, hepatobiliary 99mTc-Mebrofenin scintigraphy was performed after intravenous injection of 85 MBq and the 15-min clearance rate of ICG (ICG-C15) was measured.

RESULTS

The mean ICG-C15 was 86.86+/-1.19% (SEM). The mean 99mTc-Mebrofenin uptake rate was 12.87+/-0.52%/min. A significant correlation was obtained between 99mTc-Mebrofenin uptake rate by scintigraphy and ICG-C15 (r=0.73, P<0.0001). The mean clearance capacity of the right liver segments (79.83+/-1.63, range 47.75-95.97%) was larger than that of the left segments (20.24+/-1.55, range 6.51-52.51%).

CONCLUSION

99mTc-Mebrofenin uptake rate as assessed by scintigraphy is an efficient method for determining liver function and correlates well with ICG clearance. At the same time, 99mTc-Mebrofenin scintigraphy provides information of segmental functional liver tissue, which is of additional use when planning liver resection.

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.

[Cystadenomas with ovarian stroma in liver and pancreas: indications of embryonic migration of the gonadal epithelium]

OBJECTIVE

To provide an embryological explanation for the presence of ovarian stroma in cystadenomas of the liver and pancreas.

DESIGN

Investigation of patients and embryos.

METHOD

From 1997 to 2001 in the Academic Medical Centre, Amsterdam, the Netherlands, nine women were treated for a cystadenoma with ovarian stroma, six of which were situated in the liver and three in the tail of pancreas. In one patient with a cystadenoma in the liver, malignant changes had taken place. In embryos at 5-8 weeks development, the regional differences in the morphology of the epithelium of the peritoneal cavity and the position of the gonads in relation to the embryonic liver, pancreas and spleen were examined.

RESULTS

In the foetal period before the gonads begin to descend, they are situated directly dorsal to the liver, tail of pancreas and spleen, but are separated from these by the peritoneal cavity. The cells that cover the urogenital folds distinguish themselves from those elsewhere in the peritoneal cavity as they are bulging in shape as opposed to flattened. This activated morphology suggests that on physical contact with a neighbouring organ the cells covering the gonads may become detached and lodge in that organ.

CONCLUSION

It is likely that cystadenomas of the liver and pancreas have their origin in the cells that cover the embryonic gonads. The anomalous morphology of these covering cells in fact suggests that they are relatively easily mobilized. They are probably comparable with inoculation metastasis in the coelomic cavity. Taking the chance of malignant transformation of a cystadenoma into account, the treatment of choice is radical resection of the abnormality.

Interferon-γ increases monocyte HLA-DR expression without effects on glucose and fat metabolism in postoperative patients

Tissue injury is associated with decreased cellular immunity and enhanced metabolism. Immunodepression is thought to be counteracted by interferon (IFN)-γ, which increases human leukocyte antigen (HLA)-DR expression. Hypermetabolism could be enhanced by IFN-γ because cytokines induce a hypermetabolic response to stress. In healthy humans, IFN-γ enhanced HLA-DR expression without effects on glucose and fat metabolism. In the present study, we evaluated whether IFN-γ lacks potential harmful side effects on metabolic and endocrine pathways while maintaining its beneficial effects on the immune system under conditions in which the inflammatory response system is activated. In 13 patients scheduled for major surgery, we studied HLA-DR expression on peripheral blood monocytes before surgery and postoperatively randomized the patients into an intervention and a placebo group. Subsequently, we evaluated the effects of a single dose of IFN-γ vs. saline on short-term monocyte activation, glucose and lipid metabolism, and glucose and lipid regulatory hormones. HLA-DR expression on monocytes was restored from postoperative levels of 54% (42-60%; median and interquartiles) to 92% (91-96%) 24 h after IFN-γ adminstration but stayed low in the placebo-treated patients. IFN-γ did not affect glucose metabolism (plasma glucose, rate of appearance and dissappearance of glucose) and lipid metabolism (plasma glycerol, plasma free fatty acids, and rates of appearance and disappearance of glycerol). IFN-γ had no effect on plasma cortisol, adrenocorticotropic hormone, growth hormone, insulin, C-peptide, glucagon, epinephrine, and norepinephrine concentrations. We conclude that IFN-γ exerts a favorable effect on cell-mediated immunity in patients after major surgery without effects on glucose and lipid metabolism.

Hand-assisted laparoscopic surgery (HALS): a report of 150 procedures

BACKGROUND

This study was performed to evaluate the (long-term) morbidity associated with hand-assisted laparoscopic surgery (HALS) for various indications.

METHODS

HALS procedures for various indications were evaluated prospectively from 1995 to 2002. The primary outcome parameters were postsurgical complications and the development of incisional hernias.

RESULTS

Twenty-six splenectomies, 51 hand-assisted laparoscopic donor nephrectomies (HLDN), 34 segmental bowel resections, 29 proctocolectomies, and 10 emergency colectomies were evaluated. A Küstner or Pfannenstiel incision was used for handport placement. Minor complications (i.e., wound complications, urinary tract infection) occurred in 15%, 12%, 26%, 7%, and 33% of the patients after, respectively, splenectomy, HLDN, bowel resection, proctocolectomy, and emergency colectomy. Major complications (i.e., hemorrhage, anastomotic leakage) occurred in 15% and 12% of the patients after, respectively, bowel resection and proctocolectomy. Incisional hernias occurred in six patients (4%), all after a wound complication in the Küstner incision.

CONCLUSION

HALS is fast, safe, and feasible for various indications, especially HLDN and (procto-)colectomies. Little advantage can be expected when HALS is applied in splenectomy and segmental bowel (sigmoid) resection.

Robot-assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a comparative study

BACKGROUND

The efficacy of conventional laparoscopic cholecystectomy (CLC) was compared with robot-assisted laparoscopic cholecystectomy (RLC). Surgical trainees performed the LC to avoid the surgeon's experience bias.

METHODS

Two surgical trainees performed 10 CLCs and 10 RLCs at random with a Zeus-Aesop Surgical Robotic System. The primary efficacy parameters were the total time and the number of actions involved in the procedure. The secondary parameters were setup and dissection times, and the number of grasping and dissection actions. Surgical complications were evaluated.

RESULTS

For CLC and RLC, respectively, the total times were 95.4 +/- 28 min and 123.5 +/- 33.3 min and the total actions were 420 +/- 176.3 and 363.5 +/- 158.2. For CLC, the times required for setup (21 +/- 10.4 min) and dissection (50.2 +/- 17.7 min) were less than for RLC (33.8 +/- 11.3 min and 72 +/- 24.3 min, respectively). The numbers of grasping and dissection actions were not significantly different: 41.4 +/- 26.5 and 378 +/- 173.7, respectively, for CLC versus 48.9 +/- 27 and 314.6 +/- 141.9, respectively, for RLC.

CONCLUSION

Although feasible, RLC requires significantly more time than CLC because of slower performed actions.

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life

OBJECTIVE

To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy.

SUMMARY BACKGROUND DATA

Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients.

METHODS

Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70).

RESULTS

Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months.

CONCLUSIONS

Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

The effect of suprapubic catheterization versus transurethral catheterization after abdominal surgery on urinary tract infection: a randomized controlled trial

BACKGROUND/AIM

Transurethral catheterization is generally associated with a higher incidence of urinary tract infections than suprapubic catheterization; however, suprapubic catheterization is associated with other disadvantages such as higher costs and a more difficult technique, and at the moment there is no consensus about the use of both catheter systems. Therefore, a prospective randomized study was performed to investigate the effects of suprapubic catheterization and transurethral catheterization in patients undergoing surgery on the incidence of urinary tract infections and patient satisfaction.

METHODS

Patients who underwent an elective laparotomy were randomized and received a suprapubic or transurethral catheter. The primary end point was urinary tract infection. Other parameters of urinary tract infection, as well as duration of catheterization, hospital stay, and number of recatheterizations and of relaparotomies were monitored. Treatment 'per protocol' was also analyzed after exclusion of patients receiving another catheter than randomized for. Patients were asked for their satisfaction with the catheters and complaints during and after catheterization.

RESULTS

165 patients were eligible, of whom 19 patients had to be excluded. 75 patients were allocated to receive the suprapubic catheter and 71 the transurethral catheter. There was no difference in the incidence of a urinary tract infection between the suprapubic group (n = 9/75; 12%) and the transurethral group (n = 8/71; 11%). Most patients (6/9) who developed a urinary tract infection in the suprapubic group, however, underwent recatheterization because of postoperative complications/sepsis and relaparotomy. The incidence of urinary tract infections in patients who received a suprapubic catheter and not a transurethral catheter was 3/59 (5%). The patients did not differ with respect to satisfaction and complaints. Being a men, recatheterization and duration of catheterization are risk factors.

CONCLUSIONS

The incidence of a urinary tract infection between a suprapubic catheter and a transurethral catheter in patients undergoing major surgery was not different. A potential advantage of the suprapubic catheter (reduction of urinary tract infections) is probably partly negated, because transurethral catheters were used if recatheterization was indicated during the postoperative stay or due to complications.

Cholestatic interleukin-6-deficient mice succumb to endotoxin-induced liver injury and pulmonary inflammation

Circulating and hepatic interleukin (IL)-6 levels are strongly increased during clinical and experimental cholestasis. Cholestatic liver injury is associated with increased susceptibility to endotoxin-induced toxicity. To determine the role of IL-6 herein, extrahepatic cholestasis was induced by bile duct ligation (BDL) in IL-6-gene deficient (IL-6(-/-)) and normal (IL-6(+/+)) mice. BDL elicited increased levels of hepatic IL-6 mRNA and protein in normal mice. Hepatocellular injury 2 weeks after BDL was similar in IL-6(-/-) and IL-6(+/+) mice as demonstrated by clinical chemistry and histopathology. Administration of endotoxin to cholestatic mice 2 weeks after BDL was associated with enhanced cytokine release, severe liver damage, and death when compared with sham-operated mice. Effects of endotoxin were largely similar in sham-operated IL-6(-/-) and IL-6(+/+) mice, but cholestatic IL-6(-/-) mice were more susceptible to the toxic effects of endotoxin, as reflected by increased cytokine release, more profound liver injury and lung inflammation, and higher mortality. Although endogenous IL-6 is not important in the development of liver injury after experimentally induced obstructive jaundice, this cytokine plays an important role in decreasing hypersensitivity to endotoxin in cholestatic mice.

Interleukin-18 facilitates the early antimicrobial host response to Escherichia coli peritonitis

To determine the role of endogenous interleukin-18 (IL-18) during peritonitis, IL-18 gene-deficient (IL-18 KO) mice and wild-type mice were intraperitoneally (i.p.) infected with Escherichia coli, the most common causative agent found in septic peritonitis. Peritonitis was associated with a bacterial dose-dependent increase in IL-18 concentrations in peritoneal fluid and plasma. After infection, IL-18 KO mice had significantly more bacteria in the peritoneal lavage fluid and were more susceptible for progression to systemic infection at 6 and 20 h postinoculation than wild-type mice. The relative inability of IL-18 KO mice to clear E. coli from the abdominal cavity was not due to an intrinsic defect in the phagocytosing capacity of their peritoneal macrophages or neutrophils. IL-18 KO mice displayed an increased neutrophil influx into the peritoneal cavity, but these migratory neutrophils were less activate, as reflected by a reduced CD11b surface expression. These data suggest that endogenous IL-18 plays an important role in the early antibacterial host response during E. coli-induced peritonitis.

Decrease in core liver temperature with 10°C by in situ hypothermic perfusion under total hepatic vascular exclusion reduces liver ischemia and reperfusion injury during partial hepatectomy in pigs

OBJECTIVE

We attempted to assess liver ischemia/reperfusion injury under a mild decrease in core liver temperature of 10 degrees C by in situ hypothermic perfusion during ischemia.

METHODS

Liver ischemia was induced in pigs by total hepatic vascular exclusion with concomitant in situ perfusion with hypothermic (4 degrees C) Ringer-glucose (cold perfused group, core liver temperature maintained at 28 degrees C), with normothermic (38 degrees C) Ringer-glucose (warm perfused group) or without in situ perfusion (control group).

RESULTS

In the cold perfused, warm perfused, and control groups, 24-hour survival was 5/5, 0/5, and 3/5, respectively. Hemodynamic parameters in the cold perfused group remained stable, whereas pigs in both other groups required circulatory support. Plasma AST and interleukin-6 levels were lower in the cold perfused group than in both other groups. Hepatocellular function was best preserved in the cold perfused group as indicated by complete recovery of bile production during reperfusion and no loss of indocyanine green clearance capacity. In both other groups, bile production and indocyanine green clearance capacity were reduced significantly. The hyaluronic acid uptake capacity of pigs in the cold perfused group or control group did not differ, indicating preserved sinusoidal endothelial cell function. Histopathologic injury scores during reperfusion were significantly lower in the cold perfused group when compared to both other groups.

CONCLUSIONS

A mild decrease in core liver temperature of 10 degrees C by in situ hypothermic liver perfusion during ischemia protects the liver from ischemia/reperfusion injury. This protection appears to be related to cooling of the liver rather than to the washout of blood during perfusion.

Implications of removing a normal appendix

BACKGROUND

The diagnosis of acute appendicitis remains difficult and therefore 15-30% of the removed appendices appear to be normal. The aim of this study was to investigate morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis.

PATIENTS AND METHODS

Retrospective study of patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded.

RESULTS

In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a re-operation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complications 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2712.

CONCLUSION

The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools such as diagnostic laparoscopy should be used selectively in order not to further increase costs.

Inter- and intraindividual variabilities of perforation forces of human and pig bowel tissue

BACKGROUND

A laparoscopic bowel grasper should be suitable for safely grasping the bowel in a wide variety of patients. Therefore, the inter- and intraindividual variabilities in the strength of bowel tissue to resist perforation force should be analyzed.

METHODS

The large and small bowels of pigs ( n = 14) and the human small bowel ( n = 7) were clamped between two hemispheres 1.5 mm in diameter. The pinch force was increased until the tissue was perforated.

RESULTS

The perforation force for the pig large bowel was higher than for the small bowel (13.5 +/- 3.7 vs 11.0 +/- 2.5 N; p = 0.014). No difference was found between the human and pig small bowel (10.3 +/- 2.9 vs 11.0 +/- 2.5 N). The intercoefficient of variation varied between 22% and 28%, and the intracoefficient of variation varied between 14% and 18%.

CONCLUSIONS

The strength of the pig bowel is approximately comparable to the strength of the human bowel, and, therefore, testing of graspers on pig bowel is justified. However, due to the large interindividual variation, large safety margins should be taken into account.

Effect of a protein and energy dense N-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial

AIM

N-3 fatty acids, especially eicosapentaenoic acid (EPA), may possess anticachectic properties. This trial compared a protein and energy dense supplement enriched with n-3 fatty acids and antioxidants (experimental: E) with an isocaloric isonitrogenous control supplement (C) for their effects on weight, lean body mass (LBM), dietary intake, and quality of life in cachectic patients with advanced pancreatic cancer.

METHODS

A total of 200 patients (95 E; 105 C) were randomised to consume two cans/day of the E or C supplement (480 ml, 620 kcal, 32 g protein +/- 2.2 g EPA) for eight weeks in a multicentre, randomised, double blind trial.

RESULTS

At enrolment, patients' mean rate of weight loss was 3.3 kg/month. Intake of the supplements (E or C) was below the recommended dose (2 cans/day) and averaged 1.4 cans/day. Over eight weeks, patients in both groups stopped losing weight (delta weight E: -0.25 kg/month versus C: -0.37 kg/month; p = 0.74) and LBM (Delta LBM E: +0.27 kg/month versus C: +0.12 kg/month; p = 0.88) to an equal degree (change from baseline E and C, p<0.001). In view of evident non-compliance in both E and C groups, correlation analyses were undertaken to examine for potential dose-response relationships. E patients demonstrated significant correlations between their supplement intake and weight gain (r = 0.50, p<0.001) and increase in LBM (r = 0.33, p = 0.036). Such correlations were not statistically significant in C patients. The relationship of supplement intake with change in LBM was significantly different between E and C patients (p = 0.043). Increased plasma EPA levels in the E group were associated with weight and LBM gain (r = 0.50, p<0.001; r = 0.51, p = 0.001). Weight gain was associated with improved quality of life (p<0.01) only in the E group.

CONCLUSION

Intention to treat group comparisons indicated that at the mean dose taken, enrichment with n-3 fatty acids did not provide a therapeutic advantage and that both supplements were equally effective in arresting weight loss. Post hoc dose-response analysis suggests that if taken in sufficient quantity, only the n-3 fatty acid enriched energy and protein dense supplement results in net gain of weight, lean tissue, and improved quality of life. Further trials are required to examine the potential role of n-3 enriched supplements in the treatment of cancer cachexia.

Experimental model of obstructive, chronic pancreatitis in pigs

BACKGROUND

We aimed to develop a reproducible, experimental model of obstructive pancreatitis for future analysis of surgical interventions, and characterized this model using functional, histological and biochemical parameters.

ANIMALS AND METHODS

In 10 female pigs the pancreatic duct (PD) was ligated. After 4, 6 or 8 weeks the animals were sacrificed. Before and after ligation, glucose tolerance and intraductal pressure were measured, and pancreatic juice was collected after stimulation with cholecystokinin and secretin. Amylase and lipase activities were analyzed in plasma and juice. Pancreatic tissue was collected for histochemical analysis.

RESULTS

Within 4 weeks of ligation, the pancreas appeared atrophic. Intraductal pressure had risen significantly. Acinar-to-ductal metaplasia was accompanied by strong proliferation of stellate cells and increased collagen deposition. Islets of Langerhans appeared smaller and more numerous. Blood amylase and lipase levels were normal and glucose tolerance was unaffected. Pancreatic juice volume and amylase and lipase activities were significantly lower.

CONCLUSION

Ligation of the PD in pigs resulted in a marked fibrosing obstructive pancreatitis within 4 weeks, similar to human chronic pancreatitis in regard to clinical, functional, histological and biochemical parameters.

Interleukin-6, C-reactive protein, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells in patients after laparoscopic vs. conventional bowel resection: a randomized study

PURPOSE

The aim of the study was to investigate the effect of surgical trauma in terms of approach (laparoscopic vs. conventional surgery) and extent of bowel resection (ileocolic resection vs. colectomy) on interleukin-6 level, C-reactive protein level, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells. Second, the length of the incision was correlated with the inflammatory response.

METHODS

Thirty-four patients were analyzed as part of a randomized trial comparing laparoscopically assisted vs. open bowel resection for Crohn's disease, ulcerative colitis, and familial adenomatous polyposis. C-reactive protein levels and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells were measured preoperatively and one day after surgery. Interleukin-6 was measured preoperatively and on Days 1 and 7 postoperatively.

RESULTS

Four of the 34 patients were excluded because of blood transfusion after surgery. One day postoperatively, the interleukin-6 level peaked significantly within the laparoscopic and conventional group. There was no significant difference between the conventional and laparoscopic groups at Day 1 postoperatively. At Day 7 postoperatively, interleukin-6 levels were similar in both groups and returned to baseline levels. There was a higher C-reactive protein level in the conventional group one day after surgery than in the laparoscopic group, although the difference was not significant. Preoperative and postoperative human leukocyte antigen-DR expression on monocytes and postoperative percentage of lymphocytes expressing human leukocyte antigen-DR did not differ between the conventional and laparoscopic groups. No differences in immune response with respect to the measured parameters were noticed in patients with a large or small bowel resection segment or in patients with a small (</=8 cm) or large (>8 cm) incision.

CONCLUSIONS

These data suggest that surgical trauma did not significantly affect the immune status of patients with respect to the measured parameters in terms of either the approach or the extent of bowel resection.

Management of acute cholangitis

Endoscopic sphincterotomy (ES) is the treatment of choice for patients with (severe) acute cholangitis. For fit patients without co-morbidity with mild cholangitis and CBD stones with a gallbladder in situ, the one-stage laparoscopic approach could be considered as an alternative in centers with sufficient experience. The results of both procedures are comparable. Open surgery is relatively safe. It has a high success rate, good/excellent long-term results, but is not very attractive for the patient and should not be used routinely nowadays. Therefore, the indication should be limited for management of severe complications after ES as perforations of the duodenum, large CBD stones and patients with Mirizzi's syndrome or intrahepatic stones with stenosis of the bile duct. ES as primary treatment for CBD stones should be followed by laparoscopic cholecystectomy in 'fit' patients. In patients with malignant disease, particularly after repeated stent failure and subsequent cholangitis, bypass surgery should be considered in patients with a life expectancy of >3 months.

Implications of removing a normal appendix

BACKGROUND

The diagnosis of acute appendicitis remains difficult, and therefore 15-30% of the removed appendices appear to be normal. The aim of this study is to investigate the morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis.

PATIENTS AND METHODS

A retrospective study was performed on patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded.

RESULTS

In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a reoperation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2,712.

CONCLUSION

The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools as diagnostic laparoscopy should be used selectively in order to not further exceed costs.

[Pleural fluid in chronic pancreatitis]

In three patients, a 44-year-old schizophrenic woman and two men aged 54 and 42, who presented with dyspnoea, a pancreaticopleural fistula was diagnosed as a complication of pancreatitis, i.e. a fistulous tract between the pancreas and the pleural cavity. In general, these fistulas have a good prognosis; however, delay in finding the correct diagnosis influences the prognosis. This is often due to unfamiliarity with the disease and the non-specific presentation of patients with pleural effusion. The initial presentation usually comprises respiratory (dyspnoea, coughing due to pleural effusion) and occasional abdominal symptoms (epigastric pain). A definitive diagnosis is made when elevated pleural effusion amylase levels are demonstrated. Surgical treatment is only indicated if conservative or endoscopic treatment fails, and consists of resection of the fistula and drainage of the pancreatic duct via a lateral pancreaticojejunostomy or resection of the part of the pancreas where the fistula originates. In the first patient, surgical drainage of the fluid accumulation was applied, but she died of aspiration pneumonia after she had removed the feeding tube and had refused further treatment. Pancreatic resection resulted in recovery in the two men.

[The registration of complications of medical treatment]

The National Surgical Adverse Event Registration (LHCR) software has been fully implemented in 25 (18.7%) departments of surgery in the Netherlands. This is a relatively low percentage considering that 92.5% of all hospitals are already using a local registration system for complications. Software difficulties in creating a link between the LHCR and local systems is suggested to be the main impeding factor. There are still a number of questions, notably concerning the validity of the system for registration of all complications versus a selected group of (severe) complications, the issue of the implications of the registration system in terms of quality control and subsequent regulation or centralization of procedures, and the importance for other specialists, in particular those performing invasive procedures, to introduce a complication registration system to establish a quality control system in those areas as well.

Reinterpretation of radiological imaging in patients referred to a tertiary referral centre with a suspected pancreatic or hepatobiliary malignancy: impact on treatment strategy

Our objective was to determine the clinical importance of reinterpretation of radiological investigations performed in a referring hospital and the value of additional investigations in a referral centre. A panel of four experts retrospectively evaluated the technical quality of radiological investigations and made reinterpretation reports, of 78 patients referred with a suspected pancreatic or hepatobiliary malignancy. The value of additional radiological investigations performed in the referral centre was assessed. The quality of ultrasound and CT examinations was sufficient for reinterpretation in (36 of 69) 52% and (42 of 60) 70%, respectively. The reinterpretation reports of the ultrasound investigations were scored as "in accordance" in (30 of 36) 83%, as "minor discordance" in (3 of 36) 8% and as "major discordance" in (3 of 36) 8%. For CT proportions of (29 of 42) 69%, (8 of 42) 19% and (5 of 42) 12%, respectively, were found. Additional ultrasound ( n=55) showed no additional findings in 16%, minor additional findings in 53% and major additional findings in 31% of cases. For additional spiral CT scan ( n=47) results were of 21, 47 and, 32%, respectively. Reinterpretation of ultrasound and CT resulted in a change in treatment strategy for 7 patients (9%). Additional ultrasound or CT resulted in a change in treatment strategy for 24 patients (30%). Improved communication and reinterpretation of radiological investigations may reduce unnecessary referral.

[Laparoscopic cholecystectomy in day care; implementation of a guideline for clinical practice]

OBJECTIVE

To evaluate the extent to which the guideline to perform laparoscopic cholecystectomy in day care was followed in the institute where the guideline was developed and in the other hospitals in the Netherlands.

DESIGN

Retrospective, descriptive.

METHOD

For the patients who underwent a laparoscopic cholecystectomy in the Amsterdam University Medical Centre (AMC) during the period 1 January 1998-31 December 2000, data were collected from medical records on how the intervention was performed: in day care or during a hospital admission. The national figures were obtained from SIG Zorginformatie in Utrecht.

RESULTS

A total of 262 patients underwent a laparoscopic cholecystectomy at the AMC: 60 men and 202 women, with an average age of 43 years (range: 2-86). A total of 163 (62%) patients were eligible for treatment in day care. Laparoscopic cholecystectomy was performed in day care in the years 1998, 1999 and 2000 in 80%, 92% and 93% of patients respectively (n = 144). Of these 144 patients, 129 (90%) were discharged to home the same day. For the same years, these figures for the whole of the Netherlands were 0.8%, 1.3% and 1.7% respectively.

CONCLUSION

The clinical guideline for performing laparoscopic cholecystectomy in day care has been implemented to a large extent in the AMC but has scarcely been implemented at the national level. At the AMC, day care treatment could be carried out for 90% of the patients for whom this had been planned.

Outcome of pancreaticojejunostomy after previous endoscopic stenting in patients with chronic pancreatitis

OBJECTIVE

To assess whether previous endoscopic stenting of the pancreatic duct influences the outcome of subsequent pancreaticojejunostomy in chronic pancreatitis.

DESIGN

Retrospective analysis.

SETTING

University hospital, the Netherlands.

PATIENTS

50 patients with chronic pancreatitis, 26 of whom had previously had stents inserted and 24 who had not.

INTERVENTIONS

A questionnaire was sent to each patient to evaluate long-term pain relief, readmissions during follow-up and subjective efficacy of the operation, and risk factors for recurrent pain were calculated.

MAIN OUTCOME MEASURES

Postoperative morbidity, pain relief and subjective efficacy.

RESULTS

Patients with stents were operated on later (after 60 months of symptoms) than those without (17 months). 5 (19%) and 2 (8%) patients developed complications. No patient died. Personal follow-up (median 27 months) was obtained in 41 of 44 available patients (93%). 36 patients (88%) felt that they had benefited from pancreaticojejunostomy. 13 of the 21 patients with stents (62%) and 11 of the 20 patients without stents (55%) reported pain at least monthly, but of these 24 patients 21 patients (88%) had less pain than preoperatively; 11 (22%) had pain daily. 13 patients were readmitted for a relapse of pancreatitis, 3 of whom required partial pancreatectomy. Previous endoscopic stenting of the pancreatic duct was not a risk factor for recurrent pain (p = 0.61).

CONCLUSION

Endoscopic stenting of the pancreatic duct may be done for patients with chronic pancreatitis without adverse effects on the outcome of subsequent pancreaticojejunostomy.