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Lipping E, Saar S, Reinsoo A, Bahhir A, Kirsimägi Ü, Lepner U, Talving P. Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial. Ann Surg 2024; 279:191-195. [PMID: 37747168 DOI: 10.1097/sla.0000000000006103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate noninferiority of postoperative oral administration of antibiotics in complicated appendicitis. BACKGROUND Recent investigations have used exclusively intravenous administration of antibiotics when comparing outcomes of postoperative antibacterial therapy in complicated appendicitis. We hypothesized that oral antibacterial treatment results in noninferior outcomes in terms of postoperative infectious complications as intravenous treatment. METHODS In this pilot, open-label, prospective randomized trial, all consecutive adult patients with complicated appendicitis, including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between November 2020 and January 2023, were randomly allocated to 24-hour intravenous administration of antibiotics versus 24-hour oral administration of antibiotics after appendectomy. Primary outcomes included 30-day postoperative complications per Comprehensive Complication Index. The secondary outcome was hospital length of stay. Follow-up analysis at 30 days was conducted per intention to treat and per protocol. The study was registered at ClinicalTrials.gov (NCT04947748). RESULTS A total of 104 patients were enrolled, with 51 and 53 cases allocated to the 24-hour intravenous and the 24-hour oral treatment group, respectively. Demographic profile and disease severity score for acute appendicitis were similar between the study groups. There were no significant differences between the study groups in terms of 30-day postoperative complications. Median Comprehensive Complication Index did not differ between the study groups. Hospital length of stay was similar in both groups. CONCLUSIONS In the current pilot randomized controlled trial, the 24-hour oral antibiotic administration resulted in noninferior outcomes when compared with the 24-hour intravenous administration of antibiotics after laparoscopic appendectomy in complicated appendicitis.
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Affiliation(s)
- Edgar Lipping
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Sten Saar
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Arvo Reinsoo
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Artjom Bahhir
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ülle Kirsimägi
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
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Isand KG, Hussain S, Sadiqi M, Kirsimägi Ü, Bond-Smith G, Kolk H, Saar S, Lepner U, Talving P. Frailty Assessment Can Enhance Current Risk Prediction Tools in Emergency Laparotomy: A Retrospective Cohort Study. World J Surg 2023; 47:2688-2697. [PMID: 37589793 DOI: 10.1007/s00268-023-07140-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account. METHODS In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model. RESULTS The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65 years. However, in younger patients, this effect was less marked than in the elderly. CONCLUSION Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals.
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Affiliation(s)
- Karl G Isand
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia.
| | - Shoaib Hussain
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Maseh Sadiqi
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Ülle Kirsimägi
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Giles Bond-Smith
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Helgi Kolk
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Sten Saar
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Peep Talving
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
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Sõber L, Lepner U, Kirsimägi Ü, Kasenõmm P. Prethyroidectomy voice and swallowing disorders and the possible role of laryngopharyngeal reflux disease. LOGOP PHONIATR VOCO 2023; 48:111-116. [PMID: 34939908 DOI: 10.1080/14015439.2021.2020894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 11/16/2021] [Accepted: 12/16/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate voice and swallowing function before thyroid surgery and to explore the possible role of thyroid enlargement and laryngopharyngeal reflux (LPR). METHODS We conducted a prospective study of patients who underwent hemi- or total thyroidectomy (n = 118) and compared the results with patients of laparoscopic cholecystectomy (n = 110). All subjects underwent videolaryngostroboscopy, filled in subjective evaluations of voice, swallowing and reflux complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) and perceptual voice evaluation were conducted. RESULTS We found no difference in voice quality between study and control group, neither in subjective complaints nor in AVA or perceptual evaluation. We did find indicative signs of minor laryngeal changes in thyroid group. Swallowing Impairment Score (SIS) revealed worse swallowing function in thyroid patients (p = 0.0006). Comparison of Reflux Symptom Index (RSI) scores revealed that thyroid group patients have higher values compared to control group (p = 0.006). Nevertheless, Reflux Finding Score (RFS) showed identical scores in both groups (p = 0.220). In thyroid group there was a strong positive correlation between RSI and SIS (ρ = 0.641), but no correlation between RFS and SIS (ρ = -0.002). In addition, we found a weak positive correlation between thyroid weight and RFS (ρ = 0.379). CONCLUSIONS Changes in laryngeal area caused by thyroid disorders do not lead to subjective but indicate slight objective disturbances in voice quality. We detected a decline in swallowing quality within thyroid patients. Higher RSI scores and a positive correlation between RFS and thyroid weight, indicate a possible role of thyroid gland in LPR.
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Affiliation(s)
- Linda Sõber
- ENT Clinic, Tartu University Hospital, Tartu, Estonia
| | - Urmas Lepner
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ülle Kirsimägi
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
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Reinsoo A, Kirsimägi Ü, Kibuspuu L, Košeleva K, Lepner U, Talving P. Bile duct injuries during laparoscopic cholecystectomies: an 11-year population-based study. Eur J Trauma Emerg Surg 2023; 49:2269-2276. [PMID: 36462050 DOI: 10.1007/s00068-022-02190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/27/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE Iatrogenic bile duct injuries (BDI) following laparoscopic cholecystectomy (LC) result in major morbidity and incidental mortality. There is a lack of unselected population-based cross-sectional studies on the incidence, management, and outcomes of BDI. We hypothesised that due to improved imaging capabilities and collective laparoscopic experience, BDI incidence will decrease over the study period and compare favourably with contemporary literature. METHODS After IRB approval, all cholecystectomies performed at national public healthcare facilities between 2008 and 2018 were retrospectively reviewed. BDIs were classified according to the Strasberg classification. The follow-up period ranged from 36 to 156 months. RESULTS A total of 241 BDIs of 29,739 laparoscopic cholecystectomies (LC) resulted in overall, minor, and major BDI incidence rates of 0.81%, 0.68%, and 0.13%, respectively. No significant decline in the BDIs was noted during the study period. Drainage in 66 (42.6%) and cases ERCP stent placement in 65 (41.9%) cases were equally used in Strasberg A lesions. Suture over T-tube in 20 (42.6%) and ERCP stenting in 19 (40.4%) cases were used in Strasberg D lesions. Roux-en-Y hepatojejunostomy (RYHJ) was performed in 30 (88.9%) of Strasberg E lesions. There were 27 (11.2%) patients with long-term bile duct strictures after BDI management. The overall mortality rate of BDIs and subsequent complications was 4.6%. CONCLUSIONS The annual incidence of iatrogenic bile duct injury over an 11-years' time after laparoscopic cholecystectomy did not decline significantly. We noted an overall BDI incidence of 0.81% comprising of 0.68% minor and 0.13% of major lesions. The management of injuries met contemporary guidelines with comparable outcomes.
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Affiliation(s)
- Arvo Reinsoo
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Sütiste Tee 19, Tallinn, Estonia.
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Liis Kibuspuu
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | | | - Urmas Lepner
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Sütiste Tee 19, Tallinn, Estonia
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Murruste M, Kivilo M, Kase K, Kirsimägi Ü, Tähepõld A, Tammiksaar K. The Utility of 4D-CT Imaging in Primary Hyperparathyroidism Management in a Low-Volume Center. Medicina (Kaunas) 2023; 59:1415. [PMID: 37629704 PMCID: PMC10456658 DOI: 10.3390/medicina59081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023]
Abstract
Background: Ultrasonography (US) and the 99mTc-sestamibi parathyroid scan (SPS) may have suboptimal accuracy when detecting the localization of enlarged parathyroid gland(s) (PTG). Therefore, the more accurate four-dimensional computed tomography scan (4D-CT) has been employed for PTG imaging. Currently, there is a paucity of data evaluating the utility of 4D-CT in low caseload settings. Aim and Objectives: To evaluate the impact of PTG imaging, using 4D-CT in conjunction with its intraoperatively displayed results, on the outcomes of surgical PTX. Materials and Methods: A single-center retrospective analysis of surgically treated patients with pHPT from 01/2010 to 01/2021 was conducted. An evaluation of the impact of the preoperative imaging modalities on the results of surgical treatment was carried out. Results: During the study period, 290 PTX were performed; 45 cases were excluded due to surgery for secondary, tertiary or recurrent HPT, or due to the use of alternative imaging techniques. The remaining 245 patients were included in the study. US was carried out for PTG imaging in 236 (96.3%), SPS in 93 (38.0%), and 4D-CT in 52 patients (21.2%). The use of 4D-CT was associated with a significantly higher rate of successful localization of enlarged PTG (49 cases, 94.2%) compared to US and SPS (74 cases, 31.4%, and 54 cases, 58.1%, respectively). We distinguished between three groups of patients based on preoperative imaging: (1) PTG lateralization via US or SPS in 106 (43.3%) cases; (2) precise localization of PTG via 4D-CT in 49 (20.0%) patients; and (3) in 90 cases (36.7%), PTG imaging failed to localize an enlarged gland. The group of 4D-CT localization had significantly shorter operative time, lower rate of simultaneous thyroid resections, as well as lower rate of removal of ≥2 PTG, compared to the other groups. The 4D-CT imaging was also associated with the lowest perioperative morbidity and with the lowest median PTH in the one month follow-up; however, compared to the other groups, these differences were statistically not significant. The implementation of 4D-CT (since 01/2018) was associated with a decrease in the need for redo surgery (from 11.5% to 7.3%) and significantly increased the annual case load of PTX at our institution (from 15.3 to 41.0) compared to the period before 4D-CT diagnostics. Conclusions: 4D-CT imaging enabled to precisely locate almost 95% of enlarged PTG in patients with pHPT. Accurate localization and intraoperatively displayed imaging results are useful guides for surgeons to make PTX a faster and safer procedure in a low-volume center.
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Affiliation(s)
- Marko Murruste
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
| | - Martin Kivilo
- Faculty of Medicine, University of Tartu, 50406 Tartu, Estonia;
| | - Karri Kase
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
- Faculty of Medicine, University of Tartu, 50406 Tartu, Estonia;
| | - Ülle Kirsimägi
- Surgery Clinic of Tartu University Hospital, 50406 Tartu, Estonia; (K.K.); (Ü.K.)
| | - Annika Tähepõld
- Radiology Clinic of Tartu University Hospital, 50406 Tartu, Estonia;
| | - Kaia Tammiksaar
- Internal Medicine Clinic of Tartu University Hospital, 50406 Tartu, Estonia;
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Keskpaik T, Talving P, Kirsimägi Ü, Mihnovitš V, Ruul A, Starkopf J. Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators. Eur J Trauma Emerg Surg 2023; 49:1375-1381. [PMID: 36995396 DOI: 10.1007/s00068-023-02263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs. OBJECTIVES The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals. METHODS This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3. RESULTS Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35-105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034). CONCLUSION Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Anni Ruul
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Valner A, Kirsimägi Ü, Müller R, Kull M, Põlluste K, Kumm J, Lember M, Kallikorm R. Factors associated with hand bone changes in early rheumatoid arthritis. Musculoskeletal Care 2023; 21:108-116. [PMID: 35844169 DOI: 10.1002/msc.1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this research was to assess if hand bone mineral density (HBMD) changes associated with the appearance of erosions in early rheumatoid arthritis (ERA), compared with the population-based control group. Additionally, we tried to identify if there are novel factors that associate with HBMD and erosive changes (EC), and if they are dissimilar. The study was conducted as the data are limited. METHODS The study group consisted of 83 ERA patients and 321 controls. Dual-Energy X-Ray Absorptiometry (DXA) machine was used to measure HBMD. EC of RA (rheumatoid arthritis) were assessed in X-rays of hands using Sharp scores. Life-style habits, inflammation markers were assessed to evaluate the effects of different factors. RESULTS The presence of ERA was associated with lower HBMD compared with controls (adjusted for age, gender, height and weight; b -0.01, p = 0.045). 76% (95% CI 65.3-84.6) of ERA patients had EC in hand X-ray. Smoking habits and higher BMI (body mass index) were associated with an increased likelihood of having RA specific EC. In ERA, decreasing of HBMD was associated with the elevation of interleukin-6 (IL-6) and rheumatoid factor (RF) positivity. CONCLUSIONS In ERA, HBMD changes were not associated with the appearance of erosions. Factors that associate in ERA with HBMD changes and appearance of erosions differ. HBMD assessment together with serum IL-6 level could be useful in everyday clinical practice for better surveillance of ERA patients who do not have EC in hand X-rays.
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Affiliation(s)
- Annika Valner
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ülle Kirsimägi
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Raili Müller
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Mart Kull
- Viljandi County Hospital, Viljandi, Estonia
| | - Kaja Põlluste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaanika Kumm
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Margus Lember
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Riina Kallikorm
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
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Keskpaik T, Talving P, Kirsimägi Ü, Mihnovitš V, Ruul A, Marandi T, Starkopf J. Associations between elevated high-sensitive cardiac troponin t and outcomes in patients with acute abdominal pain. Eur J Trauma Emerg Surg 2023; 49:281-288. [PMID: 35857067 DOI: 10.1007/s00068-022-02057-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 07/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14 ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated with poor outcomes. METHODS After institutional research ethics committee approval, a retrospective review was performed on patients subjected to extended use of hs-cTnT measurements during two months period in patients admitted to ED with a chief complaint of abdominal pain, aged 30 years or older and triaged to red, orange, or yellow categories. Primary outcomes were 30-day, six-month, and one-year mortality, respectively. Adjusted mortality rates were compared using the Cox proportional hazard regression model. RESULTS Overall, 1000 consecutive patients were screened. A total of 375 patients were subjected to hs-cTnT measurement and 156 of them (41.6%) experienced OMI. None of the patients had acute myocardial infarction diagnosed in the ED. Patients with OMI had a significantly higher 30-day, six-month and one-year mortality compared to the normal hs-cTnT level group [12.8% (20/156) vs. 3.7% (8/219), p = 0.001, 34.0% (53/156) vs. 6.9% (15/219), p < 0.001 and 39.1% (61/156) vs. 9.1 (20/219), p < 0.001, respectively]. OMI was an independent risk factor for mortality at every time point analyzed. CONCLUSION Our investigation noted OMI in older patients with co-morbidities and in higher triage category presenting with abdominal pain to ED, respectively. OMI is an independent risk factor for poor outcomes that warrants appropriate screening and management strategy. Our results support the use of hs-cTnT as a prognostication tool in this subgroup of ED patients.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 51014, Tartu, Estonia.
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Anni Ruul
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Toomas Marandi
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Centre of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
- Quality Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 51014, Tartu, Estonia
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Murruste M, Kirsimägi Ü, Kase K, Veršinina T, Talving P, Lepner U. Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification. World J Clin Cases 2022; 10:7808-7824. [PMID: 36158501 PMCID: PMC9372835 DOI: 10.12998/wjcc.v10.i22.7808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/22/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.
AIM The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.
METHODS After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP.
RESULTS We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.
CONCLUSION The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.
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Affiliation(s)
- Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Karri Kase
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Tatjana Veršinina
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Peep Talving
- Department of Surgery, Board, North Estonia Medical Centre, Tallinn 13419, Estonia
| | - Urmas Lepner
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
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Sõber L, Lepner U, Kirsimägi Ü, Puksa L, Kasenõmm P. Voice and Swallowing Disorders After Thyroid Surgery. J Voice 2022:S0892-1997(22)00077-7. [PMID: 35410778 DOI: 10.1016/j.jvoice.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate voice and swallowing function following thyroid surgery, to identify dynamic changes during the follow-up period of 12-18 month and to find possible indicative signs of permanent or temporary vocal fold palsy. METHODS All participants (N = 110) were prospectively enrolled from the preoperative thyroid surgery patients between September 2013 and December 2016. All subjects underwent preoperatively, first week and 12-18 month postoperatively videolaryngostroboscopy, filled in subjective evaluation of voice (voice handicap index, [VHI]) and swallowing (swallowing impairment score) complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) measurement and perceptual voice evaluation were conducted. In the presence of laryngeal damage, additional first and sixth-month follow-up visits were planned. Patients, whom we suspected laryngeal nerve damage, underwent laryngeal electromyography 4 weeks after the operation. RESULTS On first postoperative week evaluation, no objective voice changes within patients with postoperatively intact laryngeal nerves were found. Subjective evaluations showed decline in VHI physical domain and increased strain in postoperative voice. Patients with postoperative nerve damage had a drastic decline in subjective voice quality (VHI all subscales and total score), AVA parameter jitter, MPT and perceptual voice quality. Subjective evaluation of swallowing revealed disturbances in all patients regardless of the nerve damage. We noticed remarkable differences in first week and first month visits between patients with permanent and temporary palsy in VHI total score and physical domain, MPT and perceptual breathiness and asthenia in voice. Regardless of the nerve injury, by the end of the follow-up period all changes had become statistically insignificant with the exception of perceptual evaluation of voice quality. CONCLUSIONS Patients with postoperative laryngeal nerve damage experience substantial deterioration of both subjective and objective voice quality with more extensive impairment in patients with permanent paralysis. Thyroid surgery causes subjective swallowing changes irrespective of laryngeal nerve damage. In patients without laryngeal nerve damage, swallowing function improves following thyroidectomy. Possible indicators for permanent paralysis are delayed recovery in the values of MPT and jitter and persistent perceptual breathiness and asthenia.
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Affiliation(s)
- L Sõber
- ENT Clinic, Tartu University Hospital, Tartu, Estonia.
| | - U Lepner
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ü Kirsimägi
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - L Puksa
- Sports Medicine and Rehabilitation Center, Tartu University Hospital, Tartu, Estonia
| | - P Kasenõmm
- ENT Clinic, Tartu University Hospital, Tartu, Estonia
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Murruste M, Kirsimägi Ü, Kase K, Veršinina T, Talving P, Lepner U. ‘Short’ pancreaticojejunostomy might be a valid option for treatment of chronic pancreatitis in many cases. World J Gastrointest Surg 2021; 13:1673-1684. [PMID: 35070072 PMCID: PMC8727189 DOI: 10.4240/wjgs.v13.i12.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Partington-Rochelle pancreaticojejunostomy (PJ) is an essential management option for patients with chronic pancreatitis (CP) associated with intractable pain and a dilated pancreatic duct (PD). Wide ductotomy and long PJ (L-PJ) have been advocated as the standard of care to ensure full PD decompression. However, the role of short PJ (S-PJ) in a uniformly dilated PD has not yet been evaluated.
AIM To evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP.
METHODS A retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ. The length of the PJ was adapted to anatomical alterations in PD. A comparison was made of S-PJ (< 50 mm) for uniformly dilated PD and L-PJ (50-100 mm) in the setting of multiple PD strictures, calcifications and dilatations. We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes. The primary outcomes were pain relief and quality of life (QOL); the secondary outcomes were perioperative characteristics, body weight, patients’ satisfaction with treatment, and readmission rate due to CP.
RESULTS Overall, 91 patients underwent side-to-side PJ for CP, including S-PJ in 46 patients and L-PJ in 45 patients. S-PJ resulted in better perioperative outcomes: Significantly shorter operative time (107.5 min vs 134 min), lower need for intraoperative (0% vs 15.6%) and total (2.2% vs 31.1%) blood transfusions, and lower rate of perioperative complications (6.5% vs 17.8%). We noted no significant difference in pain relief, improvement in QOL, body weight gain, patients’ satisfaction with surgical treatment, or readmission rate due to CP.
CONCLUSION Based on our data, in the setting of a uniformly dilated PD, S-PJ provides adequate decompression of the PD. As the clinical outcomes following S-PJ are not inferior to those of L-PJ, S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD.
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Affiliation(s)
- Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Karri Kase
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Tatjana Veršinina
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Peep Talving
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
- Division of Acute Care Surgery, Department of Surgery, North-Estonia Medical Centre, Tallinn 13419, Estonia
| | - Urmas Lepner
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
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12
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Murruste M, Kirsimägi Ü, Kase K, Saar S, Talving P. Long-term survival, risk factors and causes of mortality in surgically treated chronic pancreatitis. Pancreatology 2021; 21:714-723. [PMID: 33727036 DOI: 10.1016/j.pan.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND/OBJECTIVES Chronic pancreatitis (CP) is a complex disease with a high complications rate, poor quality of life and considerable mortality. Prospective investigations on long-term outcomes in chronic pancreatitis are scarce. Thus, we aimed to assess long-term survival, causes of death and impact of risk factors on survival in a cohort of surgically managed patients with chronic pancreatitis. METHODS After IRB approval, a prospective longitudinal cohort study with long-term follow-up (up to 19.6 years) was conducted. All consecutive single center patients operated between 1997 and 2019 were included. Data on health and social status, risk behavior, history of CP, indications for surgery, comorbidities and causes of death were collected. Survival analysis was performed using Kaplan-Meier analysis. Cox proportional multivariate hazard regression was used to assess the impact of risk factors on mortality. The results are reported as the hazard ratio (HR) with the 95% confidence interval (CI). The log-rank test was used to test for differences in survival between groups. RESULTS A total of 161 patients with CP were subjected to operative management due to chronic pain or local complications of CP. Forty-eight patients (29.8%) died during the follow-up period. Mortality rate was 32.8 per 1000 patient-years (PY) since the diagnosis of CP. Standardized mortality ratio (SMR) was 1.8 (2.7 for the subgroup of continuous alcohol users). Median survival after surgical treatment was 13.3 years. Univariate analysis revealed the following risk factors on survival: preoperative and postoperative continuous moderate or heavy alcohol consumption, heavy smoking, age ≥50 years, Charlson's comorbidity index (CCI) ≥4 and 2-3, unemployment, disability, insulin-dependent diabetes, pancreatic exocrine insufficiency (PEI), and low body mass index (BMI). In multivariate regression analysis lower survival was associated with continuous moderate/heavy alcohol consumption (hazard ratio (HR) 2.27), history of heavy smoking (HR 4.40), unemployment (HR 2.49), CCI 2-3 and ≥4 (HR 2.53 and HR 3.16, respectively), and BMI <18.5 (HR 4.01). Behavioral risk factors accounted for the vast majority of deaths due to chronic alcoholic liver disease (21 cases, 43.7%), smoking-related diseases (15 cases, 31.3%). CP-related mortality was 4.2%. CONCLUSIONS Long-term outcomes of surgically treated chronic pancreatitis was associated with low CP-related mortality. Alcohol-related and smoking-related diseases caused the vast majority of deaths. Thus, surgery provides the best results in patients, preventing postsurgical relapse of original behavioral risks. For achieving this, ongoing postoperative support would be highly beneficial.
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Affiliation(s)
- Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu, Estonia; Faculty of Medicine, University of Tartu, Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Karri Kase
- Department of Surgery, Tartu University Hospital, Tartu, Estonia; Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Sten Saar
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Peep Talving
- Faculty of Medicine, University of Tartu, Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Tallinn, Estonia
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Regli A, Reintam Blaser A, De Keulenaer B, Starkopf J, Kimball E, Malbrain MLNG, Van Heerden PV, Davis WA, Palermo A, Dabrowski W, Siwicka-Gieroba D, Barud M, Grigoras I, Ristescu AI, Blejusca A, Tamme K, Maddison L, Kirsimägi Ü, Litvin A, Kazlova A, Filatau A, Pracca F, Sosa G, Santos MD, Kirov M, Smetkin A, Ilyina Y, Gilsdorf D, Ordoñez CA, Caicedo Y, Greiffenstein P, Morgan MM, Bodnar Z, Tidrenczel E, Oliveira G, Albuquerque A, Pereira BM. Intra-abdominal hypertension and hypoxic respiratory failure together predict adverse outcome - A sub-analysis of a prospective cohort. J Crit Care 2021; 64:165-172. [PMID: 33906106 DOI: 10.1016/j.jcrc.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days. METHODS Mechanically ventilated patients who had blood gas analyses performed and intra-abdominal pressure measured, were included from a prospective cohort. Subgroups were defined by the absence (Group 1) or the presence of either IAH (Group 2) or HRF (Group 3) or both (Group 4). Mixed-effects regression analysis was performed. RESULTS Ninety-day mortality increased from 16% (Group 1, n = 50) to 30% (Group 2, n = 20) and 27% (Group 3, n = 100) to 49% (Group 4, n = 142), log-rank test p < 0.001. The combination of IAH and HRF was associated with increased 90- and 28-day mortality as well as with fewer ICU- and ventilation-free days. The association with 90-day mortality was no longer present after adjustment for independent variables. However, the association with 28-day mortality, ICU- and ventilation-free days persisted after adjusting for independent variables. CONCLUSIONS In our sub-analysis, the combination of IAH and HRF was not independently associated with 90-day mortality but independently increased the odds of 28-day mortality, and reduced the number of ICU- and ventilation-free days.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia; Medical School, The Notre Dame University, Fremantle, WA, Australia; Medical School, The University of Western Australia, Perth, WA, Australia.
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Bart De Keulenaer
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia; School of Surgery, The University of Western Australia, Perth, WA, Australia
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Edward Kimball
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Manu L N G Malbrain
- Faculty of Engineering, Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Brussels, Belgium; International Fluid Academy, Lovenjoel, Belgium
| | | | - Wendy A Davis
- Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Annamaria Palermo
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Dorota Siwicka-Gieroba
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Malgorzata Barud
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Ioana Grigoras
- Grigore T. Popa, University of Medicine and Pharmacy, Iasi, Romania; Regional Institute of Oncology, Iasi, Romania
| | - Anca Irina Ristescu
- Grigore T. Popa, University of Medicine and Pharmacy, Iasi, Romania; Regional Institute of Oncology, Iasi, Romania
| | | | - Kadri Tamme
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Liivi Maddison
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Anastasiya Kazlova
- Department of Intensive Care Medicine, Regional Clinical Hospital, Gomel, Belarus
| | - Aliaksandr Filatau
- Department of Intensive Care Medicine, Regional Clinical Hospital, Gomel, Belarus
| | - Francisco Pracca
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Gustavo Sosa
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Maicol Dos Santos
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Alexey Smetkin
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Yana Ilyina
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Daniel Gilsdorf
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili - Universidad del Valle, Cali, Colombia
| | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundacion Valle del Lili, Cali, Colombia
| | | | - Margaret M Morgan
- Louisiana State University Health Sciences Center, New Orleans, United States; UC Health Memorial Hospital Central, Colorado Springs, California, United States
| | - Zsolt Bodnar
- University Hospital of Torrevieja, Torrevieja, Spain; Letterkenny University Hospital, Letterkenny, Ireland
| | - Edit Tidrenczel
- University Hospital of Torrevieja, Torrevieja, Spain; Killybegs Family Health Centre, Killybegs, Ireland
| | - Gina Oliveira
- Polyvalent Intensive Care Unit, Hospitalar Center Tondela-Viseu, Tondela-Viseu, Portugal
| | - Ana Albuquerque
- Polyvalent Intensive Care Unit, Hospitalar Center Tondela-Viseu, Tondela-Viseu, Portugal
| | - Bruno M Pereira
- Postgraduate and Research Division, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, RJ, Brazil; Grupo Surgical, Campinas, SP, Brazil; Terzius Institute of Education, Campinas, SP, Brazil
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Keskpaik T, Starkopf J, Kirsimägi Ü, Mihnovitš V, Lomp A, Raamat EM, Saar S, Talving P. The role of elevated high-sensitivity cardiac troponin on outcomes following severe blunt chest trauma. Injury 2020; 51:1177-1182. [PMID: 31955863 DOI: 10.1016/j.injury.2019.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/14/2019] [Accepted: 12/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt cardiac injuries (BCI) result in poor outcomes following chest trauma. Admission ECG and troponin levels are frequently obtained in patients with suspected BCI, nevertheless, the prognostic value of cardiac troponins remains controversial. The purpose of the current study was to review the prognostic value of elevated high-sensitivity cardiac troponin T (hs-cTnT) in patients with severe blunt chest injuries. We hypothesized that elevated hs-cTnT result in poor outcomes in this subgroup of severe trauma patients. METHODS After IRB approval, all consecutive patients with Injury Severity Score (ISS) > 15 and chest Abbreviated Injury Scale (AIS) score ≥3 admitted to the major trauma centers between 1/2015 and 6/2017 were retrospectively reviewed. Primary outcomes were in-hospital and one-year mortality. Secondary outcomes included ventilator days and Glasgow Outcome Scale (GOS) score at hospital discharge. RESULTS Overall, 147 patients were included. Mean age was 49.0 (19.1) years and 75% were male. Serum troponin levels on admission were accrued in 82 (56%) patients with elevated and normal hs-cTnT levels found in 54 (66%) and in 28 (34%) patients, respectively. Elevated hs-cTnT group had significantly higher ISS and lactate level, and lower systolic blood pressure on admission. In-hospital mortality was significantly higher in patients with elevated hs-cTnT levels compared to patients with normal hs-cTnT levels (26% vs. 4%, p = 0.02). Hs-cTnT level > 14 ng/L was significantly associated with extended ventilator days and lower GOS score at hospital discharge. CONCLUSION Blunt chest trauma victims with elevated hs-cTnT levels experience significantly poorer adjusted outcomes compared to patients with normal levels. Compliance with EAST practice management guidelines following severe blunt chest trauma was not fully complied in our study cohort that warrants prospective performance improvement measures.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | - Andrus Lomp
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | | | - Sten Saar
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia.
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Kikkas EM, Sillakivi T, Suumann J, Kirsimägi Ü, Tikk T, Värk PR. Five-Year Outcome of Laparoscopic Sleeve Gastrectomy, Resolution of Comorbidities, and Risk for Cumulative Nutritional Deficiencies. Scand J Surg 2018; 108:10-16. [DOI: 10.1177/1457496918783723] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Aims: The aim of this study was to evaluate the long-term (5-year follow-up) results of laparoscopic sleeve gastrectomy in terms of weight loss and obesity-related comorbidities, as well as the risk factors associated with postoperative nutritional deficiencies. Material and Methods: The first 99 consecutive patients who underwent laparoscopic sleeve gastrectomy for the treatment of morbid obesity between October 2008 and August 2011 at Tartu University Hospital were followed prospectively in cohort study. The outpatient hospital follow-up visits were conducted at 3 months, 1 year, and 5 years postoperatively. At 5 years, the follow-up rate was 90.9%; 86 laparoscopic sleeve gastrectomy patients were included in final analysis. Results: The mean excess weight loss (%EWL) was 44.3% ± 13.0%, 75.8% ± 23.1%, and 61.0% ± 24.3% at 3 months, 1 year, and 5 years, respectively. A linear association between preoperative weight and weight at 5 years was found. Remission rates at 5-year follow-up for type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea were 68.8%, 32.7%, 27.4%, and 61.5%, respectively (all p < 0.05). There was a statistical difference (p < 0.05) in the dynamics of triglyceride, low-density lipoprotein, and high-density lipoprotein level at 5-year follow-up but the level of total cholesterol did not show significant improvement. The risk for cumulative iron, vitamin B12 deficiency, and anemia was 20%, 48%, and 28%, respectively. Conclusion: In conclusion, laparoscopic sleeve gastrectomy ensured long-term excess weight loss 61.0% at 5 years. Laparoscopic sleeve gastrectomy has a long-term effect on significant improvement in the median values of triglycerides, low-density lipoproteins, and high-density lipoproteins, but not on total cholesterol levels. There is a risk of postoperative vitamin B12 and iron deficiency.
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Affiliation(s)
- E. M. Kikkas
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - T. Sillakivi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - J. Suumann
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Ü. Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - T. Tikk
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - P. R. Värk
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
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16
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Suumann J, Sillakivi T, Riispere Ž, Syrjänen K, Sipponen P, Kirsimägi Ü, Peetsalu A. Serological biomarker testing helps avoiding unnecessary endoscopies in obese patients before bariatric surgery. BMC Obes 2018; 5:9. [PMID: 29484193 PMCID: PMC5819710 DOI: 10.1186/s40608-018-0185-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 02/01/2018] [Indexed: 02/06/2023]
Abstract
Background To assess the value of serological biomarker testing as a substitute for esophagogastroduodenoscopy (EGDS) in pre-operative assessment of patients referred for bariatric surgery. Methods Sixty-five obese patients with a mean age of 43 years (range: 21–65) and a mean body mass index (BMI) of 44 (range: 36–59) were studied. The patients were tested with a four-biomarker panel: pepsinogen I and II, gastrin-17 (basal and stimulated), and Helicobacter pylori (HP) antibodies (GastroPanel®, Biohit Oyj, Finland). On the basis of the biomarker test, the patients were classified into the HS (healthy stomach) group (n = 22) with the normal biomarker profile and the NHS (non-healthy stomach) group (n = 43). The classification of patients into HS and NHS was evaluated against the gold standard, i.e. EGDS with biopsies. Results The concordance (Cohen’s kappa) between the biomarker test and gastric histology was 0.68; 95% CI 0.504–0.854, with an overall agreement of 84.6% (95% CI 73.9–91.4%). In the NHS group, all 43 patients had biopsy-confirmed chronic gastritis: 39 non-atrophic HP-gastritis, 4 atrophic antrum gastritis (AGA) of moderate severity. In the HS group only 6 patients had mild superficial H.pylori negative gastritis. Of the 22 HS subjects with the normal biomarker profile, 20 (31% of all 65) had no complaints either, while the remaining two had reflux symptoms with esophagitis. In the NHS group 10 patients had esophagitis and 8 had also reflux symptoms. Conclusions The normal biomarker profile is an excellent surrogate for healthy stomach, implicating that pre-operative EGDS could have been avoided in 31% of our asymptomatic bariatric surgery patients who had the normal biomarker profile.
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Affiliation(s)
- Jaanus Suumann
- 1Department of Surgery, University of Tartu, Tartu, Estonia
| | | | - Živile Riispere
- 2Department of Pathology, University of Tartu, Tartu, Estonia
| | - Kari Syrjänen
- Department of Clinical Research, Biohit Oyj, Helsinki, Finland
| | | | - Ülle Kirsimägi
- 1Department of Surgery, University of Tartu, Tartu, Estonia
| | - Ants Peetsalu
- 1Department of Surgery, University of Tartu, Tartu, Estonia
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Nikkolo C, Vaasna T, Murruste M, Suumann J, Kirsimägi Ü, Seepter H, Tein A, Lepner U. Three-year results of a randomized study comparing self-gripping mesh with sutured mesh in open inguinal hernia repair. J Surg Res 2017; 209:139-144. [DOI: 10.1016/j.jss.2016.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/27/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
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18
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Nikkolo C, Kirsimägi Ü, Vaasna T, Murruste M, Suumann J, Seepter H, Lepner U. Prospective study evaluating the impact of severity of chronic pain on quality of life after inguinal hernioplasty. Hernia 2016; 21:199-205. [PMID: 28025741 DOI: 10.1007/s10029-016-1569-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The definition of chronic pain after inguinal hernioplasty and the methods of its assessment vary a great deal, which make it complicated to conduct meta-analyses. The primary aim of the present prospective study was to evaluate at which pain severity degree the quality-of-life scores will be reduced. METHOD A prospective study of patients operated for inguinal hernia was conducted. A pain questionnaire and a quality-of-life (QoL) questionnaire were completed. RESULTS Altogether, 370 patients were investigated and included in analysis. Of them, 33.8% experienced pain during different activities. Compared to the non-pain response group, significantly lower QoL scores for the Bodily pain domain were reported by patients who gave 1, 2, or 3 positive responses to the pain questionnaire. Patients with no pain as well as patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 had similar QoL scores for all domains. Patients who gave 1 positive response to the pain questionnaire and whose VAS score was >20, and patients who gave two or more positive responses to the pain questionnaire, showed significantly lower QoL scores in most of the domains compared with the non-pain group. When the patients who gave 1 positive response to the pain questionnaire and whose VAS score was ≤20 were excluded from the group of patients with pain, the rate of chronic pain was 19.7%. Considering the above result, the reduction in the rate of chronic pain from 33.8 to 19.7% was statistically significant. CONCLUSION Pain scores 20 mm or less on the VAS (0 to 100 mm) have no impact on the patients' quality of life. Uniform assessment methods of chronic pain should be developed to improve the quality of research.
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Affiliation(s)
- C Nikkolo
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - Ü Kirsimägi
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - T Vaasna
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - M Murruste
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - J Suumann
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - H Seepter
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia
| | - U Lepner
- Surgery Clinic, Tartu University Hospital, Puusepa 8, 51014, Tartu, Estonia.
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Nikkolo C, Vaasna T, Murruste M, Seepter H, Kirsimägi Ü, Lepner U. Three-Year Results of a Single-Centre Single-Blinded Randomised Study Evaluating the Impact of Mesh Pore Size on Chronic Pain after Lichtenstein Hernioplasty. Scand J Surg 2016; 105:141-6. [PMID: 26929280 DOI: 10.1177/1457496915620311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The aim of the present study was to determine whether usage of mesh with larger pores, compared with mesh with smaller pores, would result in a decreased rate of chronic pain at 3-year follow-up. According to earlier published short-term results, differences in mesh pore size do not influence the rate of chronic pain. MATERIAL AND METHODS The patients were randomized into two study groups for which meshes with similar weight but different pore size were used: the UM group received Ultrapro mesh (pore size 3-4 mm) and the OM group received Optilene LP mesh (pore size 1 mm). Pain scores were measured on a visual analog scale. The feeling of a foreign body was a yes-or-no question. RESULTS A total of 65 patients in the UM group and 63 patients in the OM group were included in analysis. Of the patients, 33.9% in the UM group and 15.9% in the OM group reported having experienced pain during different activities at 3-year follow-up (P = 0.025). Comparison with the results of 6-month follow-up (46.3% in the UM group, 34.3% in the OM group) showed that the rate of chronic pain had decreased significantly in the OM group (P = 0.009) but not in the UM group (P = 0.113). The feeling of a foreign body in the inguinal region was experienced by 23.1% of the patients in the UM group and by 15.9% in the OM group (P = 0.375). There was one hernia recurrence in the OM group. Severe preoperative pain and younger age were identified as risk factors for development of chronic pain. CONCLUSIONS Mesh with larger pores, compared with mesh with smaller pores, has no advantages in reducing the rate of chronic pain. We speculate that the reason for the higher rate of chronic pain in the study group where the mesh with larger pores was used might have been the different composition of the meshes at implantation. Also, it is possible as development of chronic pain after inguinal hernia repair is multifactorial, we failed to find a plausible explanation for this difference. Low recurrence rates were achieved with both meshes used in our study.
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Affiliation(s)
- C Nikkolo
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - T Vaasna
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - M Murruste
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - H Seepter
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ü Kirsimägi
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - U Lepner
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
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Nikkolo C, Vaasna T, Murruste M, Seepter H, Kirsimägi Ü, Lepner U. Randomized clinical study evaluating the impact of mesh pore size on chronic pain after Lichtenstein hernioplasty. J Surg Res 2014; 191:311-7. [DOI: 10.1016/j.jss.2014.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/19/2014] [Accepted: 04/09/2014] [Indexed: 11/15/2022]
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Varik K, Kirsimägi Ü, Värimäe EA, Eller M, Lõivukene R, Kübarsepp V. Incidence and Risk Factors of Surgical Wound Infection in Children: A Prospective Study. Scand J Surg 2010; 99:162-6. [DOI: 10.1177/145749691009900311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: To establish the incidence and risk factors of surgical site infection (SSI) in children operated in the Department of Paediatric Surgery of the Clinic of Surgery of Tartu University Hospital. Material and Methods: The data of wound healing were obtained for 589 children operated between 15 March 2003 and 31 March 2005. The operations were divided into general surgical (451), orthopaedic (70) and urological (68). The surgical wounds were classified as clean (442), clean-contaminated (96), contaminated (36) and dirty-infected (15). Univariate and multivariate analyses were performed to identify risk factors. Results: There were 7 SSI cases, overall rate being 1.2%. Superficial wound infection occurred in 5 cases and deep wound infection occurred in 2 cases. There was no organ/space infection. SSI was significantly more frequent in the case of contaminated and dirty-infected compared with clean or clean—contaminated operations, 7.8% and 0.6%, respectively (p = 0.0008). Wound infection endangered more children who had operation related complications compared with non-complicated cases, 11.1% and 0.4%, respectively (p < 0.0001).
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Affiliation(s)
- K. Varik
- Tartu University Department of Surgery, Tartu, Estonia
| | - Ü. Kirsimägi
- Tartu University Department of Surgery, Tartu, Estonia
| | - E.-A. Värimäe
- Tartu University Department of Surgery, Tartu, Estonia
| | - M. Eller
- Tartu University Department of Surgery, Tartu, Estonia
| | - R. Lõivukene
- Tartu University Department of Surgery, Tartu, Estonia
| | - V. Kübarsepp
- Tartu University Department of Surgery, Tartu, Estonia
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