Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography: a population-based registry study

BACKGROUND

Each year 13 000 patients undergo cholecystectomy in Sweden, and routine intraoperative cholangiography (IOC) is recommended to minimize bile duct injuries. The risk of requiring endoscopic retrograde cholangiopancreatography (ERCP) following cholecystectomy for common bile duct (CBD) stones where IOC is omitted and in patients with CBD stones left in situ is not well known.

METHODS

Data were retrieved from the population-based Swedish Registry of Gallstone Surgery and ERCP between 1 January 2009 and 10 December 2019. Primary outcome was risk for postoperative ERCP for retained CBD stones.

RESULTS

A total of 134 419 patients that underwent cholecystectomy were included and 2691 (2.0 per cent) subsequently underwent ERCP for retained CBD stones. When adjusting for emergency or planned cholecystectomy, preoperative symptoms suggestive of CBD stones, sex and age, there was an increased risk for ERCP when IOC was not performed (hazard ratio (HR) 1.4, 95 per cent c.i. 1.3 to 1.6). The adjusted risk for ERCP was also increased if CBD stones identified by IOC were managed with surveillance (HR 5.5, 95 per cent c.i. 4.8 to 6.4). Even for asymptomatic small stones (less than 4 mm), the adjusted risk for ERCP was increased in the surveillance group compared with the intervention group (HR 3.5, 95 per cent c.i. 2.4 to 5.1).

CONCLUSION

IOC plus an intervention to remove CBD stones identified during cholecystectomy was associated with reduced risk for retained stones and unplanned ERCP, even for the smallest asymptomatic CBD stones.

Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury

Background

Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients’ quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy.

Methods

A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated.

Results

In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900.

Conclusion

Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.

Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography

The aim of this study was to assess whether sex, age, ASA grade, previous history of acute pancreatitis, diabetes, hyperlipidaemia, hypercalcaemia, kidney disease and liver cirrhosis influence the risk for developing post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). A total of 15 800 ERCP procedures retrieved from the Swedish National Quality Register for Gallstone Surgery and ERCP (GallRiks) for 2006–2014 were identified and cross‐checked with the National Patient Register. Women, patients aged less than 65 years, patients with hyperlipidaemia and those with a previous history of acute pancreatitis had a significantly increased risk of PEP, whereas patients with diabetes had a significantly decreased risk.

Risk of pancreatitis following ERCP

Morbidity of cholecystectomy and gastric bypass in a national database

Background

There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

Methods

Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

Results

There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P < 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P < 0·001) to the duration of surgery.

Conclusion

Cholecystectomy should be performed before, not during or after, RYGB.

Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study

BACKGROUND

Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla.

OBJECTIVE

The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience.

METHODS

An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, 'classic appearance'; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists.

RESULTS

Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58-0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59-0.72).

CONCLUSION

The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.

Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy

Background

Whether intraoperative cholangiography can prevent iatrogenic bile duct injury during cholecystectomy remains controversial.

Methods

Data from the national Swedish Registry for Gallstone Surgery, GallRiks (May 2005 to December 2010), were analysed for evidence of iatrogenic bile duct injury during cholecystectomy. Patient- and procedure-related risk factors for bile duct injury with a focus on the rate of intended intraoperative cholangiography were analysed using multivariable logistic regression.

Results

A total of 51 041 cholecystectomies and 747 bile duct injuries (1·5 per cent) were identified; 9008 patients (17·6 per cent) were diagnosed with acute cholecystitis. No preventive effect of intraoperative cholangiography was seen in uncomplicated gallstone disease (odds ratio (OR) 0·97, 95 per cent c.i. 0·74 to 1·25). Operating in the presence (OR 1·23, 1·03 to 1·47) or a history (OR 1·34, 1·10 to 1·64) of acute cholecystitis, and open surgery (OR 1·56, 1·26 to 1·94), were identified as significant risk factors for bile duct injury. The intention to perform intraoperative cholangiography was associated with a reduced risk of bile duct injury in patients with concurrent (OR 0·44, 0·30 to 0·63) or a history of (OR 0·59, 0·35 to 1·00) acute cholecystitis.

Conclusion

Any proposed protective effect of intraoperative cholangiography was restricted to patients with (or a history of) acute cholecystitis.

Telemedicine: an important aid to perform high-quality endoscopic retrograde cholangiopancreatography in low-volume centers

BACKGROUND AND STUDY AIMS

The aim of this study was to investigate whether telemedicine can help to ensure high-quality endoscopic retrograde cholangiopancreatography (ERCP) in patients living in rural areas. The study was conducted by investigators from two centers: the Karolinska University Hospital, a high-volume center which provided the teleguided support, and the Visby District Hospital, a low-volume center.

PATIENTS AND METHODS

From September 2010 to August 2011, 26 ERCP procedures performed at a district hospital were teleguided by an experienced endoscopist at the Karolinska University Hospital. To ensure patient data protection, all communication went through a network (Sjunet) that was separate from the Internet and open only to accredited users. The indications for ERCP were common bile duct stones (n = 12), malignant strictures (n = 12), and benign biliary strictures (n = 2). In 15 cases, this was the patient's first ERCP procedure.

RESULTS

The common bile duct was successfully cannulated in all 26 teleguided procedures. The local endoscopist scored the teleguided support as crucial for the successful outcome in 8 /26 cases, as an important factor in 8, and as being of less importance in the remaining 10. In the eight cases where the teleguided support was judged to be crucial, six subsequent percutaneous transhepatic cholangiography procedures and two repeat ERCPs were avoided. The overall cannulation rate at the district hospital improved from 85 % to 99 % after teleguided support was introduced. No procedure-related complications occurred.

CONCLUSION

Distant guidance of advanced ERCP procedures in a low-volume center, through teleguided support from a high-volume center, has the potential to improve the quality of care, as reflected in high cannulation rates and the ability to complete the scheduled interventions.

Mixed virtual reality simulation--taking endoscopic simulation one step further

This pilot study aimed to assess medical students' appraisals of a "mixed" virtual reality simulation for endoscopic surgery (with a virtual patient case in addition to a virtual colonoscopy) as well as the impact of this simulation set-up on students' performance. Findings indicate that virtual patients can enhance contextualization of simulated endoscopy and thus facilitate an authentic learning environment, which is important in order to increase motivation.

Visual working memory influences the performance in virtual image-guided surgical intervention

BACKGROUND

This study addresses for the first time the relationship between working memory and performance measures in image-guided instrument navigation with Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) and GI Mentor II (a simulator for gastroendoscopy). In light of recent research on simulator training, it is now prime time to ask why in a search for mechanisms rather than show repeatedly that conventional curriculum for simulation training has effect.

METHODS

The participants in this study were 28 Swedish medical students taking their course in basic surgery. Visual and verbal working memory span scores were assessed by a validated computer program (RoboMemo) and correlated with visual-spatial ability (MRT-A test), total flow experience (flow scale), mental strain (Borg scale), and performance scores in manipulation and diathermy (MD) using Procedicus MIST-VR and GI Mentor 11 (exercises 1 and 3).

RESULTS

Significant Pearson's r correlations were obtained between visual working memory span scores for visual data link (a RoboMemo exercise) and movement economy (r = -0.417; p < 0.05), total time (r = -0.495; p < 0.01), and total score (r = -0.390; p < 0.05) using MIST-MD, as well as total time (r = -0.493; p < 0.05) and efficiency of screening (r = 0.469; p < 0.05) using GI Mentor 11 (exercise 1). Correlations also were found between visual working memory span scores in rotating data link (another RoboMemo exercise) and both total time (r = -0.467; p < 0.05) and efficiency of screening (r = -0.436; p < 0.05) using GI Mentor 11 (exercise 3). Significant Pearson's r correlations also were found between visual-spatial ability scores and several performance scores for the MIST and GI Mentor II exercises.

CONCLUSIONS

Findings for the first time demonstrate that visual working memory for surgical novices may be important for performance in virtual simulator training with two well-known and validated simulators.

Diagnostic and prognostic implications of DNA ploidy and S-phase evaluation in the assessment of malignancy in biliary strictures

BACKGROUND AND STUDY AIMS

Brush cytology of biliary strictures has a low sensitivity for diagnosing malignancy, and additional diagnostic tools are needed. The aim of the present study was to assess the diagnostic and prognostic importance of DNA measurements as an adjunct to brush cytology in patients with biliary strictures.

PATIENTS AND METHODS

All patients (n = 225) with bile duct strictures who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 1997 and October 2003 at the Department of Radiology at Karolinska University Hospital, Huddinge, Sweden, were included in the study. While 66 patients had an unclear final diagnosis and were therefore excluded, the remaining 159 patients were assessed with brush cytology and DNA flow cytometry.

RESULTS

Sensitivity and specificity of DNA aneuploidy for tumor detection were 43 % and 96 %. Using DNA analysis in addition to brush cytology, the sensitivity was 62 % compared with 57 % for brush cytology alone (not significant). Patients with diploid DNA tumors had a significantly better survival than patients with aneuploid DNA tumors ( P = 0.02). The mean survival was 10 months for diploid cancers and 6 months for aneuploid cancers.

CONCLUSION

DNA ploidy measurement may be a diagnostic method that could supplement brush cytology in the identification of malignancy in biliary strictures. DNA aneuploidy is a marker of poor prognosis in patients with malignant biliary strictures.

Objective assessment of visuospatial and psychomotor ability and flow of residents and senior endoscopists in simulated gastroscopy

BACKGROUND

Advanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training.

METHODS

Eighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests.

RESULTS

Total gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 +/- 0.8 vs 5.5 +/- 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy.

CONCLUSIONS

A virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.

The influence of alcohol and time on the S-100B levels of patients with minor head injury

The present study aimed at evaluating the S-100B serum level's reaction to (i) alcohol consumption and (ii) time elapsing between head injury and blood sampling. Nineteen patients with minor head trauma and with at least one of the following symptoms: amnesia, transient loss of consciousness or severe headache, were included in the study. Immediately after arrival venous blood samples were drawn for determination of alcohol concentration and S-100B level. Four hours later a new blood sample was taken for repeat analysis. Twenty-one healthy volunteers drank a moderate amount of alcohol. Blood samples were taken just before alcohol intake and 4 h later. Patients - After 4 h the mean S-100B level had fallen from 0.26 to 0.21 ng/ml (P < 0.01), i.e. a mean decrease of 0.05 ng/ml, 95% confidence limits: 0.02-0.09 ng/ml. The alcohol concentrations also decreased significantly from 2.00 +/- 0.27 per thousand to 1.31 +/- 0.20 per thousand, P < 0.001, mean difference = 0.69 per thousand, 95% confidence limits: 0.27-1.11 per thousand. No difference was found between the S-100B levels of patients whose serum did contain alcohol and the levels of those whose serum did not. Volunteers - The serum alcohol level reached a mean value of 0.81 per thousand +/- 0.09 per thousand. The mean S-100B level rose from 0.077 +/- 0.02 ng/ml before alcohol intake to 0.103 +/- 0.06 ng/ml, 4 h later (P < 0.01). These data indicate that the time that elapses between trauma and blood test has an effect on the S-100B level. The same goes for the drinking of even a very moderate amount of alcohol. The relative importance of these two sources of error remains to be determined.

Chronically administered islet amyloid polypeptide in rats serves as an adiposity inhibitor and regulates energy homeostasis

AIMS/HYPOTHESIS

Islet amyloid polypeptide (IAPP) reduces food intake and body weight in laboratory animals. In addition, IAPP appears to regulate nutrient metabolism. In the present studies, we investigated the effect of chronic IAPP treatment on different aspects of energy homeostasis.

METHODS

IAPP was infused (25 pmol/kg/min) from subcutaneous osmotic pumps for 2-7 days. Rats in 2 saline-infused control groups were fed ad libitum (AF) or pair-fed (PF) against the IAPP-treated rats.

RESULTS

As expected, the IAPP infusion reduced food intake and body weight gain. In addition, the IAPP treatment decreased the epididymal fat pad (vs. PF rats, p < 0.05) and lowered circulating levels of triglycerides (vs. PF rats, p < 0.05), free fatty acids (vs. PF rats, p < 0.05), leptin (vs. both AF and PF rats, p < 0.05) and insulin (vs. AF rats, p < 0.05). In contrast, glucose and protein metabolism in the IAPP-treated rats was largely unchanged, as shown in results regarding serum glucose, glucose transport in skeletal muscle, blood urea nitrogen, and glycogen and protein content in the liver and in skeletal muscle.

CONCLUSION/INTERPRETATION

In summary, chronic IAPP exposure led to a changed lipid metabolism, which was characterized by decreased adiposity, hypolipidemia and hypoleptinemia, and to unchanged glucose and protein homeostasis. These results were similar to those seen in rodents during chronic exposure to another satiety/adiposity regulator, leptin. In conclusion, chronically administered IAPP plays a role as a satiety and adiposity signal in rats, and helps regulate energy homeostasis.

The Feny�-Lindberg scoring system for appendicitis increases positive predictive value in fertile women?A prospective study in 455 patients randomized to either laparoscopic or open appendectomy

BACKGROUND

Suspected appendicitis is one of the most common indications for acute laparotomy or laparoscopy. The negative laparotomy and laparoscopy rates are high, often in the range of 15-30%, and especially high in some groups of patients such as women of child-bearing age and young patients. Different scoring systems have been introduced in order to improve diagnostic accuracy. The aim of the present study was to analyse the outcome of the Fenyö-Lindberg scoring system in a prospectively randomized multicenter trial and to analyze how well the score performed in stratified subgroups.

METHODS

The variables of the Fenyö-Lindberg scoring system were collected in a prospective study comparing laparoscopic and open surgery in suspected appendicitis and with four participating centers. None of the hospitals had used the scoring system previously. Since surgeons were unfamiliar with the score, they could not use it as a diagnostic aid. When comparing the score with the clinical outcome, retrospectively, the investigators interpreting the score were blinded regarding the surgical outcome.

RESULTS

Positive predictive value (PPV) of the Fenyö-Lindberg score was higher than that of the surgeon's clinical diagnosis in the patient cohort [0.90 vs 0.79 (p < 0.001)]. The score demonstrated an improvement of PPV in women [0.83 vs 0.70 (p < 0.01)]. PPV was increased in women between 15 and 50 years of age. In women aged 15-30 years and 31-50 years PPV increased from 0.69 to 0.82 and 0.68 to 0.86, respectively (p < 0.01). Both the sensitivity (0.77) and the specificity (0.69) of the score were, however, low.

CONCLUSION

The Fenyö-Lindberg score is an inexpensive clinical tool that may improve the diagnostic accuracy for acute appendicitis in women of childbearing age, which is a group of patients where the diagnostic accuracy usually is low and where the arsenal of diagnostic tools such as computed tomography is limited because of radiation. The low specificity of the score in women of childbearing age must, however, be kept in mind.

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience

BACKGROUND

There is still some controversy regarding the optimal timing and best method for the removal of common bile duct stones (CBDS). Intraoperative endoscopic retrograde cholangiopancreaticography (IO-ERCP) is an alternative method that should be considered for this procedure. The aim of our study was to investigate the clinical outcome of a single-step procedure (IO-ERCP) to remove CBDS, thereby combining two existing high-volume clinical modalities-i.e., laparoscopic cholecystectomy (LC) and ERCP.

METHODS

Between January 2000 and December 2001, 674 patients, 192 male and 482 female, underwent cholecystectomy at our hospital. There were 612 LC (90.8%), 37 converted procedures (5.5%), and 25 open operations (3.7%). In 592 of the patients, (87.8%) intraoperative cholangiography (IOC) was performed. In 34 (5.7%) of those who had and IOC, an IO-ERCP was performed. While the surgeon waited for the endoscopist, care was taken to introduce a thin guidewire through the lOC catheter and pass it through the sphincter of Oddi, out into the duodenum. This complementary procedure greatly facilitated the subsequent cannulation of the bile ducts.

RESULTS

The cannulation frequency of the CBD was 100%. Common bile duct stones were successfully extracted in 93.5%. Endoscopic sphincterotomy (EST), followed by the insertion of a plastic endoprosthesis, was performed in two patients with remaining stones. The CBD of these two patients was cleared by postoperative ERCP. None of the patients developed postoperative pancreatitis. The operating time was prolonged as compared with the time for LC (192 vs 110 mins; p < 0.05). The length of hospitalization for IO-ERCP patients did not differ from that for patients undergoing cholecystectomy alone (2.6 vs 2.1. days; NS).

CONCLUSIONS

The study suggests that elective IO-ERCP is a safe and efficient method for removing CBDS that has a low risk of inducing postoperative pancreatitis and does not prolong postoperative hospitalization. This technique enables perioperative extraction of CBDS without open or laparoscopic surgical exploration of the CBD and can be used safely in a routine clinical setting.

Laparoscopic vs open appendectomy in overweight patients

BACKGROUND

Laparoscopic appendectomy (LA) has been associated with a faster recovery and less postoperative pain than the open technique. However, few data are available on the clinical outcome of LA in overweight patients.

METHODS

A group of 106 patients with a body mass index (BMI) > 26.4, representing the upper quintile of 500 prospectively randomized patients, were included in the study. They were randomized to undergo either laparoscopic or open appendectomy (OA). Operating and anesthesia times, postoperative pain, complications, hospital stay, functional index (1 week postoperatively), sick leave, and time to full recovery were documented.

RESULTS

In OA, the operating time for overweight patients was significantly longer than that for patients in the normal weight range (40 vs 35 min, p < 0.05). In LA, there was no difference in operating time between the normal and overweight patients. Overweight patients who underwent LA had longer operating and anesthesia times than their OA counterparts (55 vs 40 min, p < 0.001; and 125 vs 100 min, p < 0.001, respectively). Postoperative pain was significantly greater in overweight patients who underwent OA than in those treated with the laparoscopic technique. Postoperative pain was also significantly greater in overweight patients subjected to OA than in patients of normal weight after 4 weeks; the clinical significance may, however, be of less importance since the values are low (0.26 vs 0.09, p < 0.05). There were no significant differences between the two operating techniques in terms of complications. Hospital stay was longer for overweight patients than for normal-weight patients undergoing OA (3.0 vs 2.0, p < 0.01). The functional index did not differ between any group of patients. Sick leave was longer for overweight patients who underwent OA than for normal-weight patients treated with the same technique (17 vs 13 days, p < 0.01). In the laparoscopic group, however, there were no differences between the overweight and normal-weight patients. Time to full recovery was greater in overweight patients subjected to OA than in the overweight patients in the LA group (22 vs 15 days, p < 0.001).

CONCLUSION

In this study, overweight patients who were submitted to LA had less postoperative pain and a faster postoperative recovery than overweight patients who had OA. LA also abolished some of the negative effects that overweight had on operating time, hospital stay, and sick leave with the open technique. However, anesthesia and operating times were significantly longer in LA for both overweight patients and those with a normal BMI.

Conversion from laparoscopic to open appendicectomy: a possible drawback of the laparoscopic technique?

OBJECTIVE

To analyse the reasons for, and outcome of, conversion from laparoscopic to open appendicectomy and to identify factors that may predict the need for conversion.

DESIGN

Subgroup analysis from a randomised multicentre study.

SETTING

One university hospital and four county hospitals, Sweden.

SUBJECTS

A total of 500 patients were randomised to laparoscopic (n = 244) or open (n = 256) appendicectomy. Thirty operations (12%) were converted to open appendicectomy.

MAIN OUTCOME MEASURES

Reasons for conversion, outcome, and preoperative predictive variables.

RESULTS

Difficult anatomy or the presence of an abscess were the main reasons for conversion (25/30). The incidence of perforated appendicitis was higher among patients who required conversion compared with both the open and laparoscopic group. Operating time, anaesthetic time, and duration of hospital stay were longer after conversion. Time to full recovery and length of sick leave were also longer, except for patients with perforated appendicitis. There was no difference in the complication rate. No predictive factors were identified.

CONCLUSION

The main reasons for conversion were difficult anatomy and the presence of an abscess. After conversion patients recovered more slowly than those operated on laparoscopically or by primary open operation.

Contrast radiography in small intestinal obstruction, a valuable diagnostic tool?

OBJECTIVE

To investigate the diagnostic and therapeutic potential of plain abdominal radiographs and contrast radiography in patients with suspected small intestinal obstruction.

DESIGN

Retrospective study.

SETTING

General hospital, Sweden.

MATERIAL

2357 sets of plain abdominal radiographic casenotes.

MAIN OUTCOME MEASURES

Analysis of plain abdominal radiographs for small intestinal obstruction. Establishment of the time that subsequent contrast radiography medium took to reach the caecum, and its success rate.

RESULTS

Of the 2357 plain abdominal films 1599 (68%) did not show small intestinal obstruction, 425 (18%) showed intermediate obstruction, and 333 (14%) showed small intestinal obstruction. The water-soluble contrast medium reached the colon in 394/591 (67%) of the cases with intermediate or complete small intestinal obstruction. Although the contrast medium passed to the colon there was remaining abnormality with dilated small intestine in 71/212 (33%) of the cases with intermediate obstruction and in 95/143 (66%) of the small intestinal obstruction group. The time for the contrast medium to reach the colon was 3.4 hours in the normal group, 5.5 hours in the intermediate group and 8.9 hours in the obstruction group.

CONCLUSION

The plain abdominal radiographs seem to predict the success of follow-through examinations. Contrast radiography is safe and may have a therapeutic potential in small intestinal obstruction.

[Acute abdomen calls for considerable care resources. Analysis of 3727 in-patients in the county of Stockholm during the first quarter of 1995]

A total of 3,727 in-patients with acute abdominal symptoms were identified during the first quarter of 1995 at the surgical clinics of the nine hospitals with emergency departments in the county of Stockholm. The diagnoses were: non-specific abdominal pain 24%; cholecystitis 9%; appendicitis 8%; bowel obstruction 7%; intra-abdominal malignancy, diseases of the urinary tract and peptic ulcer 6% each; gastrointestinal hemorrhage, diverticulitis of the colon and pancreatitis 5% each; other diseases as a cause of abdominal symptoms, 19%. 1,601 operations were performed of which 47% were endoscopic procedures. The mean duration of hospital stay was 4.8 days. The length of stay increased significantly with age. The age-related relative frequency of hospitalization due to acute abdominal pain was also dramatically higher in the elderly cohorts. These facts and the prognosis of an 18% increase of inhabitants 50 years of age or older until 2010 in Greater Stockholm signal an increased need of hospital resources for this large group of patients in the coming years.

Prospective randomized multicentre study of laparoscopic versus open appendicectomy

BACKGROUND

A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis.

METHODS

A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group.

RESULTS

Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0.001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P < 0.001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P < 0.01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy.

CONCLUSION

Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.

Reference sample microsphere method to measure blood flow effects on small intestinal perfusion in the rat

To evaluate whether the microsphere method, including the necessary surgical procedures, for blood flow determination creates hemodynamic stress and a secondary reduction in small intestinal perfusion, we monitored the small intestinal perfusion with laser Doppler (LD) fluxmetry in 3 groups of Sprague-Dawley rats. Group I was studied during two microsphere injections without manipulation, group II was subjected to mesenterial-root occlusion during the second injection, and for group III, vasodilatation with papaverine preceded the second injection. While cardiac output and kidney blood flow were constant at the two microsphere injections, mean blood pressure (p < 0.05) and hematocrit (p < 0.01) significantly decreased in all 3 groups. Blood glucose increased significantly (p < 0.01). LD values also declined significantly (p < 0.05) between the start and end of experiments. In group I, the initial values of 9.5 perfusion units (PU) (5-23) decreased to 6.5 PU (3-12), in group II, 10.5 PU (5-24) decreased to 7.0 PU (4-15) and in group III, 9.0 PU (5-13) decreased to 5.5 PU (4-12). In conclusion, these findings suggest that the microsphere technique with two injections of spheres and reference sample withdrawals may affect the perfusion of the small intestine in the Sprague-Dawley rat.

Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system

OBJECTIVE

To validate a simplified scoring system as an aid to the diagnosis of acute appendicitis.

DESIGN

Open prospective study.

SETTING

County district hospital, and university hospital, Sweden.

SUBJECTS

1167 Patients with suspected appendicitis.

MAIN OUTCOME MEASURES

Correlation between scoring system and final diagnosis.

RESULTS

A total of 475 patients were operated on and 392 (82.5%) of these had histologically verified appendicitis. The negative laparotomy rate was 17.5% (11.2% for men and 25.4% for women). The sensitivity of the scoring system for appendicitis at the main cut-off point (score -2 or more) was 0.73 and the specificity was 0.87. At the cut-off level (score - 17 or less) for predicting non-specific abdominal pain (NSAP) the proportion of correctly classified patients was 0.72 and the proportion of false negatives (patients with appendicitis classified as NSAP) was 0.14. Analysis of the area under the receiver operating characteristic (ROC) curve showed that the scoring system performed slightly worse in the university hospital (area 0.83) than in the district hospital where it was originally developed (area 0.89).

CONCLUSION

The scoring system was a valid instrument for discriminating between acute appendicitis and NSAP in the two centres studied. Use of the scoring system in daily clinical work was associated with a reduced rate of negative laparotomies.

Myoelectric motility patterns during mechanical obstruction and paralysis of the small intestine in the rat

The purpose of the present study was to analyze changes of the myoelectric activity in experimental mechanical obstruction and paralytic ileus of the small intestine. Myoelectric activity was recorded in the upper small intestine of conscious, fasted rats by three bipolar electrodes implanted 10 cm apart. In the basal state regular myoelectric motility complexes (MMCs) were registered in all experimental animals. Obstruction of the small intestine (n = 13) was produced by a ligature between the middle and distal electrodes. Proximal to the obstruction regular MMCs continued. After 45 +/- 15 min at the middle (p less than 0.01), and 85 +/- 10 min at the duodenal electrode (p less than 0.01), MMCs disappeared. Another motility pattern was established, characterized by clusters of spikes, occurring regularly with 2-min intervals, separated by short silent periods, and a rapid aboral migration (p less than 0.01). Distal to the obstruction the propagation of MMCs was immediately disrupted. After a quiescent period of 13 +/- 3 min irregular spiking occurred and continued throughout the experiment (p less than 0.01). Intraperitoneal instillation of 0.1 M hydrochloric acid (n = 8) produced a prompt and long-lasting inhibition of the MMCs. The quiescence lasted for 70 +/- 23 min, until the MMCs reappeared (p less than 0.01). It is concluded that complete intestinal obstruction is followed by a series of significant and well-defined changes of myoelectric activity on both sides of the obstruction. Nociceptive stimulation of the peritoneum produces intestinal paralysis. The immediate inhibition of the motility indicates that the paralysis is not secondary to inflammatory reactions.

Mechanical compliance of the small intestine related to long-standing obstruction. An experimental study in rats

Mechanical compliance was studied in rat small intestine subjected to 48 hours of simple obstruction. The values were compared with those obtained in a corresponding section of normal gut. A closed system was used, constructed for continuous measurement of volume-pressure relationships within a hollow organ. The pressure-raising velocity was regulated by programming a steering unit connected to the system. The findings accorded with the hypothesis of an increase in compliance of the obstructed small intestine. The experiments further demonstrated that repeated artificial increases in intraluminal pressure cause change in intestinal compliance.

Effects of intraluminal hydrostatic pressure on L-methionine absorption in the obstructed small intestine of the rat

The effects of elevated intraluminal hydrostatic pressure on the active absorption of the amino acid selenium 75 L-methionine has been analyzed in the normal and obstructed small intestine. An intestinal loop of defined position and length was included in a recircling perfusion system from which the elimination rate of the radiolabeled amino acid was measured. Preset pressure levels within the system were maintained by a servo-controlled unit, which added or subtracted volume to keep the pressure constant. The rate of amino acid elimination increased when the nonobstructed loop was subjected to a pressure of 10 cm H2O but decreased when exposed to 20cm H2O. Using a loop of intestine subjected to 48 hours of obstruction, amino acid elimination was greatly retarded compared with that of the nonobstructed loop. By increasing the intraluminal pressure to 10 and 20 cm H2O, the elimination rate increased, equalling that of the nonobstructed gut. The results suggest that intestinal obstruction per se decreases active absorption secondary to impaired intestinal viability. Moderately increased intraluminal pressure adds a driving force to L-methionine absorption, the mechanism of which is obscure.

Effects of intraluminal pressure on regional blood flow in obstructed and unobstructed small intestines in the rat

Small bowel circulation in the rat was studied with the microsphere technique before and after 10 minutes of elevated intraintestinal pressure. A distal small bowel loop consisting of 10 vascular arcades was used. The specimens were inflated with nitrogen gas. Regional blood flow in both obstructed and unobstructed small bowels was significantly diminished by an intraintestinal pressure of 40 mm Hg. A pressure of 20 mm Hg impaired circulation only in the obstructed small intestine, whereas the unobstructed intestine did not show a similar decrease. These findings suggest that moderate intraluminal pressures can imply a potential hazard to the vulnerable capillary bed of an obstructed intestine. Hence, it is suggested that intraoperative decompression should be performed to avoid this postoperative threat to bowel viability.