Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II.

BACKGROUND: The aim of the present study was to investigate whether the new method of complete mesocolic excision (CME) with a high (apical) vascular tie (D3 resection) had an immediate effect compared with a conventional (standard) approach even in those patients without lymph node metastases. METHODS: A cohort of 189 consecutive patients with tumour-nodal-metastasis (TNM) stages I-II and a mean age of 73 years were operated on in the period from January 2007 to December 2008 in three community teaching hospitals. The CME approach (n = 89), used in hospital A, was compared to the standard technique used (n = 105) in two other hospitals, B and C. Lymph node yields from the specimens were used as a surrogate measure of radical resections. Outcome was analysed after a median follow-up of 50.2 months. RESULTS: In-hospital mortality rate was 2.8 % in the CME group and 8.6 % in the standard group. The 3-year overall survival (OS) in the CME group was 88.1 versus 79.0 % (p = 0.003) in the standard group, and the corresponding disease-free survival (DFS) was 82.1 versus 74.3 % (p = 0.026). Cancer-specific survival was 95.2 % in the CME group versus 90.5 % in the standard group (p = 0.067). Age, operative technique, and T category were significant in multiple Cox regressions of OS and DFS. CONCLUSIONS: Compared with the standard (D2) approach, introduction of CME surgical management of colon cancer resulted in a significant immediate improvement of 3-year survival for patients with TNM stage I-II tumours as assessed by OS and DFS.

Quality of life and pain in patients with acute cholecystitis. Results of a randomized clinical trial.

BACKGROUND: Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy. METHODS: Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later. RESULTS: Patients were followed-up for a median of 67 months. Ten of 33 patients (30%, 95% CI 15%-46%) patients randomized to observation and 27 of 31 (87%, 95% CI 75 %- 99%) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36%, 95% CI 20%-53%) patients in the observation group had a gallstone related event compared to 6 of 31 (19%, 95% CI 5%-33%) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/- cholecystectomy), we did not find any significant differences in pain or quality of life measurements. CONCLUSION: Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.

The role of cefoxitin prophylaxis in chronic pilonidal sinus treated with excision and primary suture.

BACKGROUND: Treatment of chronic pilonidal sinus with excision and primary suture is followed by a relatively high proportion of wound infections. The role of preoperative antibiotic prophylaxis in improving results is not clear. STUDY DESIGN: One hundred fifty-three patients with chronic pilonidal sinus were operated on with radical excision and primary suture and randomized to receive a single dose antibiotic prophylaxis of 2 g cefoxitin intravenously (n = 78) or no prophylaxis (n = 75). RESULTS: The most common complications consisted of partial, slight separation of wound edges with slight discharge. In the group with cefoxitin, 34 patients (44 percent) had complications compared with 32 patients (43 percent) in the group without prophylaxis. Fifty-four patients (69 percent) healed within four weeks in the group with cefoxitin, whereas 48 (64 percent) healed within four weeks in the group without prophylaxis. After a follow-up period of six to 30 months, two patients in each group had not healed. Including these, two patients (3 percent) had recurrences in the group with cefoxitin and five patients (7 percent) in the group without prophylaxis (p = 0.41). CONCLUSIONS: The immediate and short-term results after excision and primary suture for chronic pilonidal sinus are not influenced significantly by a single dose prophylaxis of 2 g cefoxitin.

The result of liver resection for colorectal metastases in a small volume hospital in western Norway.

AIM: Our aim was to compare liver resection for colorectal metastases in a non-referral, small volume unit with a dedicated staff, with results from larger units. METHODS: Thirty patients (15 men and 15 women) with a median age of 64years (range 29-78) underwent hepatic resection during a 5-year period from 1997 to 2003 in a teaching hospital in western Norway. RESULTS: Sixty-three percent (19/30) of the colorectal tumours were Dukes stage C (n=19) and CEA was increased in seven patients (23%), of which four (13%) had values above 50microg/l. The metastases were synchronous with the colorectal tumours in 11 patients (37%). Non-anatomical (wedge) resections were the dominant type of surgeries and the resection margins were clear in all patients. A 77-year-old man (3%) died of MOF after right hemihepatectomy. Morbidity was encountered in eight other patients (28%). In 22 patients (76%) with recurrent disease, metastases first appeared in the liver in 18 (82%) of these patients. Seven patients (23%) have had resections for recurrences. Mean time to recurrence was 20months (range 3-87). The actuarial 5-year survival rate was 42%. Six patients (20%) are currently disease free. CONCLUSION: Although our unit has treated a small number of patients compared with specialized units elsewhere, the survival rate, as well as morbidity and mortality, were comparable. However, 62% have had recurrent liver disease and this may suggest a role for neoadjuvant or adjuvant chemotherapy in selected cases.

Traumatic and postoperative ischemic liver necrosis: causes, risk factors and treatment.

BACKGROUND: To study the cause and outcome of ischemic liver necrosis and suggest treatment of these patients. METHODS: Retrospective study of 13 patients with ischemic liver necrosis treated at our departments from 1990 until 1997. RESULTS: Ischemic liver necrosis was caused by general hypoxia (n = 1) or acute arterial occlusion (n = 12) of the celiac and superior mesenteric artery (SMA, n = 3), proper hepatic artery (PHA, n = 1), right hepatic artery (RHA, n = 2), left hepatic artery (LHA, n = 2) and intrahepatic vessels (n = 4). Six of the cases were related to surgical procedures, 5 of these (38%) were unintended arterial injuries after biliary surgery. Ten patients (77%) had risk factors contributing to the development of liver necrosis: septicemia (n = 4), jaundice and septicemia (n = 2), shock and hypoxia (n = 3) and alcoholic cirrhosis (n = 1). Five patients (38%) needed resection of the liver necrosis due to infected necrosis. Three patients (23%) died; two of these had celiac/SMA occlusion. One died due to complete gastrointestinal ischemia and severe lactacidosis, two died of multiorgan failure after bile leakage and septicemia. CONCLUSION: Ischemic liver necrosis is mainly caused by arterial occlusion due to arteriosclerosis, arterial transection during biliary surgery or blunt liver trauma, and seldom occurs without additional risk factors. 50% of the patients develop infected necrosis and need liver resection. Patients with sterile necrosis may recover without surgical procedures of the liver. The mortality in patients with central (celiac/SMA) and peripheral (CHA, PHA, RHA, LHA, intrahepatic branches) occlusions was 67% (2/3) and 11% (1/9), respectively.

Mucosal surface area of a reversed intestinal segment in rats.

Only scarce knowledge exists of morphologic changes after antiperistaltic reversal of the small intestine. Previous animal models using a reversed segment of the small intestine after massive intestinal resection have been mostly concerned with assessing absorption. A rat model was therefore developed for the purpose of studying mucosal surface area in the small intestine after reversal of an intestinal segment. A reversal of 10 cm, representing a length of about 10%, was found suitable for the investigation. Marked dilatation of the reversed segment occurred. A pronounced increase in mucosal surface area caused by mucosal hyperplasia was observed. The mucosal surface area in an anastomosed, but not reversed, segment also increased markedly compared with a group undergoing no operation, although less than in the reversed segment. We conclude that a reversed intestinal segment will increase mucosal surface area in an optimal length used for this purpose. This increase is possibly caused by prolonged exposure to intestinal chyme.

Long-term follow-up of 1059 consecutive primary and recurrent inguinal hernias in a teaching hospital.

OBJECTIVE: To study the early and late outcome of various methods of inguinal hernia repair. DESIGN: Retrospective study. SETTING: Teaching hospital, Norway. SUBJECTS: 1059 repairs of inguinal hernias in men and women by 43 surgeons. INTERVENTIONS: Analysis of patients charts, results of questionnaires concerning 712 hernias (67%) and follow-up consultations when needed. MAIN OUTCOME MEASURES: Freedom from recurrence and postoperative groin symptoms after repairs of primary and recurrent hernias. RESULTS: After a median follow-up of 5.5 years, range 3-8, the recurrence rate was 8% for primary repairs and 29% after recurrent hernias. The incidence of permanent pain or discomfort was unexpectedly high, being 11% after primary repairs and 15% after recurrent hernia repairs. CONCLUSIONS: The number of recurrences at long-term follow-up after repairs of primary and recurrent inguinal hernias was unsatisfactory. The extent of postoperative pain was surprising as this was not given enough attention during the learning period. We have introduced a uniform treatment policy with a prospective surveillance programme with the aim of improving results in our teaching programme.

Acute cholecystitis: delayed surgery or observation. A randomized clinical trial.

BACKGROUND: The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients randomly allocated to delayed operation or conservative treatment. METHODS: One-hundred-and-eighty patients were considered for participation in the study; 71 were excluded according to predefined criteria and 45 did not join for other reasons. The remaining 64 patients were randomized to cholecystectomy (n = 31) or observation (n = 33). Randomized patients were contacted regularly and followed up for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group (19%; 95% CI 5%-33%) and in 12 patients (36%; 9% CI 20%-53%) in the observation group. Twenty-seven of 31 patients randomized to cholecystectomy had a cholecystectomy at a median of 3.6 months after randomization, and, of these, 3 (11%; 95% CI 0%-23%) suffered a major and 7 (26%; 95% CI 9%-42%) a minor complication. Ten patients randomized to observation later had their gallbladders removed, 1 (10%; 95% CI 0%-29%) patient had a major and 1 (10%; 95% CI 0%-29%) a minor complication. We found no mortality after cholecystectomy. CONCLUSIONS: We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis, but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis.

Randomization to surgery or observation in patients with symptomatic gallbladder stone disease. The problem of evidence-based medicine in clinical practice.

BACKGROUND: The description and understanding of gallbladder stone disease in the medical literature are difficult because an assessment of the natural course of this symptomatic disease, with separation of patients in strictly defined groups, is generally lacking. METHOD: A multicenter study was carried out with patients randomized to either surgery or conservative, expectant treatment to examine optimal treatment and natural history in well-defined groups of symptomatic gallbladder stone disease with pain, episodes only (study group 1) or acute cholecystitis (study group 2). The patients were between 18 and 80 years of age and had right upper quadrant or midline epigastric pain and ultrasonographic evidence of gallbladder stone, with or without acute cholecystitis. Medical treatment was ordinated on the basis of signs and symptom severity. Patients randomized to surgery were placed on the hospital's waiting list and electively operated on with cholecystectomy as soon as conveniently possible. Preliminary results of follow-up are based on questionnaires mailed at regular intervals and consultations if required by the patients' symptoms. Quality of life and freedom from pain are study end points for evaluation. RESULTS: Five hundred and one patients were considered for the study, 318 patients (63.5%) belonging to group 1 and 183 (36.5%) to group 2. One hundred and eighty-four patients (36.7%) were randomized, 120 (24%) in group 1 and 64 (12.7%) in group 2. Three hundred and seventeen patients (63.3%), with an equal proportion from each study group, were excluded, the largest number of patients because of incapacitating pain or serious presenting symptoms (26%). More women (81%) than men (19%) had pain alone (group 1), but the sex ratio was reduced, 56% women and 44% men, in patients with acute cholecystitis (group 2), with a highly significant difference (P = < 0.001) between the two groups. A significant difference in patient withdrawal from randomized treatment was registered, with 24% from observation and 12% from surgery (P = 0.032), but with an equal distribution in the two study groups. CONCLUSIONS: A randomized trial of this nature is feasible but extremely difficult to perform because of the heterogeneous nature of gallbladder stone disease, leading to exclusion of many patients and difficulties in measuring and evaluating outcome variables.

Patient characteristics and symptoms in chronic pilonidal sinus disease.

Three hundred and twenty two patients with pilonidal sinus disease were studied to determine factors for the development and maintenance of the disease. A calculated incidence of the disease of 26 per 100,000 inhabitants was found. It occurred 2.2 times more often in men than in women. Age at presentation was 21 years for men and 19 for women. Patients had two years (median) disease history before being referred for treatment. A family history could be found in 38% of the patients. 50% had normal body weight, and 37% were overweight. Local trauma or irritation preceded the condition in 34%, and a sedentary occupation was reported by 44%. Male sex, adolescence or youth, and a familial disposition seem to be associated with the development of pilonidal sinus. Local trauma and overweight are the most important conditioning factors for development of symptomatic pilonidal sinus disease.

Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial.

OBJECTIVE: To find out the recurrence rate of chronic pilonidal sinus after excision and primary suture compared with open excision and healing by second intention. DESIGN: Randomised trial. SETTING: Teaching hospital, Norway. SUBJECTS: 120 Patients treated between 1987 and 1989. INTERVENTIONS: 60 Patients were treated by excision and primary suture and 60 by open excision. The median follow-up period was 4.2 years. RESULTS: Recurrent pilonidal sinus was seen in six patients (10%) after primary suture compared with three patients (5%) after open treatment (p = 0.49); 57 (95%) and 55 (92%), respectively, were satisfied with the outcome of treatment at follow-up (p = 0.72). CONCLUSION: Excision and primary suture compares favourably with open excision and healing by second intention in the treatment of chronic pilonidal sinus.

Pain and quality of life in patients with symptomatic, non-complicated gallbladder stones: results of a randomized controlled trial.

BACKGROUND: Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience postcholecystectomy symptoms, including pain. There is limited information in the literature on gallstone-related pain and its influence on quality of life. The aim of this study was to examine how pain and quality of life in patients with symptomatic, uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder. METHODS: One-hundred and thirty-seven patients were randomized to observation (watchful waiting; n = 69) or cholecystectomy (n = 68) and answered questionnaires on pain, quality of life (PGWB index and NHP Part II) at randomization and fixed intervals (6, 12 and 60 months). All gallstone-related events (hospital admission for pain, complications of gallstone disease and cholecystectomy) and crossover between treatment groups were recorded. RESULTS: Of patients randomized to observation, 35 of 69 patients (51%) eventually underwent a cholecystectomy. Significant improvements in quality of life and pain scores were detected regardless of surgical treatment. Patients that subsequently experienced gallstone-related events had significantly higher pain scores at randomization than patients that did not experience any subsequent events, and this difference was maintained throughout follow-up. CONCLUSIONS: Unexpectedly, in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life. Patients that had high intensity and frequency of pain at randomization had a higher risk of experiencing subsequent events.

Bacteriology and complications of chronic pilonidal sinus treated with excision and primary suture.

Two prospective studies were undertaken to examine the role of bacteria in the outcome after excision and primary suture for chronic pilonidal sinus disease. In the first study 52 consecutive patients were given cloxacillin as prophylaxis. In a second randomised study 51 patients were given 2 g cefoxitin intravenously (n = 25) or no prophylaxis (n = 26). From 49 out of 98 patients (50%) no microorganisms were isolated from sinuses preoperatively. Wound complications were observed postoperatively in 61% of the patients (63/103). A postoperative bacteriology sample was positive in 47 of 49 samples (96%). Preoperative presence of bacteria was not significantly associated with wound complications. Anaerobe isolates were present in 40% of patients preoperatively whereas aerobes were cultured in 43% postoperatively. After an observation period of 30-42 months, recurrences were 13% among the patients (7/52) who had been given cloxacillin. No recurrences were seen in the last study after an observation period of 18-30 months, for an overall 7% in both studies. We conclude that preoperative bacterial isolates, usually anaerobes, in chronic pilonidal sinuses do not influence the complication rate since bacterial isolates from infected wounds are mostly aerobes.

Symptomatic, non-complicated gallbladder stone disease. Operation or observation? A randomized clinical study.

BACKGROUND: Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy (n = 68) or non-operative, expectant treatment (n = 69). METHODS: Randomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Eight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor. CONCLUSIONS: We found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.

[Surgical treatment of symptomatic pancreas divisum]. / Kirurgisk behandling av symptomgivende pancreas divisum.

Pancreas divisum is found in 5% of the population. It is linked to three clinical entities; recurrent epigastric pain, and acute and chronic pancreatitis. The relation between chronic pancreatitis and pancreas divisum is, however, uncertain. Pancreas divisum is controversial as a cause of acute pancreatitis and abdominal pain. However, this association probably exists as surgical sphincteroplasty of the minor papilla alleviate symptoms in a high proportion of patients. We have treated two patients surgically. Patient 1 was hospitalized 11 times because of recurrent acute pancreatitis. Two and a half years after sphincteroplasty he has had no further attacks of abdominal pain. Patient 2 had had recurrent epigastric pain, mostly related to meals, since early childhood. Secretin stimulation initially showed normal pancreatic duct dilatation and emptying. After sphincteroplasty, and reoperation for stricture, she can eat normally without pain one year after the last operation. We conclude that in selected patients surgical treatment of symptomatic pancreas divisum is beneficial. Sphincteroplasty should be considered as treatment in patients with pancreas divisum and recurrent acute pancreatitis or pain, as long as other causes are excluded.

Rapid C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis.

C-reactive protein (CRP) has been measured in plasma of patients with acute appendicitis and in controls without appendicitis to test the accuracy and diagnostic performance of a new rapid test kit for CRP (NycoCard CRP). The values obtained for CRP by the rapid test correlated well (Rs = 0.92) with the reference method for measuring CRP. The sensitivity, specificity and predictive values were calculated at different cut-off values. At values > 10 mg l-1 a sensitivity of 58% and a negative predictive value of 72% were found. Higher values of sensitivity were observed for men than for women, 69% and 44% respectively. Patients with acute appendicitis who had had symptoms for more than 24 h, had elevated CRP values (cut-off > 10 mg l-1) in more than 80% of cases. Our study shows that the rapid CRP test and the reference CRP test gave an almost identical result.