Combined endoscopic and laparoscopic surgery (CELS) for early colon cancer in high-risk patients.

BACKGROUND: Local excision of early colon cancers could be an option in selected patients with high risk of complications and no sign of lymph node metastasis (LNM). The primary aim was to assess feasibility in high-risk patients with early colon cancer treated with Combined Endoscopic and Laparoscopic Surgery (CELS). METHODS: A non-randomized prospective feasibility study including 25 patients with Performance Status score ≥ 1 and/or American Society of Anesthesiologists score ≥ 3, and clinical Union of International Cancer Control stage-1 colon cancer suitable for CELS resection. The primary outcome was failure of CELS resection, defined as either: Incomplete resection (R1/R2), local recurrence within 3 months, complication related to CELS within 30 days (Clavien-Dindo grade ≥ 3), death within 30 days or death within 90 days due to complications to surgery. RESULTS: Fifteen patients with clinical T1 (cT1) and ten with clinical T2 (cT2) colon cancer and without suspicion of metastases were included. Failure occurred in two patients due to incomplete resections. Histopathological examination classified seven patients as having pT1, nine as pT2, six as pT3 adenocarcinomas, and three as non-invasive tumors. In three patients, the surgical strategy was changed intraoperatively to conventional colectomy due to tumor location or size. Median length of stay was 1 day. Seven patients had completion colectomy performed due to histological high-risk factors. None had LNM. CONCLUSIONS: In selected patients, CELS resection was feasible, and could spare some patients large bowel resection.

Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis.

BACKGROUND: Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES: The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA: We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS: We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS: We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS: MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.

Tomografía computarizada para el diagnóstico de la apendicitis aguda en adultos / Computed tomography for diagnosis of acute appendicitis in adults

¿Por qué es importante mejorar el diagnóstico de la apendicitis? El propósito de utilizar la tomografía computarizada (TC) en personas con sospecha de apendicitis es ayudar al médico a diferenciar entre los pacientes que necesitan una cirugía con resección del apéndice (apendicectomía) y los que no necesitan este procedimiento. ¿Cuál es el objetivo de esta revisión? El objetivo de esta revisión Cochrane fue averiguar cómo de precisa es la TC de abdomen y pelvis para el diagnóstico de apendicitis en adultos. Los investigadores de Cochrane incluyeron 64 estudios en la revisión para responder a esta pregunta. ¿Qué se estudió en la revisión? Una TC puede realizarse de varias maneras. La calidad de la imagen puede mejorarse mediante el uso de material de contraste intravenoso, y la visualización del apéndice puede ser mejor cuando se utiliza contraste oral o rectal. La TC también puede realizarse con una dosis baja de radiación. La exposición a la radiación relacionada con la TC puede aumentar el riesgo de cáncer de por vida. Esta revisión estudió la precisión de los siguientes tipos de TC: cualquier tipo de TC, TC según el tipo de contraste, y TC de baja dosis. ¿Cuáles son los principales resultados? Esta revisión incluyó 64 estudios relevantes que informaron de los resultados de 71 poblaciones de estudio diferentes con un total de 10.280 participantes. Los resultados generales indican que, en teoría, si se utilizara una TC de cualquier tipo urgencias en un grupo de 1.000 personas, de las cuales el 43% tuviese apendicitis, entonces se estima que: a) 443 personas tendrían una TC que indicaría apendicitis y, de estas, el 8% no tendría apendicitis aguda; y b) 557 personas tendrían una TC que indicaría que no hay apendicitis, y el 4% tendría en realidad apendicitis aguda. La TC de baja dosis sería tan precisa como la TC de dosis estándar para diagnosticar la apendicitis. La TC con material de contraste intravenoso, rectal u oral e intravenoso sería igual de precisa, y más precisa que la TC sin contraste. ¿Cómo de fiables son los resultados de los estudios en esta revisión? Entre los estudios incluidos, el diagnóstico final de apendicitis se basó en los hallazgos quirúrgicos o en el examen microscópico del apéndice resecado. Entre los participantes sin cirugía, la apendicitis se descartó mediante un seguimiento para ver si sus síntomas se resolvían sin apendicectomía. Es probable que este haya sido un método fiable para decidir si los pacientes realmente tenían apendicitis si el seguimiento fue cuidadoso y completo. Lamentablemente, no fue así en una proporción sustancial de los estudios incluidos. En general, se observaron algunos problemas en la forma de realizar los estudios. Esto puede haber dado lugar a que la TC parezca más precisa de lo que realmente es, aumentando así el número de resultados correctos de la TC. ¿A quién son aplicables los resultados? Los estudios incluidos en la revisión se realizaron principalmente en los servicios de urgencias. Se sospechó que todos los participantes tenían apendicitis después del examen clínico y los análisis de sangre. Los estudios incluidos evaluaron una amplia gama de tipos de TC. La edad promedio de los participantes varió entre 25 y 46años, porcentaje de mujeres varió entre el 26% y el 100%, y el porcentaje de participantes con un diagnóstico final de apendicitis varió entre el 13% y el 92% (promedio: 43%). ¿Cuáles son las implicaciones? La TC es una prueba precisa que probablemente ayude a los médicos a tratar a las personas con posible apendicitis. Los resultados de esta revisión indican que la probabilidad de que un clínico diagnostique erróneamente una apendicitis aguda parece ser baja (8% cuando la TC sugiere que tienen apendicitis). La probabilidad de no obtener un diagnóstico de apendicitis también es baja (4% cuando la TC sugiere que no tienen apendicitis). ¿Cómo de actualizada es esta revisión? Se incluyeron estudios publicados hasta el 16 de junio de 2017

No disponible

Computed tomography for diagnosis of acute appendicitis in adults.

BACKGROUND: Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not. OBJECTIVES: Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy. SEARCH METHODS: We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status. SELECTION CRITERIA: We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity. MAIN RESULTS: We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery. AUTHORS' CONCLUSIONS: The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.

Readmission and reoperation rates following negative diagnostic laparoscopy for clinically suspected appendicitis: The "normal" appendix should not be removed - A retrospective cohort study.

BACKGROUND: In cases with clinically suspected appendicitis, there is controversy regarding the decision to remove a macroscopically normal appearing appendix during laparoscopy when no other intra-abdominal pathology is found. The aim of this study was to examine the rate of appendicitis, along with readmission and reoperation rates following diagnostic laparoscopy of clinically suspected appendicitis in patients where the appendix was not removed. METHODS: We performed a retrospective cohort analysis of patients who underwent a diagnostic laparoscopy due to clinical suspicion of appendicitis where no other pathology was found and the appendix was not removed. The study period was from 2008 to 2013 and involved patients from two university hospitals in the Copenhagen area. RESULTS: Of the 271 patients included (81.6% women, median age 27), 56 (20.7%) were readmitted with right iliac fossa pain after a median time of 10 months (range 1-84). Twenty-two patients (8.1%) underwent a new laparoscopic procedure. Appendix was removed in 18 patients, of which only one showed histological signs of inflammation. The median follow-up time was 5.6 years (range 1-109 months). CONCLUSION: There was a low rate of appendicitis after a previous negative diagnostic laparoscopy. Therefore, based on results from the current study, we do not consider that it is necessary to remove a macroscopic normal appendix during laparoscopy for clinically suspected appendicitis. The high readmission rate warrants the need for further investigation or follow-up.

[Combined endoscopic laparoscopic colon polypectomy].

Combined endoscopic laparoscopic surgery (CELS) is a novel technique for resection of benign colon polyps, which are not amenable for endoscopic resection. A review of ten studies including 416 patients shows that polyps were successfully resected in 65-97% of the patients. Polyp recurrence after CELS is low, and the frequency of adenocarcinoma is comparable with the frequency in large polyps (> 2 cm) resected endoscopically. CELS can be performed for a variety of indications but should be done after renewed endoscopy. Due to the risk of cancer it should only be performed in specialized centres.

Accuracy of abdominal auscultation for bowel obstruction.

AIM: To investigate the accuracy and inter-observer variation of bowel sound assessment in patients with clinically suspected bowel obstruction. METHODS: Bowel sounds were recorded in patients with suspected bowel obstruction using a Littmann(®) Electronic Stethoscope. The recordings were processed to yield 25-s sound sequences in random order on PCs. Observers, recruited from doctors within the department, classified the sound sequences as either normal or pathological. The reference tests for bowel obstruction were intraoperative and endoscopic findings and clinical follow up. Sensitivity and specificity were calculated for each observer and compared between junior and senior doctors. Interobserver variation was measured using the Kappa statistic. RESULTS: Bowel sound sequences from 98 patients were assessed by 53 (33 junior and 20 senior) doctors. Laparotomy was performed in 47 patients, 35 of whom had bowel obstruction. Two patients underwent colorectal stenting due to large bowel obstruction. The median sensitivity and specificity was 0.42 (range: 0.19-0.64) and 0.78 (range: 0.35-0.98), respectively. There was no significant difference in accuracy between junior and senior doctors. The median frequency with which doctors classified bowel sounds as abnormal did not differ significantly between patients with and without bowel obstruction (26% vs 23%, P = 0.08). The 53 doctors made up 1378 unique pairs and the median Kappa value was 0.29 (range: -0.15-0.66). CONCLUSION: Accuracy and inter-observer agreement was generally low. Clinical decisions in patients with possible bowel obstruction should not be based on auscultatory assessment of bowel sounds.

Ultrasound-guided drainage of subcutaneous abscesses on the trunk is feasible.

INTRODUCTION: Subcutaneous trunk abscesses are frequent, and current treatment options generally involve incision. By contrast, the standard care for breast abscesses is ultrasound-guided drainage. The aim of this study was to evaluate the feasibility of ultrasound-guided drainage combined with antibiotics in the treatment of subcutaneous abscesses on the trunk. MATERIAL AND METHODS: In this prospective study, 27 patients were treated with ultrasound-guided needle aspiration and oral antibiotics. Follow-up was performed at a 3-6-day interval, and the procedure was repeated if the abscess was not obliterated. RESULTS: Treatment was initially successful in 25 of the 27 participants (93%); two patients went on to surgery. The median time from first treatment to the final control visit was nine days. The 25 patients with initial successful treatment were contacted after a median of 84 days, and six (24%) of these reported recurrence of an abscess at the puncture site. 88% of the patients reported that they were satisfied or very satisfied with ultrasound-guided drainage. CONCLUSION: Our results indicate that ultrasound-guided drainage combined with antibiotics is feasible in the treatment of small subcutaneous abscesses on the trunk. Ultrasound-guided drainage was well-tolerated, had a high degree of success and short healing times. Additional randomised studies are needed to verify our findings. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Ten-year absolute risk of osteoporotic fractures according to BMD T score at menopause: the Danish Osteoporosis Prevention Study.

UNLABELLED: In the non-HRT arms of the DOPS study, 10-year fracture risk was higher at each level of T score than predicted by the Kanis algorithm. Under-reporting of fractures in registers and inclusion of HRT users are probable explanations for inappropriately low fracture risk estimates for younger women. INTRODUCTION: International recommendations highlight the importance of absolute fracture risk in establishing intervention thresholds. The available estimates of long-term risk have been derived by combining relative risks from meta-analyses with U.S. normative BMD data and Swedish fracture incidence records. We validated the 2001 Kanis risk algorithm using incident fractures observed in untreated women in the first 10 years of the Danish Osteoporosis Prevention Study (DOPS). Comparisons were also made with the relative risks derived from a recent meta-analysis of 12 cohort studies. MATERIALS AND METHODS: We analyzed DXA of the spine and hip from 872 women who were enrolled in the non-hormone replacement therapy (HRT) arms of the study and had not received HRT, bisphosphonates, or raloxifene. We collected verified reports of fractures at each visit. We focused on fractures of the hip, spine, shoulder, and forearm to provide risks comparable with the Kanis algorithm. Accordingly, asymptomatic radiographic vertebral fractures were not included. RESULTS: Seventy-eight women (9%) sustained relevant fractures. The risk of fracture increased by 1.32 (95% CI, 1.02; 1.70) for each unit decrease in femoral neck T score and by 1.30 (95% CI, 1.06; 1.58) for each unit decrease in lumbar spine T score at baseline. Absolute fracture risk was higher than expected from the Kanis algorithm at all T score levels. The difference was greatest for participants in the higher range of T scores. At T = -1, the observed risk was 10.9% as opposed to an expected risk of 5.7%. Relative risk gradients were similar to those of the recent meta-analysis. CONCLUSIONS: In healthy women, examined in the first year or two after menopause, 10-year fracture risk was higher at each level of BMD T score than expected from the model by Kanis et al. Inclusion of HRT users in the cohorts used may have led to higher BMD values and lower absolute fracture risk in the Kanis model. These longitudinal data can be used directly in estimating absolute fracture risk in untreated north European women from BMD at menopause.

Ten-year prediction of osteoporosis from baseline bone mineral density: development of prognostic thresholds in healthy postmenopausal women. The Danish Osteoporosis Prevention Study.

Osteopenia is common in healthy women examined in the first year or two following menopause. Short-term fracture risk is low, but we lack algorithms to assess long-term risk of osteoporosis. Because bone loss proceeds at only a few percent per year, we speculated that baseline bone mineral density (BMD) would predict a large proportion of 10-year BMD and be useful for deriving predictive thresholds. We aimed to identify prognostic thresholds associated with less than 10% risk of osteoporosis by 10 years in the individual participant, in order to allow rational osteodensitometry and intervention. We analyzed dual energy X-ray absorptometry (DXA) of the lumbar spine (LS) and femoral neck (FN) from 872 women, who participated in the non-HRT arms of the Danish Osteoporosis Prevention Study and had remained on no HRT, bisphosphonates or raloxifene since inclusion 10 years ago. We defined development of a T -score below -2.5 at the LS and/or FN or incident fracture as end-point, and we derived prognostic thresholds for baseline BMD, defining 90% NPV (negative predictive value) and 90% sensitivity, respectively. Seventy-six percent of the variation in BMD of the LS at 10 years was predicted by baseline BMD. In an individual participant, a baseline BMD T -score above -1.4 (FN or LS, whichever was lower) was associated with a 10-year risk of less than 10% of developing osteoporotic BMD or fracture. This covered 69% of the population. By contrast, participants with T -scores below -1.4 had a 56% risk of fracture or low BMD within 10 years. At the population level, baseline T -score cutoffs below 0 at the LS (68% of the population), 0 at the FN (72%) or -0.6 (62%) at the lower of the two sites capture 90% of the population that developed osteoporosis during the following 10 years. A BMD measurement, performed in the first two years following menopause, is a strong long-term predictor of BMD in healthy women. The association is strong enough to provide robust prognostic thresholds, which can be used to divide the population into two prognostic classes at menopause.

[Measures for the performance of diagnostic tests]. / Mål for diagnostiske tests ydeevne.

Systematic reviews have revealed that the methodological quality of studies on diagnostic accuracy is mediocre. In addition, clinicians may experience difficulties in interpreting and using measures describing the accuracy of a test. Using the Ottawa Ankle Rule as an example, we review the measures commonly used to describe the accuracy of diagnostic tests. The performance of tests is often given in terms of sensitivity and specificity. However, these measures have no relevance to clinicians unless they can be converted into predictive values. We describe how to calculate the predictive values and how they can be determined using likelihood ratios and Fagan's nomogram. The reader is introduced to the critical appraisal of results based on studies of the accuracy of tests. We describe how both the clinical spectrum and the methodological quality can influence estimates of diagnostic accuracy and stress the inevitable uncertainty involved in extrapolating results from the literature to clinical practice. Methods of calculating the confidence intervals for estimates of accuracy are presented.

Does a distal forearm fracture lead to evaluation for osteoporosis? A retrospective cohort study in 147 Danish women.

In postmenopausal women, a low-trauma distal forearm fracture is a risk factor for osteoporosis and future fracture, which indicates osteoporosis follow-up according to prevailing guidelines. We decided to determine how often women over 45 yr presenting with a low-trauma distal forearm fracture to a Danish emergency department during a 1-yr period were followed up for osteoporosis. We performed a retrospective review of hospital records and we sent the women and their general practitioners (GPs) questionnaires regarding the follow-up undertaken in primary care. Finally, we invited the women for a densitometry to estimate the prevalence of osteoporosis. From May 1, 2001 to April 30, 2002, 147 women presented with a low-trauma distal forearm fractures. According to the review of hospital records, none of the women was referred for bone densitometry or spine X-rays. One woman had calcium and vitamin D supplementation (CVDS) prescribed and two were recommended to consult their GPs for osteoporosis follow-up. In primary care, 12 women were referred for densitometry or spine X-rays, and 11 women started CVDS after the fracture. Women with risk factors for osteoporosis in addition to the forearm fracture were not more likely to be referred for densitometry or spine X-rays (p = 0.10). The prevalence of osteoporosis was 24% among the 79 women who underwent densitometry. Our study demonstrates a low use of available measures to reduce the risk of future fracture in women with a low-trauma distal forearm fracture, and it emphasizes the need to decide on a local level how to provide osteoporosis follow-up for women with fragility fractures.