Treatment of appendiceal mass--a qualitative systematic review.

INTRODUCTION: The treatment strategy for appendiceal mass is controversial, ranging from operation or image-guided drainage to conservative treatment with or without antibiotics. The aim of this study was to assess the various treatment modalities with respect to complications and treatment failure. METHODS: The analysis was based on the principles of a qualitative systematic review. The literature was searched in PubMed for the period from 1966 to March 2014. The articles were reviewed with respect to complications, treatment failure and hospital stay. Papers on post-operative intra-abdominal abscesses and abscesses of any cause other than appendicitis were excluded as were also studies only describing recurrent appendicitis and/or interval appendectomy. Sub-analyses were performed in children, adults, and in mixed populations. RESULTS: A total of 48 studies were found eligible; they included in total 3,772 patients. Operation for appendiceal mass was beset with a moderate to high risk of complications of up to 57% and a risk of intestinal resection of up to 25%. Major complications were observed in up to 18% of cases. Conservative treatment with or without antibiotics was associated with a treatment failure rate of 8-15%. Drainage was beset with a risk of complications of 2-15% and a risk of treatment failure of 2-13%. CONCLUSION: Operation with appendectomy for appendiceal mass carries a high risk of complications compared with conservative treatment or drainage. Drainage may lower the risk of treatment failure but entails a risk of complications. Based on the best evidence, we propose a step-down treatment strategy. FUNDING: Not relevant. TRIAL REGISTRATION: Not relevant.

Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial.

BACKGROUND: Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients. METHODS AND DESIGN: The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power. DISCUSSION: This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01209663.

High morbidity after laparoscopic emergency colectomy for inflammatory bowel disease.

INTRODUCTION: Only limited data are available on subtotal laparoscopic colectomy (STC) in patients with in inflammatory bowel disease. We present the first Danish experiences with intended laparoscopic STC for inflammatory bowel disease (IBD). The primary outcome was 30-day morbidity. MATERIAL AND METHODS: The present study is a retrospective single-centre study with consecutive enrolment of patients undergoing intended STC for IBD from 1 January 2005 to 31 July 2009. The results were analysed as either emergency or elective operations. Only the most severe complication was noted for each patient. Data on medical treatment, blood tests and complications and death within 30 days were registered. RESULTS: A total of 32 patients underwent surgery (15 elective and 17 emergency procedures). Patients in the emergency group had significantly more severe disease activity than elective patients. Severe complications were recorded in 47% and 20% of the patients undergoing emergency and elective STC, respectively (p = 0.15). The overall morbidity was 72%. One emergency patient died. Five of eight emergency patients and one of three elective patients underwent conversion and experienced a major complication (p = 0.55). The overall conversion rate was 32% (p = 0.15). CONCLUSION: We found high morbidity and conversion rates in patients undergoing SLC for IBD. A prospective national Danish survey on early postoperative outcome is suggested. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Fewer urological complications after laparoscopic inguinal hernia repair without indwelling catheter.

INTRODUCTION: The number of procedures involving transabdominal preperitoneal laparoscopic surgery for inguinal hernia (TAPP) has increased in Denmark. Optimized perioperative regimens are needed. MATERIAL AND METHODS: This retrospective, single-institution study included consecutive patients during an eight-year period from 1 January 2002 to 31 December 2007 (period I) and from 1 January 2008 to 31 December 2009 (period II). In period II, perioperative indwelling catheter (Foley catheter) was not used routinely. Furthermore, the surgical technique was adjusted, a small team of dedicated TAPP surgeons was established, and two of the surgeons attended prearranged surgical training programmes. Additionally, period II patients were enrolled into structured patient protocols. The primary endpoint was complications within the first 30 days after surgery, and we also registered the rate of reoperation due to recurrence. RESULTS: A total of 684 patients underwent TAPP surgery for 946 inguinal hernias. From period I to II, the number of TAPP surgeons was reduced to a third and two surgeons received TAPP training. During period I, minor urological complications were observed in 5% (confidence interval (CI) 3.1-6.9%) compared with 1% in period II (0.0-2.5%). The overall morbidity rate was 13%. Serious complications were observed in 3% (CI 3.1-6.9%) of the cases in period I and in 2% (0.0-2.5%) of the cases in period II. For the entire eight-year study period, the cumulative rate of re-operation due to recurrence was 2%. CONCLUSION: TAPP without routine use of an indwelling catheter may reduce the risk of urological complications.

[Diagnosis and treatment of Spigelian hernia]. / Diagnostik og behandling af spigellihernie.

INTRODUCTION: Spigelian hernia is a rare condition, which is frequently difficult to diagnose. This study describes our experience and we briefly discuss our findings in relation to the sparse literature. MATERIAL AND METHODS: Seven-year retrospective study (2000-2006) with prospective follow-up in a consecutive series of patients. RESULTS: We identified a total of 12 patients with 13 spigelian hernias among 379 patients with ventral hernia (3.1%). Symptoms and clinical findings varied substantially between patients. Due to strangulation, four patients underwent acute operation and eight patients underwent elective operation (laparoscopic (n = 7); open (n = 1)). One patient was treated conservatively. After a median of 3.3 years (range 0.8 to 6.8 years) recurrence was found in one patient and one patient (without recurrence) had moderate pain at the former hernia site. DISCUSSION: Due to the relatively high risk of strangulation, all patients with spigelian hernias should be offered surgery regardless of symptoms. Pain and perhaps bulging at the semilunar line indicates a spigelian hernia, but the diagnosis can be difficult to establish. When in doubt, we suggest the use of computed tomography and, subsequently, diagnostic laparoscopy and laparoscopic repair.

[Endoscopy-assisted sigmoidostomy]. / Endoskopisk assisteret sigmoideostomianlaeggelse.

INTRODUCTION: Formation of sigmoidostoma in order to establish temporary or permanent faecal diversion is a well-known procedure. In recent years an increasing number of centres have carried out laparoscopically-assisted stoma formation instead of the traditional laparotomy. Endoscopically-assisted sigmoidostoma formation is a less well-known and less technically challenging technique. MATERIALS AND METHODS: At the gastroenterology department (Gastroenheden), Hvidovre Hospital, Denmark, we have performed 24 endoscopically-assisted sigmoidostoma formations since June 2003. The study was done retrospectively. RESULTS: 24 patients were treated with endoscopically-assisted sigmoidostoma formation. The procedure was attempted in further 5 incidences without success, and conversion was necessary. In 3 cases stoma revision was needed afterwards and performed by local procedure without laparatomy. 1 patient with T3 rectal cancer died on the 6th postoperative day. CONCLUSION: Endoscopically-assisted sigmoidostoma formation is a minimal invasive procedure, which is technically simple. In our opinion, the procedure is at least equivalent to laparoscopically-assisted sigmoidostoma formation. We recommend endoscopically-assisted sigmoidostoma formation for patients where sigmoidostomy is necessary, and where there is no other need for laparotomy and the means of conversion to laparotomy or laparoscopy are available.