Real-world accuracy of computed tomography in patients admitted with small bowel obstruction: a multicentre prospective cohort study.

PURPOSE: Small bowel obstruction (SBO) is a common surgical emergency. Previous studies have shown the value computed tomography (CT) scanning in both confirming this diagnosis and identifying indications for urgent surgical intervention, such as strangulated bowel or closed loop obstructions. However, most of the literature is based on retrospective expert review of previous imaging and little data regarding the real-time accuracy of CT reporting is available. Here, we investigated the real-world accuracy of CT reporting in patients admitted with SBO. METHODS: This was a multicentre prospective study including consecutive patients admitted with SBO. The primary outcomes were the sensitivity and specificity of CT scanning for bowel obstruction with ischaemia and closed loop obstruction. Data were retrieved from the original CT reports written by on-call radiologists and compared with operative findings. RESULTS: One hundred seventy-six patients were included, all of whom underwent CT scanning with intravenous contrast followed by operative management of SBO. Bowel obstruction with ischaemia was noted in 20 patients, with a sensitivity and specificity of CT scanning of 40.0% and 85.5%, respectively. Closed loop obstructions were noted in 26 patients, with a sensitivity and specificity of CT scanning of 23.1% and 98.0%, respectively. CONCLUSIONS: The real-world accuracy of CT scanning appears to be lower than previously reported in the literature. Strategies to address this could include the development of standardised reporting schemas and to increase the surgeon's own familiarity with relevant CT features in patients admitted with SBO.

Rectus diastasis increases risk of burst abdomen in emergency midline laparotomies: a matched case-control study.

PURPOSE: Burst abdomen is a serious complication requiring immediate surgical treatment. This study aimed to investigate the association between rectus diastasis and burst abdomen in patients undergoing emergency midline laparotomy. METHODS: A single-center, retrospective, matched case-control study of patients undergoing emergency midline laparotomy from May 2016 to August 2021 was conducted. Cases (patients who suffered from burst abdomen) were matched 1:4 with controls based on age and sex. Rectus diastasis was evaluated on CT imaging and was defined as a distance of at least three centimeters between the rectus abdominis muscles, three centimeters above the umbilicus. Midline laparotomy aponeurosis closure was standardized during the study period, using a slowly absorbable suture, sutured continuously with small bites of five millimeters and a minimum suture-to-wound ratio of 4:1. The primary outcome was the association between rectus diastasis and burst abdomen, evaluated against other suspected risk factors including obesity, liver cirrhosis, previous laparotomy, midline hernias and active smoking in a multivariate analysis. RESULTS: A total of 465 patients were included in the study, with 93 cases matched to 372 controls. Eighty-four patients had rectus diastasis (35.5% cases vs. 13.7% controls; p = < 0.001). Multivariate analysis found rectus diastasis significantly associated with burst abdomen (OR 3.06, 95% CI 1.71-5.47; p = < 0.001). No other suspected risk factors showed a significant association with burst abdomen. CONCLUSION: Rectus diastasis was highly associated with an increased risk of burst abdomen after emergency midline laparotomy.

Management and short-term outcomes of patients with small bowel obstruction in Denmark: a multicentre prospective cohort study.

AIMS: The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, a more surgically aggressive strategy has traditionally been used, but to what extent patient outcomes differ from international reports is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark. METHODS: This was a prospective cohort study conducted at six acute hospitals in Denmark over a 4-month period. Patients aged ≥ 18 years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30 day morbidity and mortality rates. RESULTS: 316 patients were included during the study period. The median age was 72 years and 56% were female. Diagnosis was made by computed tomography (CT) in 313 patients (99.1%), with the remaining three diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 119 (78.3%). Urgent surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The entire cohort had a 30 day mortality rate of 7.3% and a 30 day morbidity rate of 17.1%. CONCLUSIONS: The management of SBO in Denmark differs markedly to previous international reports, with an almost ubiquitous use of CT for diagnosis and a high proportion of patients undergoing urgent surgery. Despite higher rates of surgery, patient outcomes are broadly similar to reports of more conservative strategies, perhaps due to a reduction in delayed operations. TRIAL REGISTRATION: Trial registration number: NCT04750811. Trial registration date: 11/02/2021.

Effect of remote ischaemic preconditioning on mortality and morbidity after non-cardiac surgery: meta-analysis.

BACKGROUND: Remote ischaemic preconditioning (RIPC) has been shown to have a protective role on vital organs exposed to reperfusion injury. The aim of this systematic review was to evaluate the effects of non-invasive RIPC on clinical and biochemical outcomes in patients undergoing non-cardiac surgery. METHODS: A systematic literature search of PubMed, EMBASE, Scopus, and Cochrane databases was carried out in February 2020. RCTs investigating the effect of non-invasive RIPC in adults undergoing non-cardiac surgery were included. Meta-analyses and trial sequential analyses (TSAs) were performed on cardiovascular events, acute kidney injury, and short- and long-term mortality. RESULTS: Some 43 RCTs including 3660 patients were included. The surgical areas comprised orthopaedic, vascular, abdominal, pulmonary, neurological, and urological surgery. Meta-analysis showed RIPC to be associated with fewer cardiovascular events in non-cardiac surgery (13 trials, 1968 patients, 421 events; odds ratio (OR) 0.68, 95 per cent c.i. 0.47 to 0.96; P = 0.03). Meta-analyses of the effect of RIPC on acute kidney injury (12 trials, 1208 patients, 211 events; OR 1.14, 0.78 to 1.69; P = 0.50; I2 = 9 per cent), short-term mortality (7 trials, 1239 patients, 65 events; OR 0.65, 0.37 to 1.12; P = 0.12; I2 = 0 per cent), and long-term mortality (4 trials, 1167 patients, 9 events; OR 0.67, 0.18 to 2.55; P = 0.56; I2 = 0 per cent) showed no significant differences for RIPC compared with standard perioperative care in non-cardiac surgery. However, TSAs showed that the required information sizes have not yet been reached. CONCLUSION: Application of RIPC to non-cardiac surgery might reduce cardiovascular events, but not acute kidney injury or all-cause mortality, but currently available data are inadequate to confirm or reject an assumed intervention effect.

Optimal Timing for Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review.

BACKGROUND AND AIMS: Endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy is often used as definitive treatment for common bile duct stones. The aim of this study was to investigate the optimal time interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. MATERIALS AND METHODS: PubMed and Embase were searched for studies comparing different time delays between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Observational studies and randomized controlled trials were included. Primary outcome was conversion rate from laparoscopic to open cholecystectomy and secondary outcomes were complications, mortality, operating time, and length of stay. RESULTS: A total of 14 studies with a total of 1930 patients were included. The pooled estimate revealed an increase from a 4.2% conversion rate when laparoscopic cholecystectomy was performed within 24 h of endoscopic retrograde cholangiopancreatography to 7.6% for 24-72 h delay to 12.3% when performed within 2 weeks, to 12.3% for 2-6 weeks, and to a 14% conversion rate when operation was delayed more than 6 weeks. CONCLUSION: According to this systematic review, it is preferable to perform cholecystectomy within 24 h of endoscopic retrograde cholangiopancreatography to reduce conversion rate. Early laparoscopic cholecystectomy does not increase mortality, perioperative complications, or length of stay and on the contrary it reduces the risk of reoccurrence and progression of disease in the delay between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

No difference in sexual dysfunction after transabdominal preperitoneal (TAPP) approach for inguinal hernia with fibrin sealant or tacks for mesh fixation.

BACKGROUND: Postoperative sexual dysfunction in relation to laparoscopic groin hernia surgery may be related to methods of mesh fixation. However, this has not been investigated earlier. Moreover, results regarding sexual dysfunction in females have not been reported systematically. The aim of this study was to compare fibrin sealant versus tacks for fixation of mesh regarding sexual dysfunction in males and females. METHODS: Using the Danish Hernia Database, patients operated laparoscopically for groin hernia with a transabdominal preperitoneal (TAPP) procedure with fibrin sealant or tacks for mesh fixation were sent a questionnaire regarding sexual dysfunction. Sexually active patients without recurrence were evaluated in this study. RESULTS: Pain during sexual activity was present in 115 of 1019 (11.3 %) males and 17 of 147 (11.6 %) females. There was no difference between fibrin sealant and tacks for mesh fixation and no difference between genders. Pain intensity, characteristics and origin were comparable between fibrin sealant and tacks for both genders. We found a relationship between a higher rate of sexual dysfunction and lower age for both genders. CONCLUSION: We found no difference between fibrin sealant and tacks in pain during sexual activity or intensity of pain. However, younger age may be a risk factor for pain during sexual activity. Considering the high rate of postoperative sexual dysfunction, it is important to include this topic in the preoperative patient information.

Familial clustering and risk of groin hernia in children.

BACKGROUND: The hypothesis was that groin hernias are hereditary. This study was undertaken to establish the degree of familial clustering of groin hernias on a nationwide scale. METHODS: A register-based cohort was created consisting of all children in Denmark whose parents were born in 1970 or later by the use of the Danish Civil Registration System. Within this cohort, all groin hernia operations were identified. To establish the risk estimates associated with a positive family history of groin hernia operation, information on groin hernia operations in fathers, mothers and siblings was also assessed. RESULTS: In the cohort of 408 381 persons, a total of 4966 were operated on for groin hernia (incidence rate 2·12 per 1000 person-years at risk). A person with a mother who had undergone surgery for a groin hernia had an increased risk of 2·89 (95 per cent c.i. 2·48 to 3·34) of having a groin hernia operation; a person with a father operated on for a groin hernia had an increased risk of 1·75 (1·58 to 1·94); and a person with a sibling operated on for a groin hernia had an increased risk of 2·54 (2·17 to 2·96). The strongest association was seen between mothers who had been operated on for groin hernia and their daughters (increased risk 6·01, 95 per cent c.i. 4·53 to 7·80), compared with the risk in girls who did not have a mother who had undergone surgery for groin hernia. CONCLUSION: Groin hernias are clustered in families, with the strongest relationship seen between mothers and their daughters.

Advanced age is a risk factor for proximal adenoma recurrence following colonoscopy and polypectomy.

BACKGROUND: Knowledge of risk factors for recurrence of colorectal adenomas may identify patients who could benefit from individual surveillance strategies. The aim of this study was to identify risk factors for recurrence of colorectal adenomas in a high-risk population. METHODS: Data were used from a randomized clinical trial that showed no effect of aspirin-calcitriol-calcium treatment on colorectal adenoma recurrence. Patients at high risk of colorectal cancer who had one or more sporadic colorectal adenomas removed during colonoscopy were followed up for 3 years. Independent risk factors associated with recurrence and characteristics of recurrent adenomas were investigated in a generalized linear model. RESULTS: After 3 years, the recurrence rate was 25·8 per cent in 427 patients. For younger subjects (aged 50 years or less), the recurrence rate was 19 per cent; 18 of 20 recurrent adenomas were located in the distal part of the colon. For older subjects (aged over 70 years), the recurrence rate was 35 per cent, and 16 of 25 recurrent adenomas were in the proximal colon. Age (odds ratio (OR) 1·04, 95 per cent c.i. 1·01 to 1·07) and number of adenomas (OR 1·27, 1·11 to 1·46) at the time of inclusion in the study were independent risk factors for recurrence. CONCLUSION: In contrast to current guidelines, advanced age is not a reason to discontinue adenoma surveillance in patients with an anticipated live expectancy in which recurrence can arise.

Short-term outcome after Onstep versus Lichtenstein technique for inguinal hernia repair: results from a randomized clinical trial.

PURPOSE: Because of the high number of patients with chronic pain following inguinal hernia repair, a new, simple and safe method of repair is needed. Onstep is a new type of inguinal hernia repair that might be able to reduce postoperative acute and chronic pain. The aim of this study was to investigate if there were differences in early postoperative pain during the first 10 days between the Onstep and the Lichtenstein technique. METHODS: This was a double-blinded, randomized clinical trial conducted in five surgical departments in Denmark, from April 2013 to June 2014. Eligible participants for this study were male patients, >18 years, with a primary inguinal hernia. Experimental treatment in this study was the Onstep technique, which was compared with the Lichtenstein repair. Primary outcome was postoperative pain during the first 10 days following surgery. Secondary outcomes included duration of surgery, period for return to normal daily activities (days), and recurrence. Randomization was done in blocks and stratified on centers. Participants and study personnel handling questionnaires and analysis were blinded to the allocation. RESULTS: In total, 290 participants were randomized. We found no significant differences between the groups regarding early postoperative pain or minor postoperative complications. Four patients had a recurrence within the first 10 days of follow-up, one patient in the Lichtenstein group and three patients in the Onstep group, p = 0.30. CONCLUSION: The Onstep technique for inguinal hernia repair was safe and had comparable results to the Lichtenstein repair regarding short-term pain and postoperative complications. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01753219).

The prevalence of umbilical and epigastric hernia repair: a nationwide epidemiologic study.

PURPOSE: Umbilical and epigastric hernia repair are common surgical procedures; however, the nationwide gender and age-specific prevalence of these repairs is unknown, and this knowledge could form the basis for new studies. METHODS: A nationwide register-based study covering all people living in Denmark on December 31st, 2010 was performed. Within this population all umbilical and epigastric hernia repairs from January 1st, 2006 to December 31st, 2010 were identified using data from the Danish National Hospital Register, and 5-year prevalence estimates were calculated. RESULTS: The study population covered 5,639,885 persons (49 % males). A total of 10,107 patients (68 % males) were operated for an umbilical hernia and 2412 patients (55 % males) were operated for an epigastric hernia. The age-specific 5-year prevalence differed for both hernia types. The highest 5-year prevalence of umbilical hernia repairs was seen in males aged 60-70 years with a 5-year prevalence of 0.53 % (95 % CI 0.51-0.56 %) and the highest age-specific 5-year prevalence of epigastric hernia repair was seen in 40-50 year females with a 5-year prevalence of 0.086 % (95 % CI 0.077-0.095 %). CONCLUSION: The gender and age-specific 5-year prevalence of umbilical and epigastric hernia repair differed in a nationwide population.

The diagnostic value of a panel of serological markers in acute appendicitis.

BACKGROUND: Appendicitis is a frequent reason for hospital admissions. Elevated C-reactive protein, white blood cell count, and serum bilirubin have been suggested as individual markers for appendicitis and appendiceal perforation. The aim of this study was to analyze if a combination of serologic markers could increase the prognostic accuracy of diagnosing non-perforated and perforated appendicitis. MATERIAL AND METHODS: Demographic data, histological findings, blood tests, and clinical symptoms were collected on all patients who underwent a diagnostic laparoscopy, a laparoscopic appendectomy, or conventional (open) appendectomy between May 2009 and May 2012 from a surgical department. The patients were grouped into those with either perforated appendicitis, non-perforated appendicitis, or differential diagnosis. Univariate and multivariate models were used to identify which markers were useful in predicting acute and perforated appendicitis, and receiving operating characteristics curves were used to find the specificity, sensitivity, and the negative and positive predictive values. RESULTS: A total of 1008 patients were operated under suspicion of appendicitis. From these, 700 patients had a pathologically verified inflamed appendix and 190 had a perforated appendix. Patients with acute appendicitis had significantly higher blood levels of white blood cell, bilirubin, C-reactive protein, and alanine transaminase than patients without appendicitis. Patients with perforated appendicitis had significantly higher levels of white blood cell, bilirubin, and C-reactive protein than patients with non-perforated appendicitis. The highest positive predictive value to discriminate between acute appendicitis and non-appendicitis was of a linear regression model combining white blood cell count, bilirubin, and alanine transaminase. C-reactive protein levels and a linear regression model, including white blood cell count, bilirubin, and C-reactive protein levels as variables, had the highest negative predictive values when discriminating between perforated and non-perforated appendicitis. CONCLUSION: Combining blood markers was useful in predicting appendicitis and perforated appendicitis. In addition to C-reactive protein and white cell count, blood levels of bilirubin, and alanine transaminase may be useful.

The initial experience of introducing the Onstep technique for inguinal hernia repair in a general surgical department.

BACKGROUND AND AIMS: A new technique for the repair of inguinal hernia, called Onstep, has been described. This technique places the mesh in the preperitoneal space medially and between the internal and external oblique muscles laterally. The Onstep technique has not yet been described outside the inventors' departments. This study was based on the first 80 patients operated by the Onstep technique in a general surgical department. The objective of the study was to investigate postoperative pain and complications following the Onstep repair of inguinal hernia. MATERIAL AND METHODS: A total of 80 patients, operated in our department, were followed up in the medical files and contacted by letter. Patients were asked to fill out the Inguinal Pain Questionnaire, Carolinas Comfort Scale, and the Activity Assessment Scale, in order to assess postoperative pain. RESULTS: No perioperative complications occurred. The response rate was 85% on the mailed questionnaires. No patients had any activities they were not able to perform. Activity Assessment Scale results: 80.3% did not have substantial pain-related impairment of daily function. Carolinas Comfort Scale results: 94.8% did not have a symptomatic repair. Inguinal Pain Questionnaire results: 95.5% reported no pain or pain that was easily ignored. CONCLUSIONS: It seems from this study that the Onstep technique is a safe method for inguinal hernia repair regarding perioperative and postoperative complications. The postoperative pain seems to be equal to or lower than after the Lichtenstein technique.

Preoperative risk factors for anastomotic leakage after resection for colorectal cancer: a systematic review and meta-analysis.

AIM: Colorectal anastomotic leakage is a serious complication. Despite extensive research, no consensus on the most important preoperative risk factors exists. The aim of this systematic review and meta-analysis was to evaluate risk factors for anastomotic leakage in patients operated with colorectal resection. METHOD: The databases MEDLINE, Embase and CINAHL were searched for prospective observational studies on preoperative risk factors for anastomotic leakage. Meta-analyses were performed on outcomes based on odds ratios (OR) from multivariate regression analyses. The Newcastle-Ottawa scale was used for bias assessment within studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels. RESULTS: This review included 23 studies evaluating 110,272 patients undergoing colorectal resection for cancer. The meta-analyses found that a low rectal anastomosis [OR = 3.26 (95% CI: 2.31-4.62)], male gender [OR = 1.48 (95% CI: 1.37-1.60)] and preoperative radiotherapy [OR = 1.65 (95% CI: 1.06-2.56)] may be risk factors for anastomotic leakage. Primarily as a result of observational design, the quality of evidence was regarded as moderate or low for these risk factors according to the GRADE approach. CONCLUSION: Based on the best available evidence, important preoperative risk factors for colorectal anastomotic leakage have been identified. Knowledge on risk factors may influence treatment and procedure-related decisions, and possibly reduce the leakage rate.

No consensus on restrictions on physical activity to prevent incisional hernias after surgery.

PURPOSE: In the postoperative phase after colorectal surgery, restrictions on physical activity are often recommended for patients to prevent incisional hernias. However, evidence does not support that restrictions may prevent such hernias. The purpose of this study was to evaluate the extent of restrictions on physical activity recommended for patients operated for colorectal cancer and to evaluate the agreement among surgical specialists. METHODS: A questionnaire was sent to 60 general surgeons (specialists) in Denmark and Sweden working in academic departments of surgery with a high volume of colorectal cancer resections. The questionnaire was case based and contained questions regarding possible restrictions on physical activity recommended for patients 0-2, 2-6 and >6 weeks after resection for colorectal cancer. Agreement among the surgeon on whether restrictions should be recommended was analyzed. RESULTS: Forty-one surgeons answered the questionnaire (68.3 %). The probability that two randomly chosen specialists agreed on whether restrictions should be given was generally low for the first two time periods (0-2 and 2-6 weeks); however, at >6 weeks there was a high level of agreement. Moreover, the number of restrictions recommended was different between the 41 surgeons (p < 0.0005) and more restrictions were recommended for open compared with laparoscopic surgery (p < 0.0005). CONCLUSIONS: Major disagreements exist on the degree of restrictions on physical activity that should be recommended for patients after colorectal surgery. As there is no evidence to support that specific restrictions prevent hernia formation, these are merely based on personal preferences. Clinical studies in this area are therefore highly warranted.

Oral chemoprevention with acetyl salicylic Acid, vitamin D and calcium reduces the risk of tobacco carcinogen-induced bladder tumors in mice.

Bladder cancer is a common urological malignancy with high recurrence rate, which may be reduced by chemoprevention. The aim was to evaluate chemoprevention in a mouse model of tobacco carcinogen-induced bladder tumors. A total of 60 A/J mice were randomized to normal diet, diet with low calcium, and diet with chemoprevention (acetyl salicylic acid, 1-alpha 25(OH)2-vitamin D3 and calcium). There were significantly fewer tumors (0 (0-0) vs. 0 (0-2), p = .045) and fewer animals with tumors (0/20 vs. 5/20, p = .045) in the chemoprevention group compared with controls. Thus, chemoprevention diet effectively reduced the tumor promoting effect of tobacco carcinogens in the mouse bladder.

An experimental animal model for abdominal fascia healing after surgery.

BACKGROUND: Incisional hernia (IH) is a well-known complication after abdominal surgical procedures. The exact etiology of IH is still unknown even though many risk factors have been suggested. The aim of this study was to create an animal model of a weakly healed abdominal fascia that could be used to evaluate the actively healing fascia. Such an animal model may promote future research in the prevention of IH. METHODS: 86 male Sprague-Dawley rats were used to establish a model involving six experiments (experiments A-F). Mechanical testing of the breaking strength of the healed fascia was performed by testing tissue strips from the healed fascia versus the unincised control fascia 7 and 28 days postoperatively. RESULTS: During the six experiments a healing model was created that produced significantly weaker coherent fascia when compared with the control tissue measured in terms of mechanical breaking strength. This new animal model employed myofascial closing after a full thickness abdominal incision using a running suture with fast-absorbable suture material. This technique produced a weak myofascial layer compared with the control tissue measured in terms of breaking strength after both 7 and 28 days. CONCLUSION: It was possible to create a healed but weak abdominal fascia in rats with a minimum of defects after incision using a running suture technique in the fascia. In contrast to other models, regular tissue defects were absent, and the model can therefore be used to evaluate the changes, both histological and mechanical, in the actively healing fascia, which may lead to incisional herniation. Furthermore, the model may also be used to study interventions performed to promote healing. This contrasts with existing models with regular fascia defects, which are not well suited for this purpose.

Hyperbilirubinemia as a predictor for appendiceal perforation: a systematic review.

BACKGROUND AND AIMS: Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin may be a useful marker for appendiceal perforation. The purpose of this systematic review was to evaluate studies investigating elevated serum bilirubin as a predictor for appendiceal perforation. MATERIAL AND METHODS: Medline, Embase, and Cochrane databases were searched for studies evaluating elevated bilirubin in the diagnosis of perforated appendicitis. Study selection criteria included English language papers evaluating serum bilirubin as a marker of appendiceal perforation in humans. A total of 189 abstracts were screened for eligibility, of which five clinical studies were included in this study. RESULTS: Bilirubin was significantly higher in patients with appendiceal perforation compared with patients with appendicitis without perforation. Elevated serum bilirubin had a sensitivity ranging from 0.38 to 0.77 and a specificity ranging from 0.70 to 0.87 in predicting appendiceal perforation. CONCLUSIONS: Elevated serum bilirubin for determining the risk of perforation in appendicitis has low sensitivity but higher specificity. This measure can therefore be used as a supplement in the diagnostic process.