Surgeon-Performed Ultrasound in Diagnosing Acute Cholecystitis and Appendicitis.

BACKGROUND: The use of ultrasound (US) outside the radiology department has increased the last decades, but large studies assessing the quality of bedside US are still lacking. This study evaluates surgeon-performed US (SPUS) and radiologist-performed US (RPUS) with respect to biliary disease and appendicitis. METHODS: Between October 2011 and November 2012, 300 adult patients, with a referral for an abdominal US, were prospectively enrolled in the study and examined by a radiologist as well as a surgeon. The surgeons had undergone a 4-week-long US education. US findings of the surgeon and of the radiologist were compared to final diagnosis, set by an independent external observer going through each patient's chart. RESULTS: Among 183 patients with suspected biliary disease, 74 had gallstones and 21 had acute cholecystitis. SPUS and RPUS diagnosed gallstones with a sensitivity of 87.1 versus 97.3%. Specificity was 96.0 versus 98.9%, and the accuracy 92.3 versus 98.2%. The sensitivity, specificity and accuracy for acute cholecystitis by SPUS and RPUS were: 60.0 versus 80.0%, 98.6 versus 97.8% and 93.9 versus 95.6%, respectively. Among 58 patients with suspected appendicitis, 15 had the disease. The sensitivity, specificity and accuracy for appendicitis by SPUS and RPUS were: 53.3 versus 73.3%, 89.7 versus 93.3% and 77.3 versus 86.7%, respectively. CONCLUSION: SPUS is reliable in diagnosing gallstones. Diagnosing cholecystitis and appendicitis with US is more challenging for both surgeons and radiologists. TRIAL REGISTRATION NUMBER: The study was registered at clinicaltrials.gov. Registration number: NCT02469935.

Accuracy of Surgeon-Performed Ultrasound in Detecting Gallstones: A Validation Study.

BACKGROUND: Symptomatic gallstone disease is a common diagnosis in patients with abdominal pain. Ultrasound is considered the gold standard method to identify gallstones. Today the examination may be performed bedside by the treating clinician. Bedside ultrasound could provide a safe and time-saving diagnostic resource for surgeons evaluating patients with suspected symptomatic gallstones; however, large validation studies of the accuracy and reliability are lacking. The aim of this study was to prospectively investigate the accuracy of surgeon-performed ultrasound for the detection of gallstones. METHODS: Between October 2011 and November 2012, 179 adult patients, with an acute or elective referral for an abdominal ultrasound examination, were examined with a right upper quadrant ultrasound scan by a radiologist as well as a surgeon. The surgeons had undergone a four-week-long ultrasound education before participating in the study. Ultrasound findings of the surgeon were compared to those of the radiologist, using radiologist-performed ultrasound as reference standard. RESULTS: Surgeon-performed ultrasound agreed with radiologist findings in 169 of 179 patients regarding the detection of gallstones, providing an accuracy of 94 %. The sensitivity was 88 % (67/76), specificity 99 % (102/103), positive predictive value 99 % (67/68), and negative predictive value 92 % (102/111). Agreement between the diagnosis set by the radiologists and the surgeons was high: Cohen's Kappa coefficient = 0.88. CONCLUSIONS: Ultrasound-trained surgeons may accurately diagnose gallstones using ultrasound and reach a high level of agreement with radiologists.

Patient factors influencing the effect of surgeon-performed ultrasound on the acute abdomen.

PURPOSE: To evaluate the effect of surgeon-performed ultrasound on acute abdomen in specific patient subgroups regarding the diagnostic accuracy and further management. METHODS: Eight hundred patients attending the emergency department at Stockholm South General Hospital, Sweden, for abdominal pain, were randomized to either receive or not receive surgeon-performed ultrasound as a complement to routine management. Patients were divided into subgroups based on patient characteristics, symptoms or first preliminary diagnosis set at the emergency department before randomization. Outcomes measured were diagnostic accuracy, admission rate and requests for further examinations. Timing of surgery was evaluated for patients with peritonitis. RESULTS: Increased diagnostic accuracy was seen in patients with body mass index > 25, elevated C-reactive protein, peritonitis, age 30-59 years and/or upper abdominal pain. Decreased need for further examinations and/or fewer admissions were seen in all groups except in patients with a preliminary diagnosis of appendicitis. Among patients with non-specific abdominal pain, admission frequency was decreased with 14% when ultrasound was used (P = 0.007). Among patients with peritonitis, requiring surgery, 61% in the ultrasound group were admitted for surgery directly from the emergency department compared to 19% in the control group. CONCLUSION: In different ways, surgeon-performed ultrasound is helpful for the majority of patients admitted to the emergency department for abdominal pain. Taking into account other shown benefits and the lack of adverse effects, we find the method worth consideration for routine implementation.

Randomized clinical trial of bedside ultrasound among patients with abdominal pain in the emergency department: impact on patient satisfaction and health care consumption.

BACKGROUND: Previous research shows that surgeon-performed ultrasound for patients presenting with abdominal pain in the emergency department leads both to higher diagnostic accuracy and to other benefits. We have evaluated the level of patient satisfaction, health condition and further health care consumption after discharge from the emergency department. METHODS: A total of 800 patients who attended the emergency department for abdominal pain were randomized to surgeon-performed ultrasound or not as a complement to standard examination. All patients were interviewed by telephone six weeks after the visit to the emergency department using a structured questionnaire including information about health condition, satisfaction and medical examinations. A regional health register was used to check health care consumption over two years and mortality was checked for in the personal data register. RESULTS: We found a higher self-rated patient satisfaction in the ultrasound group when leaving the emergency department. After six weeks the figures were equal. There were fewer patients in the ultrasound group with completed or planned complementary examinations after six weeks (31.1%) compared with the control group (41.4%), p=0.004. There was no difference found in the two-year health care consumption or mortality between the groups. CONCLUSION: For patients with acute abdominal pain, bedside ultrasound examination is related to higher satisfaction and decreased short-term health care consumption. No major effects were revealed when evaluating effects on a long-term basis, including mortality. The previously proven benefit together with the lack of adverse effects from the method makes ultrasound well worth considering for implementation in emergency departments. TRIAL REGISTRATION: The study has been registered in ClinicalTrials.gov ID NCT00550511.

Is preoperative vaginal cleansing necessary for control of infection after first trimester vacuum curettage?

BACKGROUND: Traditionally, the vagina is cleansed, before a curettage is performed. A previous study, comparing cleansing with chlorhexidine solution and cleansing with saline solution before vacuum aspiration in the first trimester, did not show any difference in the frequency of postoperative pelvic inflammatory disease. We wanted to investigate whether this was true also for vaginal cleansing with chlorhexidine, compared to no vaginal cleansing at all. METHODS: Consecutive women having surgical first trimester legal abortions were randomized to vulvar and vaginal cleansing with chlorhexidine or vulvar cleansing only. The frequency of postabortion pelvic inflammatory disease was evaluated with patient questionnaires and study of medical records. RESULTS: Of the 486 patients included in the study, vaginal cleansing was performed on 246 and no vaginal cleansing on 240. The frequency of probable pelvic inflammatory disease was 2.4% with cleansing and 2.1% without cleansing (no significant difference). CONCLUSIONS: Under certain conditions, preoperative vaginal cleansing can be safely omitted.

A retrospective comparison between lamicel and gemeprost for cervical ripening before surgical interruption of first-trimester pregnancy.

To study the effect and complication rate of lamicel versus gemeprost as pretreatment to vacuum aspiration for the interruption of early pregnancy, the files of 622 medical records of women having a first-trimester abortion at Söder Hospital were studied retrospectively. Group A consisted of 317 women treated with lamicel in 1995 and Group B of 305 women treated with gemeprost in 1996. Complications were more common in Group A than in Group B (55 vs. 22; p < 0.05). Re-admission took place more often in Group A (25) than in Group B (6) (p < 0.05). The complications were more severe in Group A than in Group B. Using multivariate logistic regression analysis, the only impact factor for having a complication was the use of product for cervical priming. Gemeprost for preoperative treatment was found to render a fairly low rate of complications in this study, while complication rate was higher after treatment with lamicel.