Immediate effects of urgent reorganisation of emergency department-based treatment pathway in nonperforated appendicitis: a retrospective study.

BACKGROUND: Acute appendicitis is a global disease and a very common indication for emergency surgery worldwide. The need for hospital resources is therefore constantly high. The administration in Kanta-Häme Central Hospital, Southern Finland, called for an urgent reorganisation due to shortage of hospital beds at the department of general surgery. Postoperative treatment pathway of patients with nonperforated acute appendicitis was ordered to take place in the Emergency Department (ED). The aim of this study was to assess, whether this reorganisation was feasible and safe, i.e. did it affect the length of in-hospital stay (LOS) and the 30-day complication rate. METHODS: This is a retrospective pre- and post-intervention analysis. After the reorganisation, most patients with nonperforated appendicitis were followed postoperatively at the 24-h observation unit of the ED instead of surgical ward. Patients operated during the first 3 months after the reorganisation were compared to those operated during the 3 months before it. A case met inclusion criteria if there were no signs of appendiceal perforation during surgery. Exclusion criteria comprised age < 18 years and perforated disease. RESULTS: Appendicectomy was performed on 112 patients, of whom 62 were adults with nonperforated appendicitis. Twenty-seven of the included patients were treated before the reorganisation, and 35 after it. Twenty of the latter were followed only at the ED. Postoperative LOS decreased significantly after the reorganisation. Median postoperative time till discharge was 15.7 h for all patients after the reorganisation compared to 24.4 h before the reorganisation (standard error 6.2 h, 95% confidence interval 2.3-15.2 h, p < 0.01). There were no more complications in the group treated postoperatively in the ED. CONCLUSIONS: Early discharge of patients with nonperforated appendicitis after enforced urgent reorganisation of the treatment pathway in the ED observation unit is safe and feasible. Shifting the postoperative monitoring and the discharge policy of such patients to the ED - instead of the surgical ward - occurred in the majority of the cases after the reorganisation. This change may spare resources as in our series it resulted in a significantly shorter LOS without any increase in the 30-day complication rate.

Brief Pain Inventory (BPI) Health Survey After Midline Laparotomy With the Rectus Sheath Block (RSB) Analgesia: A Randomised Trial of Patients With Cancer and Benign Disease.

BACKGROUND/AIM: Our original hypothesis was that the rectus sheath block (RSB) analgesia could enhance patient satisfaction and decrease pain following midline laparotomy. PATIENTS AND METHODS: Initially, 56 patients were randomized into four groups; control group (n=12), single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) RSB analgesia groups. The BPI (Brief Pain Inventory) survey was conducted preoperatively and at one and four weeks and 12 months postoperatively. The patients pain 24 h postoperatively and satisfaction 48 h postoperatively was filled on an 11-point numeric rating scale (NRS). RESULTS: The repeated-dose group had lower BPI severity score (p=0.045) and BPI interference score (p=0.043) mean values postoperatively compared to the three other groups separately. Also, the time effect on the linear mixed model in BPI interference score mean values was statistically significant (p=0.008), which means that in the repeated dose group preoperative BPI severity score [2.7 (3.9)] and interference score [4.3 (4.2)] mean (SD) values were significantly higher than the BPI severity score [1.3 (0.8)] and interference score [1.5 (1.8)] mean (SD) values following surgery. CONCLUSION: The higher elevation in BPI severity score and decrease in interference score values in the repeated dose group and also the time effect in a linear mixed model in BPI interference score were statistically significant.

Rectus Sheath Block (RSB) Analgesia Could Enhance Significantly the Patient Satisfaction Following Midline Laparotomy in Benign Disease and in Cancer: A Prospective Study With Special Reference to Nitrosative Stress Marker Nitrotyrosine (NT) Plasma Concentrations.

BACKGROUND/AIM: Our hypothesis was that rectus sheath block (RSB) analgesia could enhance satisfaction following midline laparotomy in patients with benign disease and cancer patients. PATIENTS AND METHODS: Initially, 56 patients were randomized into four groups; control group (n=12), single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) RSB analgesia groups. The plasma concentrations of the NT marker were measured just before, immediately after and 24 h after operation. Patient satisfaction at 24 h postoperatively was filed on a 11-point numeric rating scale (SFS24; 0=fully unsatisfied; 10=fully satisfied). RESULTS: The RSB analgesia significantly enhanced the SFS24 scores in the study groups (p=0.001). The median plasma NT concentrations (pg/ml) following surgery (POP1) were significantly lower in patients with cancer versus patients with benign disease (5.3 vs. 7.6, p=0.008). Jitter plots of the individual SFS24 values versus plasma NT concentrations were significantly correlated in benign and cancer patients (r=-0.284, p=0.028). CONCLUSION: The RSB analgesia could significantly enhance patient satisfaction following midline laparotomy. Plasma NT concentrations versus patient satisfaction following surgery are significantly correlated in benign disease and cancer.

Plasma Catalase in Relation to Pain Following Midline Laparotomy: A Prospective Study of Patients with Benign Diseases and Patients with Cancer.

BACKGROUND/AIM: The relationship of plasma concentrations of the oxidative stress biomarker catalase with pain on numeric rating scale at rest (NRSr) and under wound pressure 24 hours postoperatively (NRSp) in midline laparotomy patients with rectus sheath block (RSB) analgesia are unknown. Our original hypothesis was that RSB analgesia might reduce postoperative pain. PATIENTS AND METHODS: Initially, 56 patients were randomized to four groups: control group (n=12), single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) RSB analgesia groups. The plasma concentrations of catalase were measured immediately before, immediately after and 24 hours after surgery. The pain at rest and under pressure were scored on an 11-point numeric rating scale 24 hours postoperatively (NRSr and NRSp; 0: no pain; 10: worst pain). RESULTS: The median plasma concentration of catalase increased immediately after surgery (p=0.007), but then decreased 24 hours postoperatively compared with immediately after surgery (p<0.001). The control group and the RSB groups did not differ in individual NRSr and NRSp values following surgery. Scatter plots of the plasma catalase versus superoxide dismutase concentrations were positively correlated in the patients (r=0.314, p<0.001). In addition, scatter plots of the individual NRSr and NRSp values versus plasma values of catalase were inversely correlated in patients (r=-0.221, p=0.03 and r=-0.238, p=0.02, respectively). CONCLUSION: The RSB analgesia does not reduce postoperative pain. Plasma catalase levels and pain following surgery are significantly correlated in patients regardless of disease type.

A prospective, randomized, open label, controlled study investigating the efficiency and safety of 3 different methods of rectus sheath block analgesia following midline laparotomy.

BACKGROUND: There is a controversy regarding the efficacy of rectus sheath block (RSB). The aim of the present study was to evaluate analgesic efficacy and safety of three different methods of RSB in postoperative pain management after midline laparotomy. METHODS: A prospective, randomized, controlled, open-label clinical trial with 4 parallel groups was conducted in a tertiary care hospital in Finland. A total of 57 patients undergoing midline laparotomy were randomized to the control group (n = 12) or to 1 of the 3 active RSB analgesia groups: single-dose (n = 16), repeated-doses (n = 12), or continuous infusion (n = 17). Opioid consumption with iv-patient-controlled analgesia pump was recorded, and pain scores and patients' satisfaction were surveyed on an 11-point numeric rating scale for the first 48 postoperative h. Plasma concentrations of oxycodone and levobupivacaine were analyzed. All adverse events during the hospital stay were recorded. RESULTS: Oxycodone consumption was less during the first 12 h in the repeated-doses and in the continuous infusion groups (P = .07) and in numerical values up to 48 h in the repeated-doses group. Plasma oxycodone concentrations were similar in all 4 groups. Pain scores were lower in the repeated-doses group when coughing during the first 4 h (P = .048 vs. control group), and at rest on the first postoperative morning (P = .034 vs. the other 3 groups) and at 24 h (P = .006 vs. the single-dose group). All plasma concentrations of levobupivacaine were safe. The patients' satisfaction was better in the repeated-doses group compared with the control group (P = .025). No serious or unexpected adverse events were reported. CONCLUSIONS: RSB analgesia with repeated-doses seems to have opioid sparing efficacy, and it may enhance pain relief and patients' satisfaction after midline laparotomy.

Patients with Increased Levels of the Oxidative Stress Biomarker SOD1 Appear to Have Diminished Postoperative Pain After Midline Laparotomy: A Randomised Trial with Special Reference to Postoperative Pain Score (NRS).

BACKGROUND/AIM: The levels of the oxidative stress biomarker superoxide dismutase (SOD1) in plasma in relation to pain at rest 24 hours after (NRS24) midline laparotomy in patients with rectus sheath block (RSB) analgesia is unknown. PATIENTS AND METHODS: Initially, 56 patients (39 with cancer), each with an intravenous oxycodone pump as patient-controlled analgesia, were randomized to four groups: control group, no RSB (n=12), single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) of RSB analgesia. The plasma levels of SOD1 were measured directly before, immediately after and 24 hours after surgery. Pain at rest was scored on an 11-point numeric rating scale 24 hours postoperatively (NRS24: 0=no pain to 10=worst pain). RESULTS: The median plasma level of SOD1 increased immediately after operation and this was statistically highly significant (p=0.007). The median plasma level of SOD1 then decreased 24 hours postoperatively and this postoperative decrease was also statistically highly significant (p<0.001). The median plasma levels of SOD1 did not differ significantly between patients with benign disease and those with cancer, preoperatively and after surgery. There was highly significant positive correlation between SOD1 and glutathione peroxidase (GPX1) values postoperatively (r=0.67, p<0.001) and a trend for an inverse correlation between the individual values of the NRS24 and plasma SOD1 values postoperatively in patients with benign disease and those with cancer (r=-0.30, p=0.09). CONCLUSION: Midline laparotomy significantly alters the level of oxidative stress marker SOD1 immediately after surgery, but the level normalizes 24 hours following surgery. Interestingly, patients with increased levels of SOD1 appeared to have diminished postoperative pain after midline laparotomy.

Does Rectus Sheath Block Analgesia Alter Levels of the Oxidative Stress Biomarker Glutathione Peroxidase: A Randomised Trial of Patients with Cancer and Benign Disease.

AIM: To evaluate whether the overall satisfaction, as measured by numeric rating scale (NRS), regarding rectus sheath block (RSB) analgesia is associated with the plasma glutathione peroxidase (GPX1) level. The second end-point of the study was to evaluate the differences in GPX1 levels in patients with and without RSB analgesia, with special emphasis on benign or malign disease status. PATIENTS AND METHODS: Initially, 56 patients were randomized to the placebo group (n=12) and to one of three active RSB analgesia groups: single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) groups. The plasma level of GPX1 was measured at three time points: just before, immediately after and 24 h after surgery. The overall satisfaction and an opinion on the success of the analgesic procedure were surveyed using an 11-point numeric rating scale 24 h postoperatively (NRS from 0, completely dissatisfied, to 10, fully satisfied). RESULTS: The placebo group and the three active groups were similar in terms of their perioperative data. The plasma level of GPX1 decreased postoperatively in all four groups. No differences were detected in the GPX1 values between the placebo and the three active groups combined preoperatively and immediately after operation. However, the patients in the single-dose group had a significantly lower median GPX1 values 24 h after surgery compared to the three other groups separately (p=0.032). The median (interquartile range) plasma level of GPX1 differed significantly between patients with benign disease and those with cancer preoperatively (18.0, 12.5-22.0 versus 10.0, 6.3-18.8 pg/ml, p=0.006) and cancer diagnosis was correlated with lower individual plasma GPX1 values (r=-0.42, p=0.004). CONCLUSION: The placement of RSB analgesia does not significantly affect the level of oxidative stress biomarker GPX1 in patients with benign disease or cancer. A new finding with possible clinical relevance is that patients with cancer appeared to have a trend for lower plasma GPX1 values.

Does the Rectus Sheath Block Analgesia Reduce the Inflammatory Response Biomarkers' IL-1ra, IL-6, IL-8, IL-10 and IL-1ß Concentrations Following Surgery? A Randomized Clinical Trial of Patients with Cancer and Benign Disease.

AIM: To evaluate whether the post-surgery placement of the rectus sheath block analgesia (RSB) reduces the inflammatory response following surgery. The main hypothesis of our study was to find any correlation between patients' pain experience, numeric rating scale (NRS) postoperatively and concentrations of inflammatory response biomarkers, such as interleukin-1 receptor antagonist (IL-1ra), IL-6, IL-8, IL-10, IL-1ß, in patients with benign disease and cancer. PATIENTS AND METHODS: Initially, 46 patients with midline laparotomy were randomized to the placebo group (n=11) and to one of the three active groups; single-dose (n=12), repeated-dose (n=12) and continuous infusion (n=11) RSB analgesia groups. Plasma concentrations of high-sensitivity C-reactive protein (hs-CRP) and five interleukins (IL-1ra, IL-6, IL-8, IL-10, IL-1ß) were measured at three time points; just before, immediately after and 24 h after operation. The primary end-point was to compare plasma concentrations of the hs-CRP and five interleukins in the placebo group and in the three different RSB analgesia groups in patients with benign disease and cancer. RESULTS: The placebo group and three active groups were similar in terms of demographic variables and perioperative data. Of the anti-inflammatory cytokines, patients in the continuous infusion group had significantly higher IL-10 median values postoperatively than the three other study groups (p=0.029). In addition, patients in the three active groups combined had significantly higher IL-10 median values immediately after operation than the placebo group (p=0.028; in all patients with benign disease and cancer). There is a significant correlation between the individual values of NRS and IL-10 values postoperatively in the placebo group and the three active groups separately (r=0.40, p=0.03) and also a significant correlation between the individual values of the NRS scale and IL-1ß values postoperatively in the placebo group and the three active groups separately (r=0.38, p=0.04). CONCLUSION: Placement of RSB analgesia does not significantly reduce the inflammatory response biomarkers' concentrations in patients with benign disease or cancer patients. A new finding in the present work is a significant correlation in the NRS scale versus plasma concentrations of anti-inflammatory cytokine IL-10 and pro-inflammatory cytokine IL-1ß postoperatively suggesting that inflammation and pain are related.

Does Post-Surgery Placement of Rectus Sheath Block Analgesia Alter the Oxidative Stress Biomarker 8-OHdG Concentrations: A Randomised Trial of Patients with Cancer and Benign Disease.

BACKGROUND: The aim of the study was to evaluate whether the post-surgery placement of the rectus sheath block (RSB) analgesia could alter the oxidative stress response. The main hypothesis of our study was to find some correlation between patients' pain experience, numeric rating scale (NRS) and the concentration of oxidative stress marker, 8-OHdG (8-hydroxy-2'-deoxyguanosine) in patients with benign disease and cancer. MATERIALS AND METHODS: Initially, 46 patients were randomized to the placebo group (n=11) and to one of the three active groups; single-dose (n=12), repeated-dose (n=12) and continuous infusion (n=11) RSB analgesia group. The plasma concentrations of the hs-C-reactive protein (CRP) and 8-OHdG were measured at three time points: just before, immediately after and 24 h after operation. The primary end-point was to compare plasma concentrations of the hs-CRP and 8-OHdG in the placebo group and in the three different RSB analgesia groups in patients with benign disease and cancer. RESULTS: The placebo group and three active groups were similar in terms of demographic variables and the perioperative data. The patients in the continuous infusion group had a trend for lower median 8-OHdG values post-operatively than the three other study groups (p=0.147; in all patients with benign disease and cancer). The patients in the cancer group showed a trend for higher median 8-OHdG values in the repeated-dose group than the patients in the benign group (p=0.241). There was a significant inverse correlation between the individual values of the plasma hs-CRP and 8-OHdG in patients with benign disease and cancer (r=-0.40, p=0.02). However, there was no significant correlation between the individual values of the NRS score and 8-OHdG post-surgery in patients with benign disease and cancer. CONCLUSION: The results suggest that the placement of RSB analgesia does not significantly alter the oxidative stress marker 8-OHdG concentrations in patients with benign disease or cancer patients. A new finding with possible clinical relevance is a significant inverse correlation between the individual plasma values of the hs-CRP and 8-OHdG in patients with benign disease and cancer.

Characteristics of patients with a retained wireless capsule endoscope (WCE) necessitating laparotomy for removal of the capsule.

AIM: A capsule endoscope is a wireless miniature camera used to take images of the small bowel mucosa. Retention of the wireless capsule endoscope (WCE), defined as at least two weeks' retention or an obstruction demanding removal by laparotomy, is the main and practically only complication of the procedure. The aim of this study was to evaluate the characteristics of patients with a retained WCE necessitating laparotomy for removal of the capsule or capsule fragments. PATIENTS AND METHODS: The medical records of 555 patients who had undergone the WCE procedure over a 7-year period (2002-2008) were reviewed. The indications for the WCE procedure were, obscure gastrointestinal bleeding, Crohn's disease, abdominal pain and suspicion of malignancy. RESULTS: A retained WCE requiring operative treatment was found in 10 cases (in nine patients, twice in one patient). The WCE retention frequency of 1.8% (10/555) equalled that in the literature. CONCLUSION: The retention rate of WCE capsules is low and routine examination of the small bowel with MRI or CT is not necessary before WCE. These examinations were enable to predict WCE retention according to our results.

Division of the hepatic branch of the anterior vagus nerve in fundoplication: effects on gallbladder function.

BACKGROUND: Cutting the hepatic branch of the anterior vagus nerve makes laparoscopic fundoplication technically easier; however, there is little data about the effect of cutting the nerve on gallbladder function. METHODS: One surgeon (MPä) preserved this nerve until March 2001 when he changed the technique. We investigated patients consecutively operated on before and after this date. A symptom questionnaire was returned by 59 patients, of whom 19 in both groups were successfully further investigated. The follow-up varied from 4 to 9 years postoperatively. The volume of the gallbladder was measured by ultrasonography before and after a fatty test meal. Alkaline phosphatase (ALP), alanine aminotransferase (ALAT), bilirubin, and amylase were determined from plasma. RESULTS: There was no difference in symptoms or use of antireflux medication between the groups. No difference was found in the levels of bilirubin, ALAT, or ALP. A mild elevation in plasma amylase was noted after nerve division (p = 0.041). The gallbladder ejection fraction did not differ between groups, but the fasting gallbladder volume was smaller when the nerve was cut (median 18.1 (range, 6-57.7) ml versus median 23.2 (range, 7.9-66.7) ml; p = 0.049). Both differences in plasma amylase and gallbladder fasting volume were clearer in male patients. CONCLUSIONS: Cutting the hepatic branch of the anterior vagus nerve during fundoplication may reduce the size of gallbladder, but it has no effect on the ejection fraction. No clinical significance has been noted to date. Prospective trials will be necessary to confirm these findings.