Role of surgeon-performed ultrasound on further management of patients with acute abdominal pain: a randomised controlled clinical trial.

BACKGROUND: The use of bedside ultrasound performed by the surgeon or emergency physician on duty at the emergency department is increasing. A study was performed which is the first randomised study to evaluate the benefits of surgeon-performed ultrasound for the management of the acute abdomen. METHODS: 800 patients who attended the emergency department at Stockholm South General Hospital, Sweden for abdominal pain were randomised either to receive or not receive surgeon-performed ultrasound as a complement to routine management. Outcome measures included the number of complementary investigations, time spent in the emergency department, admission rate, length of hospital stay if admitted, admission to surgery and timing of surgery if required. RESULTS: The number of complementary ultrasound examinations was considerably higher in the group who did not receive bedside ultrasound (18.8 percentage points difference, p<0.001). The admission rate was lower in the ultrasound group (7.2 percentage points difference, p = 0.041) and the proportion of patients requiring surgery submitted for surgery directly from the emergency department was higher in the ultrasound group (18.5 percentage points difference, p = 0.013). CONCLUSION: This study shows benefits in the management of the acute abdomen resulting in fewer further requested examinations, fewer admissions and shorter lead times to surgery. On the basis of these results, it is recommended for implementation in emergency departments. TRIAL REGISTRATION NUMBER: NCT00550511.

Impact of surgeon-performed ultrasound on diagnosis of abdominal pain.

BACKGROUND: A randomised study was performed to evaluate the diagnostic accuracy of surgeon-performed ultrasound in the emergency department for patients presenting with abdominal pain. METHODS: Surgeons responsible for the examination of study patients underwent 4 weeks of ultrasound training. 800 patients who were attending the emergency department for abdominal pain were randomised to undergo or not undergo surgeon-performed ultrasound as a complement to standard examination. The preliminary diagnosis made by the surgeon, with or without ultrasound, was compared with the final diagnosis made by a senior surgeon 6-8 weeks later. RESULTS: Diagnostic accuracy was significantly higher in the group examined with ultrasound (64.7% vs 56.8%, p = 0.027). Ultrasound proved to be helpful in making or confirming a correct diagnosis in 24.1% of cases receiving ultrasound and to contribute in 2.9%. In 22.3% of patients the diagnosis of non-specific pain was confirmed by normal findings. Ultrasound was misleading in 10.2% of cases and had no influence on the diagnosis in 40.0%. CONCLUSION: For patients with acute abdominal pain, higher diagnostic accuracy is achieved when surgeons use ultrasound as a diagnostic complement to standard examination. The use of bedside ultrasound should be considered in emergency departments.

A 16-year haemodynamic follow-up of women with pregnancy-related medically treated iliofemoral deep venous thrombosis.

OBJECTIVES: to evaluate clinical and functional long-term outcomes following pregnancy-related medically treated iliofemoral deep venous thrombosis (DVT). DESIGN: retrospective follow-up of patients identified through a registry search. MATERIAL AND METHODS: twenty-five women underwent clinical examination, colour duplex ultrasound and computerised strain-gauge plethysmography on two occasions a mean of nine and 16 years after DVT. RESULTS: 40% of the patients were completely asymptomatic and 52% had no clinical signs of venous disease after a mean follow-up of 16 years. The clinical signs were in general mild, and none of the 25 patients had skin changes or ulcers. Deep venous reflux was found in 36% of the patients; the same percentage at nine- and 16-years follow-up, and 24% had normal ultrasonographic appearance of all deep veins. None of the patients had plethysmographic evidence of outflow obstruction. There was a significant relationship between measures of venous reflux and the presence of leg swelling, but there was no clear relation between functional abnormalities and the extent of the initial DVT. CONCLUSION: even after 16 years there are relatively mild symptoms and signs of venous disease in women with medically treated pregnancy-related iliofemoral DVT. Our results do not support earlier stated opinions that these patients represent a particular risk group for developing post-thrombotic syndrome.

Personal decontamination after exposure to stimulated liquid phase contaminants: functional assessment of a new unit.

OBJECTIVE: To evaluate the efficacy of a decontamination station following exposure of volunteers to liquids with physical characteristics comparable to sarin and mustard gas. DESIGN: Twenty-four volunteers participated in the experiment which was performed with all staff wearing personal protective equipment including respiratory protection. The clothes, skin, and hair of the volunteers were contaminated with the simulated liquid phase contaminants, ethyl lactate and methyl salicylate. Sulphur hexafluoride gas was used to confirm the ventilation efficacy. Decontamination followed guidelines using a two-stage procedure. In the first chamber, all volunteers received a 3-minute shower with water at 30 degrees C, and their clothes but not their respiratory masks were removed. In the second, they were twice washed thoroughly with soap and water. After decontamination, the volunteers entered a third chamber for first aid measures. RESULTS: The air concentration of sulphur hexafluoride was reduced by 1:10,000 between the first and the third chambers. Ethyl lactate and methyl salicylate were measured in low concentrations in the third chamber. The capacity was 16 volunteers per hour with two-thirds on stretchers. After self-decontamination of the staff, the concentration of ethyl lactate increased significantly in the third chamber, consistent with residual ethyl lactate adsorbed by their underwear. This observation revealed a deficiency in the guidelines for self-decontamination. CONCLUSION: The capacity of the decontamination unit was found to be 16 volunteers per hour. The ventilation system and guidelines of the decontamination unit were demonstrated to be effective under the conditions examined. The self-decontamination of the staff was not optimal.

Risk factors for major thromboembolism and bleeding tendency after elective general surgical operations. The Fragmin Multicentre Study Group.

OBJECTIVE: To elucidate those factors that contribute to the risk of major postoperative thromboembolism and perioperative bleeding tendency. DESIGN: Retrospective multiple logistic regression analysis. SETTING: 7 Scandinavian hospitals (6 Swedish and 1 Norwegian). SUBJECTS: 2070 patients undergoing elective major abdominal surgery. INTERVENTIONS: Patients were randomised to receive 2500 or 5000 XaI units of low molecular weight heparin daily. MAIN OUTCOME MEASURES: Major thromboembolism (proximal deep vein thrombosis confirmed by phlebography or necropsy, or pulmonary embolism confirmed by scintigraphy or necropsy, or both). Bleeding tendency (bleeding complications which were not explained by local haemorrhagic lesions or by coexisting disease). RESULTS: Previous thromboembolism, leg fracture or arthroplasty, present leg ulcer or malignant disease, operating time longer than 150 minutes, preoperative transfusion of 2 or more units, and preoperative hospital stay of 6 days or more (but not age, body weight, or varicose veins) were independent predictors for major postoperative thromboembolism. The risk was significantly increased with an increasing number of such risk factors. The risk of developing a diffuse bleeding complication was dependent on the dose of low molecular weight heparin, particularly in patients without risk factors. CONCLUSIONS: The use of a narrow definition of thromboembolism lead to a pattern of risk factors which was partly different from that found in previous studies, which were usually based on diagnosis with the 125I-fibrinogen uptake test.

The long-term outcome of proximal vein thrombosis during pregnancy is not improved by the addition of surgical thrombectomy to anticoagulant treatment.

OBJECTIVES: To compare the long-term outcome for pregnant/puerperal women with iliofemoral venous thrombosis treated either with thrombectomy and additional anticoagulants or with anticoagulants alone. DESIGN: Retrospective study of two treatment methods. MATERIALS: Thirty women with iliofemoral venous thrombosis during pregnancy or puerperium were treated with thrombectomy and additional anticoagulants. Twenty-five women, with the same condition, treated with anticoagulants only were obtained from a registry. The mean follow-up time for both groups was 9 years. The patients of the two groups were well matched, had the same risk factor score and were comparable except for duration of symptoms before treatment. METHODS: The follow-up comprised history and clinical examination, colour Duplex ultrasound and venous strain-gauge plethysmography. RESULTS: Patency of iliac veins, symptoms of chronic venous disease, venous emptying and venous reflux did not differ between the groups. A significant reduction of outflow was found in 20% of the surgically treated patients and 16% of the controls. Impaired muscle pump function was seen in less than half of the patients in both groups. CONCLUSIONS: Surgical thrombectomy does not offer any advantage over anticoagulation treatment alone in the long-term outcome for patients with iliofemoral venous thrombosis during pregnancy or puerperium.

Thromboprophylaxis with a low molecular weight heparin (tinzaparin) in emergency abdominal surgery. A double-blind multicenter trial.

In this prospective randomized double-blind study the thromboprophylactic effect of postoperative low molecular weight heparin (tinzaparin) was compared with placebo in 80 patients undergoing emergency abdominal surgery. The fibrinogen uptake test was used but because of withdrawal of the labelled fibrinogen from the market the calculated number of patients was not reached. However, this is one of the few studies in emergency abdominal surgery we thought it important to report. The frequency of deep vein thrombosis was reduced with prophylaxis from 22% (95% conf. intervall 11-38%) to 8% (2-21%), a risk reduction of 65%, which is however not significant. Together with data from the few previously published studies it can be concluded that patients undergoing emergency abdominal surgery seem to benefit from prophylaxis, which should be instituted either before operation or at latest 24 hours after. The exact prophylactic relation between pre- and post-operative start would, however, require a separate, randomized study.

Clinical relevance of the fibrinogen uptake test in patients undergoing elective general abdominal surgery--relation to major thromboembolism and mortality. Fragmin Multicentre Study Group.

Postoperative thromboembolic complications were evaluated in 2578 patients undergoing elective abdominal surgery, all receiving prophylaxis with low molecular weight heparin. A positive fibrinogen uptake test (FUT) developed in 217 patients (8.4%), while 37 patients (1.4%) had major thromboembolism (TE, defined as proximal deep vein thrombosis and/or pulmonary embolism, verified with phlebography, pulmonary scintigraphy or autopsy). In only 14% a positive FUT was associated with a major TE event. In 19% of the patients with major TE the FUT was negative. In multiple logistic regression the independent predictors for major TE were partially different from those for positive FUT. Thirty day mortality was 3.0%. There were significant associations between both positive FUT and major TE on one hand and mortality on the other (relative risks 2.4 and 5.8, respectively). FUT is not a good predictor of major TE. Both positive FUT and major TE indicate a significant risk of postoperative death.

Thromboprophylaxis in emergency surgery.

Except for hip fracture surgery, emergency surgery has been only exceptionally studied concerning thromboprophylaxis. There are, however, several reasons to believe the frequency to be fairly high and that the patient group would be in need of prophylaxis. This paper discusses various emergency situations and also gives the design for an ongoing controlled study on the effect of postoperative start of thromboprophylaxis with low molecular weight heparin in emergency abdominal surgery.

Peroperative endotoxin concentrations in portal and peripheral venous blood in patients undergoing right hemicolectomy for carcinoma.

OBJECTIVE: To find out the incidence of systemic and portal endotoxaemia in a homogeneous group of patients with colonic cancer undergoing a standard operation, and to compare them with a control group with benign disease. DESIGN: Open study. SETTING: Department of Surgery, Stockholm Söderhospital. SUBJECTS: 15 of 17 consecutive patients admitted for right hemicolectomy for cancer, and four control subjects (one with angiodysplasia, and three with ulcerative colitis) who were to undergo right hemicolectomy and proctocolectomy. INTERVENTION: After mobilisation of the colon, 10 ml samples of blood were taken simultaneously from a mesocolic vein, and from an antecubital vein, for assay of endotoxin. RESULTS: Raised concentrations of endotoxin were found in the portal blood of 4 of the 15 patients with cancer, and in two of the four with benign disease. One of the four with cancer also had a raised value in peripheral blood. There was no correlation between increased endotoxin concentration and tumour size, Dukes' stage, or development of infective complications. CONCLUSION: Pronounced concentrations of endotoxin are found only rarely in patients undergoing right hemicolectomy for cancer. The most likely explanation is translocation of endotoxin through mucosa damaged by an ulcerating tumour.

Deep venous thrombosis after emergency gastrointestinal operations: a pilot study.

In a prospective pilot study, 30 patients over 50 years of age undergoing major emergency gastrointestinal surgery were examined with the 125I-fibrinogen uptake test for postoperative deep venous thrombosis (DVT). Prophylaxis against thrombosis was at that time not used routinely for the emergency patients. The surgeon decided for each patient whether and when prophylaxis with low-dose heparin, 5,000 units twice daily, should be given. DVT was diagnosed in 11 patients (37%; 95% confidence interval 20 to 56%), in five of them bilaterally. No thrombi occurred within seven days in the patients who received low-dose heparin from the day of surgery. Major emergency gastrointestinal surgery carries a high risk of postoperative DVT.

Nodular fasciitis and fibromatosis of the female breast simulating breast cancer. Case reports.

One case of nodular fasciitis and one of fibromatosis of the female breast are reported. These rare lesions simulated breast cancer clinically and mammographically. Histological diagnosis was obtained by excision of the lesions. A literature search in three large databases gave only 4 reported cases of nodular fasciitis of the female breast, fibromatosis was relatively more common in this location.

Conventional heparin and semisynthetic heparin analogue (SSHA) alteration of blood coagulation after embolic occlusion of human renal circulation.

Blood coagulation and fibrinolytic variables were measured in a peripheral vein in a study of 21 consecutive patients before and after angio-embolization of renal carcinoma. The first ten patients received conventional heparin, 5000 IU twice daily, and the following eleven a semi-synthetic heparin analogue (SSHA), 50 mg twice daily, for 5 days. The first injection was given 2 hours before embolization and the last injection at least 12 hours before the last blood sampling. Both groups showed increased levels of FPA on day 5-7, indicating that the anticoagulant influence had ceased. F VII levels decreased only in the SSHA group from embolization to day 3, but were increased in both groups on day 5-7. Levels of thrombin-antithrombin complexes (TAT) were significantly increased in the heparin group 2 hours after embolization, indicating that thrombin activity had been formed. The corresponding TAT level in the SSHA group was not significantly increased. The differences could possibly indicate a different mechanism of action on blood coagulation of SSHA as compared with heparin, with involvement of extrinsic pathway and maybe by-passing antithrombin III inhibition.

Terlipressin (triglycyl-lysine vasopressin) controls acute bleeding oesophageal varices. A double-blind, randomized, placebo-controlled trial.

The haemostatic effect of terlipressin (triglycyl-lysine vasopressin; Glypressin) on bleeding from oesophageal varices was evaluated in a placebo-controlled, double-blind, randomized clinical trial. Patients with clinically suspected liver cirrhosis were included in the study if they had been admitted to hospital with an extensive haemorrhage within the last 24h before diagnostic endoscopy. The patients randomized after stratification for severity of liver disease. Terlipressin or placebo was administered as intravenous bolus injections every 4th h during a period of 24 to 36 h or until the clinical course necessitated active intervention (failure or withdrawal). Sixty patients entered the study; 31 patients were allocated to receive terlipressin, and 29 patients to receive placebo. Bleeding from varices was arrested in 28 of the 31 receiving terlipressin, as compared with 17 of the 29 receiving placebo (p less than 0.01). Patients receiving active drug required significantly fewer blood transfusions (p less than 0.05). Most of the side effects were classified as mild and were registered in the terlipressin group.

Blood coagulation alterations after embolic occlusion of the renal circulation.

Alterations in blood coagulation and fibrinolysis after embolic occlusion of renal adenocarcinoma were investigated in 11 patients. Peripheral vein blood was collected before, 2 hours after and on the first, third and fifth to seventh day after embolization. Five patients had renal vein blood sampling before and 2 hours after embolization. Increased levels of fibrinogen, plasminogen and antiplasmin were found on days 1-3. Antithrombin III showed a slight decrease between days 1 and 3 after embolization. All measured variables were lower in renal vein compared with simultaneous samples from peripheral vein. In renal vein samples, consumption of antiplasmin and antikallikrein was indicated. Fibrinopeptide A (FPA) was increased, with a mean maximum 2 hours after embolization. The findings seemed mainly to monitor acute phase reaction but also activation of blood coagulation and fibrinolysis. Embolization might be used as a human model of coagulation activation and acute phase reaction.

Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis.

Sixty patients operated for ilio-femoral venous thrombosis with thrombectomy and temporary arterio-venous fistula (AVF) were evaluated. Fifty-one thromboses occurred in women and 48 were left-sided. A triggering mechanism was found in most patients. Fifty per cent of the women were pregnant or in the immediate postpartum period, one third of all patients had a recent operation or trauma and in one third a hereditary disorder could be traced. Blood coagulation studies postoperatively revealed disorders in the coagulation or fibrinolytic systems in 34 of 47 investigated patients. At operation it was possible to open the iliac vein in 50 patients and 42 received a functioning AVF. The AVF was closed after 3 months. Forty-six patients have been followed from 6 months to 5 years with one or several of the following investigations: venous plethysmography, radionuclide venography or routine venography. At follow-up the iliac vein was judged to be patent in 29 patients, in 17 it was occluded and in 8 patients it was probably occluded. All patients over 50 years of age were among those with occluded veins as were 6 of 9 men. The best results were achieved in women operated during pregnancy or in the puerperium. Venous thrombectomy with temporary AVF is effective treatment for ilio-femoral venous thrombosis, particularly in younger females with an obvious precipitating cause e.g. pregnancy or delivery.

Massive hematemesis due to an aorto-oesophageal fistula. Case report.

A patient with massive hematemesis due to an aorto-oesophageal fistula is presented. An aorto-oesophageal fistula is mostly a fatal disease. In the literature it is pointed out that recognition of the clinical syndrome with midthoracic pain, massive arterial hemorrhage and exsanguination after a symptom-free interval might ameliorate the prognosis. In the reported patient the correct diagnosis was not immediately suspected. The patient, however, survived a long operation and exsanguination without any major postoperative complications or sequelae.