Jakob Burcharth

Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA.

Objective: To evaluate short-term outcomes of a new treatment for perforated diverticulitis with purulent peritonitis in a randomized controlled trial. Background: Perforated diverticulitis with purulent peritonitis (Hinchey III) has traditionally been treated with surgery including colon resection and stoma (Hartmann procedure) with considerable postoperative morbidity and mortality. Laparoscopic lavage has been suggested as a less invasive surgical treatment. Methods: Laparoscopic lavage was compared with colon resection and stoma in a randomized controlled multicenter trial, DILALA (ISRCTN82208287). Initial diagnostic laparoscopy showing Hinchey III was followed by randomization. Clinical data was collected up to 12 weeks postoperatively. Results: Eighty-three patients were randomized, out of whom 39 patients in laparoscopic lavage and 36 patients in the Hartmann procedure groups were available for analysis. Morbidity and mortality after laparoscopic lavage did not differ when compared with the Hartmann procedure. Laparoscopic lavage resulted in shorter operating time, shorter time in the recovery unit, and shorter hospital stay. Conclusions: In this trial, laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III was feasible and safe in the short-term.

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

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.

Nationwide prevalence of groin hernia repair.

Introduction Groin hernia repair is a commonly performed surgical procedure in the western world but large-scaled epidemiologic data are sparse. Large-scale data on the occurrence of groin hernia repair may provide further understanding to the pathophysiology of groin hernia development. This study was undertaken to investigate the age and gender dependent prevalence of groin hernia repair. Methods In a nationwide register-based study, using data from the Civil Registration System covering all Danish citizens, we established a population-based cohort of all people living in Denmark on December 31st, 2010. Within this population all groin hernia repairs during the past 5 years were identified using data from the ICD 10th edition in the Danish National Hospital Register. Results The study population covered n = 5,639,885 persons. During the five years study period 46,717 groin hernia repairs were performed (88.6% males, 11.4% females). Inguinal hernias comprised 97% of groin hernia repairs (90.2% males, 9.8% females) and femoral hernias 3% of groin hernia repairs (29.8% males, 70.2% females). Patients between 0–5 years and 75–80 years constituted the two dominant groups for inguinal hernia repair. In contrast, the age-specific prevalence of femoral hernia repair increased steadily throughout life peaking at age 80–90 years in both men and women. Conclusion The age distribution of inguinal hernia repair is bimodal peaking at early childhood and old age, whereas the prevalence of femoral hernia repair increased steadily throughout life. This information can be used to formulate new hypotheses regarding disease etiology with regard to age and gender specifications.

Colorectal carcinogenesis-update and perspectives

Colorectal cancer (CRC) is a very common malignancy in the Western World and despite advances in surgery, chemotherapy and screening, it is still the second leading cause of cancer deaths in this part of the world. Numerous factors are found important in the development of CRC including colonocyte metabolism, high risk luminal environment, inflammation, as well as lifestyle factors such as diet, tobacco, and alcohol consumption. In recent years focus has turned towards the genetics and molecular biology of CRC and several interesting and promising correlations and pathways have been discovered. The major genetic pathways of CRC are the Chromosome Instability Pathway representing the pathway of sporadic CRC through the K-ras, APC, and P53 mutations, and the Microsatellite Instability Pathway representing the pathway of hereditary non-polyposis colon cancer through mutations in mismatch repair genes. To identify early cancers, screening programs have been initiated, and the leading strategy has been the use of faecal occult blood testing followed by colonoscopy in positive cases. Regarding the treatment of colorectal cancer, significant advances have been made in the recent decade. The molecular targets of CRC include at least two important cell surface receptors: the epidermal growth factor receptor and the vascular endothelial growth factor receptor. The genetic and molecular knowledge of CRC has widen the scientific and clinical perspectives of diagnosing and treatment. However, despite significant advances in the understanding and treatment of CRC, results from targeted therapy are still not convincing. Future studies will determine the role for this new treatment modality.

Patient-Related Risk Factors for Recurrence After Inguinal Hernia Repair A Systematic Review and Meta-Analysis of Observational Studies

Background. Several factors influence the risk of recurrence after inguinal hernia surgery; however, a systematic review and meta-analysis of patient-related risk factors for recurrence after inguinal hernia surgery has not been performed earlier. Methods. MEDLINE, Embase, and Cochrane databases were searched in June 2013 for studies evaluating patient-related risk factors for recurrence after inguinal hernia operation. Observational studies evaluating nontechnical patient-related risk factors for recurrence after inguinal hernia surgery were included. Outcome variables were grouped under patient demographics, hernia characteristics, connective tissue composition and degradation, habits and social relations, and conditions related to inguinal hernia recurrence. Results. From a total of 5061 records screened, we included 40 observational studies enrolling 720 651 inguinal hernia procedures in 714 917 patients in the systematic review. Of the 40 studies, 14 studies were included in 8 meta-analyses evaluating sex, hernia type, hernia size, re-recurrence, bilaterality, mode of admission, age, and smoking as risk factors for recurrence after inguinal hernia surgery in a total of 378 824 procedures in 375 620 patients. Conclusions. We found that female sex, direct inguinal hernias at the primary procedure, operation for a recurrent inguinal hernia, and smoking were significant risk factors for recurrence after inguinal hernia surgery. This knowledge of patient-related risk factors for recurrence after inguinal hernia surgery could be implemented in clinical practice.

Patient education has a positive effect in patients with a stoma: a systematic review

A systematic review was performed to assess whether education of patients having stoma formation improves quality of life and whether it is cost effective.

Gastrointestinal Surgery and Related Complications in Patients with Ehlers- Danlos Syndrome: A Systematic Review

Introduction: Ehlers-Danlos syndrome (EDS) is a rare inherited group of connective tissue diseases characterized by joint hypermobility, skin hyperextensibility and bruising tendency. Common features of patients with EDS include vascular and gastrointestinal perforations. The purpose of this systematic review is to address gastrointestinal diseases and the complications associated with surgical treatment of diseases relating to the gastrointestinal system in patients with EDS. Methods: PubMed search including the Medical Subject Heading (MeSH) terms ‘Ehlers-Danlos Syndrome’ and ‘Gastrointestinal Diseases’, and an Embase search including the Map Term to Subject Heading ‘Ehlers-Danlos Syndrome’ with ‘AND’ function of the keyword ‘Gastrointestinal’. Results: The literature search resulted in inclusion of 53 articles after application of eligibility criteria. The primary results drawn from the literature was that spontaneous ruptures of vessels and spontaneous perforations of the sigmoid colon occur in patients with EDS. Conclusion: Surgery in patients with EDS is associated with a high risk of complications, which is why preoperative indications should be considered. Optimal therapy for these patients includes the awareness that EDS is a systemic disease involving fragility, bleeding and spontaneous perforations from almost all organ systems. Often, a nonsurgical approach can be the best choice for these patients, depending on the condition.

Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial

Context Patients who have perforated diverticulitis with purulent peritonitis are frequently managed surgically with open colon resection, often together with formation of a stoma. Laparoscopic lavage has been proposed as an alternative surgical approach that might involve less morbidity, including a decreased need for additional operations. Contribution This randomized trial of patients who have perforated diverticulitis with purulent peritonitis found that laparoscopic lavage resulted in a decreased need for reoperations compared with open colon resection. Implication Laparoscopic lavage may be an option for the management of perforated diverticulitis with purulent peritonitis. Diverticulosis of the colon is a common condition in Western countries. The incidence increases with age to reach 34% to 56% of persons older than 70 years (1, 2). In the presence of diverticulosis, 15% to 25% also develop diverticulitis. This can be divided into uncomplicated and complicated disease in which complicated diverticulitis may require surgical intervention (35). Complicated diverticulitis is mostly classified according to the Hinchey grading system (grades I to IV) (6). In Hinchey grades III and IV, diverticular perforation into the abdominal cavity has resulted in purulent or fecal peritonitis, respectively. These conditions require emergency surgical intervention and are associated with high morbidity (25% to 75%) and mortality (2% to 30%) (710). Historically, the Hartmann procedure has been most commonly performed, which includes colon resection and colostomy; another option is resection of the affected part of the colon with primary anastomosis with or without diverting ileostomy (9, 11, 12). The strategy in both cases is to reverse the stoma in a second surgery, with subsequent risk for morbidity and mortality (13). Although stoma reversal is a scheduled surgical procedure, it must be considered as a consequence of the primary procedure and due to perforated diverticulitis. The other option is to avoid further surgery, which will leave the patient with a permanent stoma. Recent literature suggests that perforated diverticulitis with purulent peritonitis could be treated with a less invasive approach and reduce the risk for subsequent procedures. On the basis of prospective data, it was suggested in 2008 (14) that Hinchey grade III perforated diverticulitis could be managed by laparoscopic lavage alone, with reduced risk for morbidity and mortality. The potential benefits of laparoscopic lavage are suggested by case series or retrospective studies and 1 prospective study (15), but they are not substantiated in recently published results from 2 randomized trials (16, 17). In addition, there is 1 ongoing randomized trial (18). We previously published the protocol and short-term results of the present trial (19, 20). The hypothesis in this trial was that laparoscopic lavage as emergency treatment of perforated diverticulitis with purulent peritonitis could be a definitive treatment and would lead to fewer patients in need of further surgeries. The primary objective of this trial was to compare laparoscopic lavage and the Hartmann procedure with regard to the percentage of patients with 1 or more reoperations within 12 months. Secondary objectives included analysis of mortality, adverse events, length of hospital stay, and health-related quality of life. Methods Study Design This prospective, open-label, randomized, controlled trial compared laparoscopic lavage and the Hartmann procedure. Nine departments of surgery in Sweden and Denmark included patients from February 2010 until February 2014. The trial was approved by the Board of Ethical Approval in Gothenburg, Sweden (registration number 378-09) and the Danish ethical committee (protocol H-4-2009-088). A detailed description of the protocol has previously been published (19) and is available at www.ssorg.net. Patients We included patients who had suspected acute perforated diverticulitis and imaging showing intra-abdominal free air or fluid and were candidates for surgery (as judged by the surgeon). Those unfit for surgery or participating in conflicting trials were not included. Patients gave written informed consent. Those with other diagnoses, such as colorectal cancer found in the resected specimen or diagnosed at a later colon examination (which was part of the trial protocol), or those who withdrew their consent after being randomly assigned were not included in the per-protocol analysis of the primary outcome. A screening log was held, with monthly review of all patients discharged with a diagnosis of diverticulitis. Those who could be included but were not were recorded retrospectively. Randomization The on-call surgeon enrolled the participants in accordance to the inclusion criteria. The protocol did not require the surgeon to specialize in colorectal surgery. Diagnostic laparoscopy was performed. If Hinchey grade III perforated diverticulitis was found, patients were randomly assigned to either laparoscopic lavage (intervention) or the Hartmann procedure (control). Randomization was stratified by hospital in blocks of 10 with a 1:1 allocation ratio. The sequence was computer-generated by an independent statistician. Allocation was concealed to the staff by sequentially numbered, opaque, sealed envelopes. The circulating nurse in the operating room opened the envelope after the surgeon decided to randomly assign the patient to a group. Procedures In the intervention group, laparoscopic lavage was performed with saline at body temperature, 3 L or more, until clear fluid was returned. In the control group, colon resection and colostomy with open technique was performed (the Hartmann procedure). Both groups received a passive drain in the pelvis, which was left in place for at least 24 hours. The postoperative care was conducted according to local guidelines. All specimens removed during surgery in the Hartmann group had pathologic analysis. If a diagnosis other than diverticulitis was found, the patient was not included in the secondary analysis. Data were collected prospectively by health care professionals using clinical record forms at baseline, during the operation, for the postoperative period until discharge from the hospital, and at each follow-up (6 to 12 weeks, 6 months, and 12 months). Assessment at follow-ups included clinical examination, listing of adverse events, and readmissions or reoperations. Colon examination (colonoscopy or computed tomography colonography) was to be performed within 12 months to exclude other possible diagnoses. All patients were asked to complete the EuroQol 5-dimensional questionnaire (EuroQol-5D) containing generic (nonspecific) instruments at discharge and both the EuroQol-5D and Short Form-36 Health Survey (SF-36) (2123) at 6 and 12 months. The validated Swedish and Danish translations of the instruments were used (2426). EuroQol-5D allows for comparisons between patients with different diseases and representative normative populations and includes 5 dimensions of health (mobility, self-care, usual activities, pain or comfort, and anxiety or depression). The answering categories were no problems, low levels of problems, and severe problems. It also assesses global health from worst imaginable health state (score of 0) to best imaginable health state (score of 100) using a visual analogue scale. The questionnaire reflects the respondents situation at the day of completion. The SF-36 is a generic instrument consisting of 8 sections and can be used to evaluate a patients health status with a 14-day recall period. It was summarized into physical and mental component summary scores (27). Outcomes The primary outcome was the percentage of patients with 1 or more reoperations within 12 months. We defined the term 12-month follow-up used in the protocol as 12 months plus 30 days for practical reasons because all follow-up visits were not performed at exactly 12 months. Secondary outcomes were number of reoperations, hospital readmissions, total length of hospital stay during 12-month follow-up, postoperative adverse events, incisional hernia, bowel obstruction, mortality, persisting stoma at 12 months, and quality of life. Data on adverse events were collected prospectively in the clinical record forms, and before analysis, they were classified retrospectively according to ClavienDindo (28). This classification is based on the type of treatment required for the adverse event. Before classification, a decision was made to combine Hinchey grade I and II cases to reduce the risk for misclassification. Percutaneous drainage without general anesthesia was not registered as a reoperation but as an adverse event. Statistical Analysis In a retrospective study, 40% of patients who had the Hartmann procedure because of perforated diverticulitis had another operation at least once within 12 months after the index procedure (7). To detect a 75% reduction in the relative risk for the primary end point, 32 evaluable patients per group were required, assuming an annual incidence of 40% in the control group with 80% power using a 2-sided chi-square test at the 5% significance level. A statistical analysis plan was created before the analysis. The main analysis population consisted of all randomly assigned patients. In addition, an analysis of a per-protocol population was performed. The primary and secondary outcomes were analyzed with a generalized linear model using robust variance estimation and a log-link function with group as the factor, site as the covariate, and log (time in study) as the offset (29). For the primary outcome, we used a Poisson distribution because the model failed to converge for a binomial distribution (30). For the secondary outcomes, we used a negative binomial distribution. Length of hospital stay (total number of days during 12-month follow-up) had a right-skewed distribution and was analyzed by a linear mode

The inheritance of groin hernia: a systematic review

BackgroundGroin hernia has been proposed to be hereditary; however, a clear hereditary pattern has not been established yet. The purpose of this review was to analyze studies evaluating family history and inheritance patterns and to investigate the possible heredity of groin hernias.MethodsA literature search in the MEDLINE and Embase databases was performed with the following search terms: genetics, heredity, multifactorial inheritance, inheritance patterns, sibling relations, family relations, and abdominal hernia. Only English human clinical or register-based studies describing the inheritance of groin hernias, family history of groin hernias, or familial accumulation of groin hernias were included.ResultsEleven studies evaluating 37,166 persons were included. The overall findings were that a family history of inguinal hernia was a significant risk factor for the development of a primary hernia. A family history of inguinal hernia showed a tendency toward increased hernia recurrence rate and significantly earlier recurrence. The included studies did not agree on the possible inheritance patterns differing between polygenic inheritance, autosomal dominant inheritance, and multifactorial inheritance. Furthermore, the studies did not agree on the degree of penetrance.ConclusionThe literature on the inheritance of groin hernias indicates that groin hernia is most likely an inherited disease; however, neither the extent of familial accumulation nor a clear inheritance pattern has yet been found. In order to establish whether groin hernias are accumulated in certain families and to what extent, large register studies based on hernia repair data or clinical examinations are needed.Groin hernia repair (inguinal and femoral hernia) is among the most commonly performed gastrointestinal surgical procedures [1]. Emergency groin hernia surgery is associated with increased mortality, increased patient-related morbidity, and increased hospital stay compared with elective groin hernia procedures [2, 3]. Identifying patients at high risk of developing groin hernia would therefore provide the possibility of timely elective surgical intervention, thus reducing the rate of emergency procedures. It could also potentially make way for individualized surgical methods in the future.

Effect of Diclofenac on Cyclooxygenase-2 Levels and Early Breaking Strength of Experimental Colonic Anastomoses and Skin Incisions

Background: Recently, there has been a focus on the effect of the nonsteroidal anti-inflammatory drugs on the anastomotic leakage rate after colorectal surgery. Methods: An experimental, randomized, placebo-controlled prospective study on 32 male Wistar rats was carried out. We examined the effect of diclofenac 4 mg/kg/day on the cyclooxygenase-2 (COX-2) enzyme in the anastomotic tissue and on the breaking strength of anastomotic and incisional wounds. The operation was performed with colonic resection and hand-sewn anastomosis. After 3 days, the rats were sacrificed and the breaking strength and the COX-2 content of the anastomosis were measured. Results: There was a significantly reduced level of COX-2 in the rats treated with diclofenac (p = 0.001); no significant differences in any of the breaking strength measurements and no significant correlation between COX-2 levels and breaking strength of the anastomotic or incisional wounds could be found (p = 0.073 and p = 0.727). Conclusion: This study for the first time showed that a diclofenac dose of 4 mg/kg/24 h was sufficient to reduce the level of COX-2 enzymes in the anastomotic tissue in rats. This inhibition of the inflammatory response did not lead to reduced breaking strength of either anastomotic or incisional wounds. Whether there is a detrimental effect of COX inhibition on colorectal anastomoses in the clinical setting remains controversial.