Jyrki Kössi

Population‐based study of the surgical workload and economic impact of bowel obstruction caused by postoperative adhesions

Intestinal obstruction is the most severe consequence of adhesion formation. This study examined the annual surgical workload and costs of intestinal obstruction caused by postoperative intra‐abdominal adhesions.

Randomized clinical trial of tissue glue versus absorbable sutures for mesh fixation in local anaesthetic Lichtenstein hernia repair.

Chronic pain may be a long‐term problem related to mesh fixation and operative trauma after Lichtenstein hernioplasty. The aim of this study was to compare the feasibility and safety of tissue cyanoacrylate glue versus absorbable sutures for mesh fixation in Lichtenstein hernioplasty.

The Significance of Tumor Markers for Proliferation and Apoptosis in Predicting Survival in Colorectal Cancer

PURPOSEClinicopathologic staging is even today the best prognostic factor in both colon and rectal cancers. There is still considerable variation in survival within the stages. To find other prognostic indicators we investigated six biologic markers associated with apoptosis and cell proliferation.METHODSFormalin-fixed, paraffin-embedded tissue samples of 363 patients with primary colon or rectal cancer of Dukes Stages A to D were chosen for immunohistochemical staining of five tumor markers: bcl-2, p53, Ki-67, cyclin D1, and carcinoembryonic antigen. Also, the number of apoptotic cells was studied by the terminal deoxynucleotidyl transferase-mediated d-UTP nick end labeling method in 347 cases. The study was done on specially prepared tissue arrays.RESULTSIn rectal cancer, patients with a Ki-67 labeling index of 5 percent or higher had a better prognosis than those with a lower index. Also, positive cytoplasmic p53 expression predicted a favorable outcome in rectal cancer. In colon cancer, positive nuclear staining of cyclin D1 reflected better survival. Weak and moderate staining of carcinoembryonic antigen correlated with better prognosis than strong staining, but negative staining predicted poor outcome. High apoptotic index of 100 or higher correlated with poor prognosis in colon cancer. However, in rectal cancer, the trend was the opposite. Bcl-2 staining tended to be more intense in samples of patients living 5 years or longer compared with those with worse prognosis.CONCLUSIONSColon cancer and rectal cancer seem to have different biologic behavior, at least with respect to apoptosis, cytoplasmic p53 expression, and perhaps Ki-67 and carcinoembryonic antigen. Further studies are needed to clarify the significance of these factors.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy.

BACKGROUND: Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. OBJECTIVE: The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. DESIGN: This is a prospective, multicenter, randomized controlled clinical trial. SETTINGS: This study was conducted at 2 university and 3 central Finnish hospitals. PATIENTS: From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. INTERVENTIONS: In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. MAIN OUTCOME MEASURES: The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. RESULTS: Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. LIMITATIONS: The study was limited by its small size and short follow-up time. CONCLUSIONS: Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.

Sexual functioning, quality of life and pelvic pain 12 months after endometriosis surgery including vaginal resection

Objective. To evaluate sexual function, quality of life and pelvic pain after endometriosis surgery including vaginal resection. Design. Prospective observational study with 12 months follow up. Setting. Regional central hospital and university hospital. Population. Twenty‐two patients with deep endometriotic nodules in the posterior fornix of the vagina undergoing complete excision of endometriosis, including vaginal resection. Methods. Sexual functioning was measured with the McCoy Female Sexuality Questionnaire, quality of life with a generic questionnaire (15D) and pain with a 10‐point visual analog scale. Questionnaires were completed before and 12 months after the surgery. Main outcome measures. Changes in sexual function scores, quality‐of‐life scores and pain. Results. Twelve months after surgery, the sexual satisfaction score was higher (p= 0.03) and the sexual problems score lower (p= 0.04) compared with baseline values. Health‐related quality‐of‐life scores for discomfort and symptoms (p= 0.001), distress (p= 0.04), vitality (p= 0.03) and sexual activity (p= 0.001), and the overall 15D score (p < 0.001), were significantly improved. The severity of all studied types of pain was significantly decreased (p < 0.05). Conclusions. Complete excision of endometriosis, including vaginal resection, seems to offer a significant improvement in sexual functioning, quality of life and pelvic pain in symptomatic patients with deeply infiltrating endometriotic nodules in the posterior fornix of the vagina. This surgery may be associated with complications and adverse new‐onset symptoms, and should be performed only after thorough consultation with the patient.

Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery.

Postoperative intraabdominal adhesions cause morbidity of varying degree. Intestinal obstruction is the most severe complication of adhesions. This study examined the importance of previous surgery on clinical and economic workloads caused by intestinal obstruction due to postoperative intraabdominal adhesions. All emergency hospitalizations due to adhesion-related intestinal obstruction from January 1, 1999 to December 31, 1999 in a hospital district serving roughly 450,000 inhabitants was reviewed retrospectively. The patient population was divided into six groups according to the site of previous surgery, and the total as well as group-related surgical workload and direct costs of inpatient care were analyzed. There were 123 hospitalizations due to postoperative adhesion-related intestinal obstruction during the study period. A total of 101 patients had experienced 176 operations. The most prevalent operations were colorectal (with or without other operations), upper abdominal, and female reproductive system procedures. Colorectal surgery preceded 40% and 38% of inpatient episodes and inpatient days, respectively. Altogether, 40 operations were performed because of adhesion-related intestinal obstruction. No differences between groups were seen in terms of the mean operating or theater time. Total annual inpatient costs due to emergency hospitalizations for intestinal adhesion-related obstruction related to colorectal surgery in a hospital district serving roughly 450,000 inhabitants was

Randomized Multicenter Trial Comparing Glue Fixation, Self-gripping Mesh, and Suture Fixation of Mesh in Lichtenstein Hernia Repair (FinnMesh Study).

72,520.60 (U.S. dollars) which accounted for 35.3% of all annual costs caused by postoperative adhesion-related intestinal obstructions. There were no significant differences between groups regarding the total mean inpatient episode costs. Intestinal obstruction due to postoperative adhesions poses substantial costs for the society. Colorectal operations are the most important procedures preceding adhesion-related intestinal obstruction, accounting for 35.3% to 46.8% of the total clinical workload or costs attributable to postoperative adhesion-related obstruction.

Differential effects of hexoses and sucrose, and platelet-derived growth factor isoforms on cyclooxygenase-1 and -2 mRNA expression in keloid, hypertrophic scar and granulation tissue fibroblasts.

OBJECTIVE Three different mesh fixation techniques were compared to find out how to perform a safe and cost-effective open inguinal hernioplasty in day-case setting with the best outcomes with regard to chronic pain. SUMMARY BACKGROUND DATA Mesh fixation method may influence on the incidence of chronic pain after Lichtenstein hernioplasty. METHODS Lichtenstein hernioplasty was performed under local anesthesia in 625 patients as day-case surgery in 8 Finnish hospitals. The patients were randomized to receive either a cyanoacrylate glue (Histoacryl, n = 216), self-gripping mesh (Parietex ProGrip, n = 202), or conventional nonabsorbable sutures (Prolene 2-0, n = 207) for mesh fixation. The incidence of wound complications, pain, recurrences, and patients discomfort was recorded on days 1, 7, 30, and 1 year after surgery. The primary endpoint was the sensation of pain measured by pain scores and the need of analgesics after 1 year of surgery. RESULTS The type and size of inguinal hernias were similar in the 3 study groups. The duration of operation was 34 ± 13, 32 ± 9, and 38 ± 9 minutes in the glue, self-gripping, and suture groups, respectively (P < 0.001). There were no significant differences postoperatively in pain response or need for analgesics between the study groups. Two superficial infections (0.3%), 31 wound seromas (5.0%), and 4 recurrent hernias (0.6%) were recorded during a 1-year follow-up. Some 25 patients (4.2%) needed occasionally analgesics for chronic groin pain. A feeling of a foreign object and quality of life were similar in all study groups. CONCLUSIONS This randomized trial failed to prove that mesh fixation without sutures causes less inguinodynia than suture fixation in Lichtenstein hernioplasty. Mesh fixation without sutures is feasible without compromising postoperative outcome.

Initial Experience of the Feasibility of Single-Incision Laparoscopic Appendectomy in Different Clinical Conditions

Abstract Cyclooxygenase (COX) is the key enzyme in the formation of prostaglandins in inflammation. In the present study the effects of biomedically relevant hexose sugars (glucose, fructose, galactose, mannose) and sucrose disaccharide on the expression of COX-1 and COX-2 genes were evaluated in granulation tissue fibroblasts, hypertrophic scar fibroblasts and keloid fibroblasts. The effects of three isoforms (AA, AB and BB) of PDGF on COX gene expression in granulation tissue fibroblasts were also examined. All cell lines expressed COX-1 mRNA, whilst fibroblasts derived from abnormal scars did not express COX-2 mRNA. COX-1 mRNA expression was decreased by sugars in granulation tissue fibroblasts and increased in hypertrophic scar fibroblasts. No major changes were seen in keloid fibroblasts. On the other hand, COX-2 mRNA expression in granulation tissue fibroblasts was decreased dramatically in the presence of fructose, mannose and sucrose and moderately in the presence of galactose. All isoforms of PDGF increased COX-1 and COX-2 mRNA expression in granulation tissue fibroblasts, the most marked increases being elicited by PDGF-BB. All fibroblast cell lines studied expressed the COX-1 gene while the COX-2 gene was not expressed by abnormal scar-derived fibroblasts. Further, granulation tissue fibroblasts seemed to behave differently under the influence of sugars compared to hypertrophic scar fibroblasts whilst keloid fibroblasts seemed to be relatively unaffected by sugars. In addition, the PDGF-BB isoform is a potent inducer of COX-2 gene expression in wound fibroblasts. These findings may be relevant to the development of abnormal scars and indicate the need for further studies.

Mannose reduces hyaluronan and leukocytes in wound granulation tissue and inhibits migration and hyaluronan-dependent monocyte binding.

Introduction. Single-incision laparoscopic surgery (SILS) is a new technique developed for performing operations without a visible scar. Preliminary studies have reported the use of the technique mainly in cholecystectomy and appendectomy. We evaluated the feasibility of the technique in various appendicitis conditions including children, fertile women and obese patients. Materials and Methods. SILS technique was used in a random sample of patients hospitalised for suspected appendicitis. The ordinary diagnostic laparoscopy was performed and the appendix was removed if needed. The ligation of appendix was performed by thread loop, absorbable clip or endoscopic stapler. The details regarding the recovery of patients were collected prospectively. Results. Ten SILS procedures were performed without conversions or complications. The patient series included uncomplicated and complicated appendicitis patients. The mean age of the patients was 37 years (range 13–63), mean BMI was 26 (range 18–31), mean operative time was 40 minutes (range 18–31), and mean postoperative stay was 2 days (range 1–5). Conclusions. SILS technique is feasible for obese patients, uncomplicated and complicated appendicitis as well as for exploratory laparoscopy. Most common methods to ligate appendix are feasible with SILS technique. The true benefit of the technique should be assessed by randomised controlled trials.