Ola Reiertsen

Diagnostic Laparoscopy in 1043 Patients with Suspected Acute Appendicitis

OBJECTIVE To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN Three prospective protocols. SETTING Three departments of surgery, one in Norway and two in Sweden. SUBJECTS 1043 patients aged 15 years or over. INTERVENTIONS Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

Laparoscopic and open operation in patients with perforated peptic ulcer

OBJECTIVES To compare the results of laparoscopic and open operations in patients with perforated peptic ulcer. DESIGN Retrospective analysis. SETTING Central hospital, Norway. SUBJECTS 74 patients (36 men, 38 women, median age 69.5 years (18-86)) admitted with perforated peptic ulcers from November 1991-May 1996. INTERVENTIONS Suture of the ulcer, patching with the greater omentum and lavage, in 49 by open operation and 25 laparoscopically. MAIN OUTCOME MEASURES Duration of postoperative hospital stay, operating time, number of doses of analgesic, postoperative body temperature, complications, and mortality. RESULTS There was a significant difference (p = 0.0001) in median operating time: 100 minutes (range 48-160) in the laparoscopic group and 50 minutes (range 20-160) in the open group. The median hospital stay was 8 days in both groups: range 3-23 days in the laparoscopic group and 2-28 days in the open group. There were no significant differences between the two groups with regard to median number of doses of analgesic, median body temperature, complications or mortality. CONCLUSION Laparoscopic operation for perforated peptic ulcer can be considered as safe as open operation.

Total mesorectal excision for rectal cancer : Difference in outcome for low and high rectal cancer

PURPOSEThis prospective study was designed to assess the outcome through the first five years after the introduction of total mesorectal excision in 1993 in a Norwegian central hospital, with special regard to the difference between low (≤6 cm from anal verge) and high (>6 cm) rectal cancers.METHODSA total of 140 patients (81 males; median age, 64 (range, 29–87) years) underwent surgery for rectal cancer under curative intention.RESULTSLocal recurrence rates were 8 of 44 (18 percent) for the low cancers and 5 of 96 (5 percent) for the high, a statistically significant difference (P = 0.0014). Corresponding numbers when the R1 resections are excluded were 5 of 36 (13 percent) for the low and 4 of 92 (4 percent) for the high cancers (P = 0.002). The five-year survival after R0 resections of cancers <6 cm was significantly reduced compared with those >6 cm. The five-year overall survival for the whole material was 72 percent.CONCLUSIONSSurgery alone for rectal cancer can achieve overall good results, with five-year overall survival of 72 percent. The prognosis of the cancers of the lower rectum seems to be inherently different from the tumors of the higher level, both concerning local recurrence and five-year survival, suggesting different biologic behavior of the two cancers.

Prophylactic mesh at end-colostomy construction reduces parastomal hernia rate: A randomized trial

Parastomal hernia (PSH) is the most common complication of an end‐colostomy and about one‐quarter of patients need operative repair, which is often unsuccessful. A randomized trial was carried out to compare the results of using mesh or no mesh at the time of formation of a colostomy with the clinical identification of PSH as the primary outcome.

Evaluation of Enoxaparin Given before and after Operation to Prevent Venous Thromboembolism during Digestive Surgery: Play-the-Winner Designed Study

Abstract A total of 316 patients were included in a play-the-winner (PTW) designed study comparing the safety of enoxaprain started preoperatively versus postoperatively as prophylaxis against venous thromboembolism for digestive surgery. In a PTW-designed study the treatment of any next patient depends on the outcome of the previous patient. If successful, the next patient receives the same treatment, if not, the comparative regimen is given. Excessive bleeding according to specified criteria, severe adverse reactions, clinically detected deep venous thrombosis (DVT), or pulmonary embolism (PE) were criteria for classification as “loser.” The PTW design allocates most patients to the superior treatment. The main variable in PTW studies is the number of consecutive patients receiving the same treatment. In this study 163 patients were allocated to postoperatively started and 153 to preoperatively started prophylaxis with enoxaparin. The frequency of “winners” was found to be 82.8% and 78.4% in the post- and preoperatively treated groups, respectively. No significant differences were found between the groups with regard to frequency of “winners” or the number of consecutive patients before change of treatment. The percentile of survival distribution did not detect superiority of any group. Prophylaxis against postoperative venous thromboembolism for digestive surgery using enoxaparin can safely be started preoperatively.

Comparison of Sequential and Fixed-Sample Designs in a Controlled Clinical Trial with Laparoscopic versus Conventional Cholecystectomy

BACKGROUND The aim of this study was to compare a fixed-sample and a sequential design with regard to study duration, sample size, and medical results in a real-life situation. METHODS A randomized study comparing laparoscopic and conventional cholecystectomy was carried out with a fixed-sample design, parallel with a sequential design. The main variable was duration of postoperative convalescence. RESULTS In the fixed-sample trial the necessary number of patients was calculated to be 72. The sequential trial was conclusive after inclusion of 24 patients and reduced the duration of the study from 43 to 18 weeks. Additionally, the sequential trial reached the same conclusions as the fixed-sample trial in all the observed variables except for one. CONCLUSION The present study indicates that sequential design should be used more frequently in clinical trials, to involve the smallest possible number of patients necessary to reach a conclusion.

Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson’s disease in the Nordic region

Abstract Objective. Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson’s disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. Material and methods. A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson’s disease patients with the primary goal of providing guidance on best practice for the Nordic countries. Results. Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. Conclusions. LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson’s disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.

Endoscopic treatment of colorectal carcinoma.

All malignant pedunculated polyps of the colon can be removed totally by colonoscopy alone. Resection of the colon is only necessary in those few instances where the cancer portion is poorly differentiated and where there are cancer cells in lymphatic or vascular channels. Malignant well differentiated sessile polyps are adequately managed by the endoscopic technique as well if the polypectomy is believed to have been complete and this can be confirmed by follow-up biopsies after 4-8 weeks. In these patients Laser therapy may also be of value. Endoscopic Laser therapy may be of value as a symptomatic treatment in patients with advanced malignant disease with obstruction or bleeding.