Panu Mentula

Vacuum and mesh‐mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients

Several temporary abdominal closure techniques have been used in the management of open abdomen. Failure to achieve delayed primary fascial closure results in a large ventral hernia. This retrospective analysis evaluated whether the use of vacuum‐assisted closure and mesh‐mediated fascial traction (VACM) as temporary abdominal closure improved the delayed primary fascial closure rate compared with non‐traction methods.

Plasma anti‐inflammatory cytokines and monocyte human leucocyte antigen‐DR expression in patients with acute pancreatitis

Background: Immune suppression plays a role in the pathogenesis of acute pancreatitis. The purpose was to describe plasma anti‐inflammatory cytokines and blood monocyte human leucocyte antigen (HLA)‐DR expression, a cellular marker of immune suppression, in relation to clinical outcome in acute pancreatitis. Methods: We studied 74 patients with acute pancreatitis admitted within 72u2005h after symptom onset; 27 had mild disease and 47 severe disease, of whom 20 developed organ failure. Plasma cytokine concentrations and monocyte HLA‐DR density were determined at admission and 1, 2, 3, 7, 14 and 21 days later. Results: The levels of interleukin‐1 receptor antagonist, interleukin‐6 and interleukin‐10 correlated inversely to monocyte HLA‐DR expression; each marker correlated with disease severity. Interleukin‐4, ‐11 and ‐13 levels were low. Organ failure occurred at median 36u2005h (range 8 to 158) after admission and was predicted at admission by the combination of interleukin‐6 and interleukin‐10 with sensitivity of 95%, specificity of 88% and positive likelihood ratio of 7.6 (95% confidence interval 3.3 to 17). Patients with secondary infections had a lower proportion of HLA‐DR positive monocytes than did controls at day 14 (median: 32% versus 65%; nu2005=u20057) and at day 21 (median: 49% versus 83%; nu2005=u20056), Pu2005<u20050.05 each. In the organ failure group, HLA‐DR expression did not differ between survivors and non‐survivors. Conclusions: Determining the severity of anti‐inflammatory reaction at admission and monitoring the course of immune suppression provide a means for predicting clinical outcome in acute pancreatitis.

Circulating cytokines in predicting development of severe acute pancreatitis

IntroductionSevere acute pancreatitis (AP) is associated with high morbidity and mortality. Early prediction of severe AP is needed to improve patient outcomes. The aim of the present study was to find novel cytokines or combinations of cytokines that can be used for the early identification of patients with AP at risk for severe disease.MethodsWe performed a prospective study of 163 nonconsecutive patients with AP, of whom 25 had severe AP according to the revised Atlanta criteria. Admission serum levels of 48 cytokines and growth factors were determined using Bio-Plex Pro Human Cytokine Assay 21-plex and 27-plex magnetic bead suspension panels. Admission plasma levels of C-reactive protein (CRP), creatinine and calcium were measured for comparison. In subgroup analyses, we assessed the cytokine profiles of patients with severe AP (n = 14) who did not have organ dysfunction (OD) upon admission (modified Marshall score <2).ResultsOf 14 cytokines elevated in the severe AP group, interleukin 6 (IL-6) and hepatocyte growth factor (HGF) levels were independent prognostic markers of severe AP. IL-6, HGF and a combination of them predicted severe AP with sensitivities of 56.0%, 60.0% and 72.0%, respectively, and specificities of 90.6%, 92.8% and 89.9%, respectively. The corresponding positive likelihood ratio (LR+) values were 5.9, 8.3 and 7.1, respectively. The predictive values of CRP, creatinine and calcium were comparable to those of the cytokines. In subgroup analyses of patients with severe AP and without OD upon admission, we found that IL-8, HGF and granulocyte colony-stimulating factor (G-CSF) levels predicted the development of severe AP, with G-CSF being the most accurate cytokine at a sensitivity of 35.7%, a specificity of 96.1% and a LR+ of 9.1.ConclusionsIL-6 and HGF levels upon admission have prognostic value for severe AP which is similar to levels of CRP, creatinine and calcium. Although IL-6 and HGF, as either single or combined markers, were not perfect in identifying patients at risk for severe AP, the possibility that combining them with novel prognostic markers other than cytokines might improve prognostic accuracy needs to be studied. The accuracy of IL-8, HGF and G-CSF levels in predicting severe AP in patients without clinical signs of OD upon admission warrants larger studies.

Risk of colon cancer after computed tomography-diagnosed acute diverticulitis: is routine colonoscopy necessary?

BackgroundCurrent guidelines recommend computed tomography (CT) for diagnosing diverticulitis and for routine follow-up colonoscopy to rule out cancer. Scientific data to support routine colonoscopy after acute diverticulitis are scarce and conflicting. This study aimed to evaluate the risk of colon cancer mimicking diverticulitis, and hence the need for routine colonoscopy after CT-diagnosed acute diverticulitis.MethodsThis study was a retrospective analysis of patients treated for acute diverticulitis in a single academic institution during 2006–2010. Data regarding age, sex, laboratory parameters, prior diverticulitis, surgical operations, pathology reports, and CT characteristics were collected. Risk factors for finding colon cancer after CT-diagnosed acute diverticulitis were identified by multivariate analysis.ResultsThe study enrolled 633 patients with CT-diagnosed acute diverticulitis. Of these patients, 97 underwent emergency resection, whereas 536 were treated conservatively, 394 of whom underwent colonoscopy. The findings showed 17 cancers (2.7xa0%) in patients with an initial diagnosis of acute diverticulitis. As shown by CT, 16 cancer patients (94xa0%) had abscess, whereas one patient had pericolic extraluminal air but no abscess. Of the patients with abscess, 11.4xa0% had cancer mimicking acute diverticulitis. No cancer was found in the patients with uncomplicated diverticulitis. Besides abscess, other independent risk factors for cancer included suspicion of cancer by a radiologist, thickness of the bowel wall exceeding 15xa0mm, no diverticula observed, and previously undiagnosed metastases.ConclusionsRoutine colonoscopy after CT-proven uncomplicated diverticulitis seems to be unnecessary, but colonoscopy should be performed for patients with a diagnosis of diverticular abscess.

A new adult appendicitis score improves diagnostic accuracy of acute appendicitis--a prospective study.

BackgroundThe aim of the study was to construct a new scoring system for more accurate diagnostics of acute appendicitis. Applying the new score into clinical practice could reduce the need of potentially harmful diagnostic imaging.MethodsThis prospective study enrolled 829 adults presenting with clinical suspicion of appendicitis, including 392 (47%) patients with appendicitis. The collected data included clinical findings and symptoms together with laboratory tests (white cell count, neutrophil count and C-reactive protein), and the timing of the onset of symptoms. The score was constructed by logistic regression analysis using multiple imputations for missing values. Performance of the constructed score in patients with complete data (nu2009=u2009725) was compared with Alvarado score and Appendicitis inflammatory response score.Results343 (47%) of patients with complete data had appendicitis. 199 (58%) patients with appendicitis had score value at least 16 and were classified as high probability group with 93% specificity.Patients with score below 11 were classified as low probability of appendicitis. Only 4% of patients with appendicitis had a score below 11, and none of them had complicated appendicitis. In contrast, 207 (54%) of non-appendicitis patients had score below 11. There were no cases with complicated appendicitis in the low probability group. The area under ROC curve was significantly larger with the new score 0.882 (95% CI 0.858 – 0.906) compared with AUC of Alvarado score 0.790 (0.758 – 0.823) and Appendicitis inflammatory response score 0.810 (0.779 – 0.840).ConclusionsThe new diagnostic score is fast and accurate in categorizing patients with suspected appendicitis, and roughly halves the need of diagnostic imaging.

Upregulated but insufficient generation of activated protein C is associated with development of multiorgan failure in severe acute pancreatitis

IntroductionDisturbed protein C (PC) pathway homeostasis might contribute to the development of multiple organ failure (MOF) in acute pancreatitis (AP). We therefore evaluated circulating levels of PC and activated protein C (APC), evaluated monocyte deactivation in AP patients, and determined the relationship of these parameters to MOF.Patients and methodsThirty-one patients in the intensive care unit were categorized as cases (n = 13, severe AP with MOF) or controls (n = 18, severe AP without MOF). Blood samples were drawn every second day to determine the platelet count, the levels of APC, PC, and D-dimer, and the monocyte HLA-DR expression using flow cytometry. The APC/PC ratio was used to evaluate turnover of PC to APC.ResultsDuring the initial two weeks of hospitalization, low PC levels (<70% of the adult mean) occurred in 92% of cases and 44% of controls (P = 0.008). The minimum APC level was lower in cases than in controls (median 85% versus 97%, P = 0.009). Using 87% as the cut-off value, 8/13 (62%) cases and 3/18 (17%) controls showed reduced APC levels (P = 0.021). A total of 92% of cases and 50% of controls had APC/PC ratios exceeding the upper normal limit (P = 0.013). Plasma samples drawn before MOF showed low PC levels and high APC/PC ratios. HLA-DR-positive monocytes correlated with PC levels (r = 0.38, P < 0.001) and APC levels (r = 0.27, P < 0.001), indicating that the PC pathway was associated with systemic inflammation-triggered immune suppression.ConclusionPC deficiency and decreased APC generation in severe AP probably contributed to a compromised anticoagulant and anti-inflammatory defence. The PC pathway defects were associated with the development of MOF. The data support feasibility of testing the use of APC or PC to improve the clinical outcome in AP.

Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial

BackgroundLaparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published.Methods/DesignThis is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years.DiscussionTo the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction.Trial registrationClinicalTrials.gov identifier:NCT01867528. Date of registration May 26th 2013.

Components separation technique is feasible for assisting delayed primary fascial closure of open abdomen

Background and aims: The goal after open abdomen treatment is to reach primary fascial closure. Modern negative pressure wound therapy systems are sometimes inefficient for this purpose. This retrospective chart analysis describes the use of the ‘components separation’ method in facilitating primary fascial closure after open abdomen. Material and methods: A total of 16 consecutive critically ill surgical patients treated with components separation during open abdomen management were analyzed. No patients were excluded. Results: Primary fascial closure was achieved in 75% (12/16). Components separation was performed during ongoing open abdomen treatment in 7 patients and at the time of delayed primary fascial closure in 9 patients. Of the former, 3/7 (43%) patients reached primary fascial closure, whereas all 9 patients in the latter group had successful fascial closure without major complications (pu2009=u20090.019). Conclusion: Components separation is a useful method in contributing to successful primary fascial closure in patients treated for open abdomen. Best results were obtained when components separation was performed simultaneously with primary fascial closure at the end of the open abdomen treatment.

Early inflammatory response in acute pancreatitis is little affected by body mass index.

Objective. Obesity is a known risk factor for severe acute pancreatitis (AP), but the mechanism by which it affects the severity of AP is not fully understood. The main objective of this study was to investigate the relationship between obesity and inflammatory markers in AP. Material and methods. Thirty patients with AP who developed organ failure (Group I) and 87 patients with AP who survived without organ failure (Group II) were studied. Patients’ height and weight were measured at admission for calculation of body mass index (BMI). Blood samples were taken at admission for measurement of plasma interleukin (IL)-1β, IL-6, IL-10, IL-1 receptor antagonist, procalcitonin, C-reactive protein (CRP) and monocyte human leucocyte antigen (HLA)-DR expression. Results. Group I patients had higher BMI values (median 26.2 kg/m2) than Group II patients (25.2 kg/m2), p=0.033. Both CRP values and monocyte HLA-DR expression showed a significant correlation with BMI (Spearmans rank correlation r=0.32, p=0.003 and r=−0.33, p=0.002, respectively). The correlation between BMI and monocyte HLA-DR expression was significant in Group II patients (r=−0.34, p=0.002) but not in Group I patients (r=−0.02, p>0.05). There was no correlation between BMI and IL-1β, IL-6, IL-10, IL-1 receptor antagonist or procalcitonin. Conclusions. BMI did not affect either pro-inflammatory or anti-inflammatory cytokine levels in early AP. However, in patients with mild AP, BMI correlated positively with CRP levels and inversely with monocyte HLA-DR expression, which might reflect an amplified inflammatory response in these patients. Taken together, acute inflammatory response in AP, which ultimately determines the severity of AP, was little affected by BMI.

High admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis

PurposeDebate on the effect of in-hospital delay on the risk of perforation in appendicitis persists, and the results from previous studies are controversial. The aims of this study were to present the effect of in-hospital delay on the risk of perforation in appendicitis and to assess the utility of C-reactive protein (CRP) measurement in detecting the patients with complicated appendicitis.MethodsProspectively collected data of 389 adult patients who underwent surgery for acute appendicitis were analyzed in order to find the most accurate method for recognizing the pre-hospital perforations. The effect of in-hospital delay on the further risk of perforation in patients with not yet perforated acute appendicitis was then analyzed.ResultsOut of 389 patients with appendicitis, 91 patients (23.4xa0%) had complicated appendicitis, 23 with abscess, and 68 with free perforation. Admission CRP level of 99xa0mg/l or higher was 90.3xa0% specific for complicated appendicitis. In patients with admission CRP less than 99xa0mg/l, the incidence of perforation doubled from 9.5 to 18.9xa0% when the in-hospital delay increased from less than 6xa0h to more than 12xa0h.ConclusionsComplicated appendicitis can be identified with a high CRP level on admission. Delaying surgery can increase the risk of perforation.