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- Andersson, M., et al.
(författare)
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The appendicitis inflammatory response score : A tool for the diagnosis of acute appendicitis that outperforms the Alvarado score
- 2008
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 32:8, s. 1843-1849
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Tidskriftsartikel (refereegranskat)abstract
- Background: The clinical diagnosis of appendicitis is a subjective synthesis of information from variables with ill-defined diagnostic value. This process could be improved by using a scoring system that includes objective variables that reflect the inflammatory response. This study describes the construction and evaluation of a new clinical appendicitis score. Methods: Data were collected prospectively from 545 patients admitted for suspected appendicitis at four hospitals. The score was constructed from eight variables with independent diagnostic value (right-lower-quadrant pain, rebound tenderness, muscular defense, WBC count, proportion neutrophils, CRP, body temperature, and vomiting) in 316 randomly selected patients and evaluated on the remaining 229 patients. Ordered logistic regression was used to obtain a high discriminating power with focus on advanced appendicitis. Diagnostic performance was compared with the Alvarado score. Results: The ROC area of the new score was 0.97 for advanced appendicitis and 0.93 for all appendicitis compared with 0.92 (p = 0.0027) and 0.88 (p = 0.0007), respectively, for the Alvarado score. Sixty-three percent of the patients were classified into the low- or high-probability group with an accuracy of 97.2%, leaving 37% for further investigation. Seventy-three percent of the nonappendicitis patients, 67% of the advanced appendicitis, and 37% of all appendicitis patients were correctly classified into the low- and high-probability zone, respectively. Conclusion: This simple clinical score can correctly classify the majority of patients with suspected appendicitis, leaving the need for diagnostic imaging or diagnostic laparoscopy to the smaller group of patients with an indeterminate scoring result. © 2008 Société Internationale de Chirurgie.
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- Andersson, Roland, 1950-
(författare)
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The natural history and traditional management of appendicitis revisited : spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis
- 2007
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 31:1, s. 86-92
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Tidskriftsartikel (refereegranskat)abstract
- Background The principle of early exploration on wide indications in order to prevent perforation has been the guiding star for the management of patients with suspected appendicitis for over 100 years, dating back to a time when appendicitis was a significant cause of mortality. Since then there has been a dramatic decrease in mortality due to appendicitis. Emerging evidence calls for a new understanding of the natural history of untreated appendicitis. This motivates a reappraisal of the fundamental principles for the management of patients with suspected appendicitis. Methods Analysis of epidemiologic and clinical studies that elucidate the natural history of appendicitis, i.e. the possibility of spontaneous resolution or the risk of progression to perforation, the determinants of the proportion of perforations and mortality, and the consequence of in-hospital delay. Results The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that perforation can seldom be prevented, that the risk of perforation has been exaggerated and that in-hospital delay is safe. An alternative understanding of the inverse relationship between the proportion of negative explorations and perforation and the increasing proportion of perforation with length of time is presented, mainly explaining these findings by selection due to spontaneous resolution. Conclusion Evidence suggests that spontaneous resolution of untreated, non-perforated appendicitis is common and that perforation can rarely be prevented and is associated with a lower increase in mortality than was previously thought. This motivates a shift in focus from the prevention of perforation to the early detection and treatment of advanced appendicitis. In order to minimize mortality, morbidity and costs avoidance of negative appendectomies is more important then preventing perforation. In patients with an equivocal diagnosis where advanced appendicitis is deemed less likely a correct diagnosis is more important than a rapid diagnosis. These patients can safely be managed by active observation with an improved diagnostic work-up under observation, which has consistently shown a low proportion of negative appendectomies without an increase in the proportion of perforations or morbidity. A high proportion of perforations can be explained by selection due to undiagnosed resolving appendicitis. The proportion of perforation is therefore a questionable measure of the quality of the management of patients with suspected appendicitis and should be used with caution.
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- Bergenfelz, Anders, et al.
(författare)
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Serum levels of uric acid and diabetes mellitus influence survival after surgery for primary hyperparathyroidism: A prospective cohort study
- 2007
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 1432-2323 .- 0364-2313. ; 31:7, s. 1393-1402
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Tidskriftsartikel (refereegranskat)abstract
- Background Primary hyperparathyroidism (pHPT) is associated with an increased mortality attributable to cardiovascular disease (CVD), suggested to be alleviated by surgery. The exact mechanism of the beneficial influence of parathyroidectomy on survival is unknown. Furthermore, studies suggest that there is no increased mortality compared to the mortality rate in the general population during recent years. This study therefore investigated relative survival (RS), as well overall mortality associated with the clinical and biochemical variables in patients undergoing operation for sporadic pHPT. Furthermore, the influence of surgery on biochemical variables associated with pHPT was analyzed. Methods A group of 323 patients with sporadic pHPT operated between September 1989 and July 2003 were followed from surgery over a 10-year period. The median and mean follow-up time was 69 and 70 months, respectively (range: 1-120 months). Relative survival (RS) was calculated, and the impact of clinical and biochemical variables on overall death were evaluated. Results Postoperatively, serum levels of triglycerides and uric acid decreased. Glucose levels and glomerular filtration rate remained unchanged. A decreased RS was evident during the latter part of the 10 year follow-up period. In the multivariate Cox-analysis, diabetes mellitus (hazard ratio [HR] = 2.8, 95%; confidence interval [CI] 1.2-6.7), and the combination of an increased level of serum uric acid and cardiovascular disease (CVD) (HR = 8.6, 95%; CI 1.5-49.7) was associated with a higher mortality. The increased risk of death was evident for patients with persistently increased levels of uric acid postoperatively (HR = 4.8, 95%; CI = 1.4-16.01) Conclusions Patients undergoing operation for pHPT had a decreased RS during a 10-year follow-up compared to the general population. This decrease in RS is associated with diabetes mellitus and increased levels of uric acid pre-and postoperatively.
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- Bergquist, Henrik, 1969, et al.
(författare)
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Functional and radiological evaluation of free jejunal transplant reconstructions after radical resection of hypopharyngeal or proximal esophageal cancer
- 2007
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Ingår i: World J Surg. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 31:10, s. 1988-95
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Tidskriftsartikel (refereegranskat)abstract
- Cancer of the pharyngoesophageal junction (PEJ) is associated with late onset of symptoms, high morbidity, and a dismal prognosis. Radical surgery with pharyngolaryngectomy and reconstruction with a free vascularized jejunal transplant has been increasingly practiced in the treatment of these patients. This strategy is not devoid of challenges, and the present study is aimed at evaluating the long-term functional outcome among patients who have undergone such surgical treatment. Ten patients (mean age 59 years) with a mean follow-up time of 54 months were included. Clinical assessment, health-related quality of life (HRQL) questionnaires, and a standardized radiography examination were used for evaluation. The Karnofsky index ranged from 60 to 90 (mean 82). Global QL scores (EORTC QLQ-C30) had a mean value of 74, and the mean scores for dysphagia-related items of the EORTC QLQ OES-18 questionnaire were within the lower range. Radiographic signs of disturbed bolus transport through the jejunal transplant were found in all patients examined despite the grading of dysphagia from 0 to 1. The Watson dysphagia score varied between 0.5 and 45.0 (mean 16.2). No correlations were found between radiographic findings and the clinical evaluations or the outcomes assessed by the HRQL questionnaires. HRQL was found to be generally good after cancer of the PEJ and jejunal transplant insertion. Most patients reported mild dysphagia. Radiologic signs of disturbed bolus passage were common, but their clinical impact seemed questionable.
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- Björck, Martin, et al.
(författare)
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Classification : important step to improve management of patients with an open abdomen
- 2009
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 33:6, s. 1154-1157
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Tidskriftsartikel (refereegranskat)abstract
- This short report is a distillation of the proceedings from a consensus group meeting in January 2009. It outlines a proposed classification system for patients with an open abdomen (OA). The classification allows (1) a description of the patient's clinical course; (2) standardized clinical guidelines for improving OA management; and (3) improved reporting of OA status, which will facilitate comparisons between studies and heterogeneous patient populations. The following grading is suggested: grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization); grade 1B, contaminated OA without adherence/fixity; grade 2A, clean OA developing adherence/fixity; grade 2B, contaminated OA developing adherence/fixity; grade 3, OA complicated by fistula formation; grade 4, frozen OA with adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this classification system will facilitate communication, clarify OA management, and potentially improve patient care.
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- Brauckhoff, M., et al.
(författare)
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Limitations of intraoperative adrenal remnant volume measurement in patients undergoing subtotal adrenalectomy
- 2008
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 32:5, s. 863-872
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Tidskriftsartikel (refereegranskat)abstract
- Background: Recent studies have shown that a minimum of approximately one-third of one normal adrenal gland is required for sufficient adrenocortical stress capacity. Correlation between intraoperative measurement, determination of remnant size by computed tomography (CT), and adrenocortical stress capacity has not been examined so far. Methods: Twenty-two patients with familial pheochromocytoma (n = 13), sporadic pheochromocytoma (n = 3), and adrenocortical tumors (n = 6) who underwent unilateral or bilateral subtotal adrenalectomy (STAE, 28 adrenal remnants) were prospectively studied. Patients were examined in a multi-slice CT to determine residual adrenal tissue and by ACTH test 4 days and 3 months postoperatively. Results: There was a slight significant correlation between intraoperative and CT calculated volumes (r = 0.77, p < 0.001). However, volumes assessed by CT were almost doubled compared with intraoperative determination (p < 0.001). Although recovery of adrenal function could be observed, no significant changes of remnant volumes could be detected within 3 months. In patients with familial pheochromocytoma, there was a significant correlation between residual adrenal volume and stimulated cortisol levels (P < 0.001). A distinct minimum of adrenal volume for intact adrenocortical stress capacity could not be exactly determined, however, in one patient with only 10% residual adrenal tissue intact stress capacity was found. Conclusions: Residual adrenal tissue of approximately 10-15% offers intact stress capacity. However, an exact determination of the size of an adrenal remnant after STAE has limitations. CT gives larger volumes compared with intraoperative determination. For calculation of a volume-function correlation of residual adrenal tissue, in clinical practice, the determination of relative adrenal residual volume is acceptable. © 2008 Société Internationale de Chirurgie.
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