Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial

Importance

Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking.

Objective

To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up.

Design, Setting, and Participants

This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298).

Interventions

Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days.

Main Outcomes and Measures

The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design.

Results

After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave.

Conclusions and Relevance

This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03236961.

Is reassessment of Computed Tomography Reports Worthwhile in Acute Diverticulitis?

INTRODUCTION

Since the assessment of the disease severity in acute diverticulitis (AD) is of utmost importance to determine the optimal treatment and the need for follow-up investigations, we wanted to investigate whether the first CT report is compatible with daytime reassessment report and whether the value of initial report changes according to the experience of the radiologist.

METHODS

Consecutive patients from tertiary referral centre with AD were included. CT images done in the emergency department were initially analysed by either resident radiologists or consultant radiologists and then later reanalysed by consultant abdominal radiologists. Discrepancies between reports were noted.

RESULTS

Of total of 562 patients with AD, CT images were reanalysed in 439 cases. In 22 reports (5.0%) the final report was significantly different from the initial report and management changed in 20 cases. In reports of uncomplicated acute diverticulitis, reanalysis changed initial assessment in 4.0% of the cases and in complicated acute diverticulitis (CAD) in 9.1%. When consultant and resident radiologists were compared, there was no significant difference.

CONCLUSION

Although no statistical difference could be noted between residents and consultants, the final report was significantly different in overall 5% of the cases when reanalysed at normal working hours by an experienced consultant abdominal radiologist. Therefore, we conclude that reassessment of CT reports is worthwhile in AD.

Role of land cover in Finland's greenhouse gas emissions

We present regionally aggregated emissions of greenhouse gases (GHG) from five land cover categories in Finland: artificial surfaces, arable land, forest, waterbodies, and wetlands. Carbon (C) sequestration to managed forests and unmanaged wetlands was also assessed. Models FRES and ALas were applied for emissions (CO2, CH4, N2O) from artificial surfaces and agriculture, and PREBAS for forest growth and C balance. Empirical emission coefficients were used to estimate emissions from drained forested peatland (CH4, N2O), cropland (CO2), waterbodies (CH4, CO2), peat production sites and undrained mires (CH4, CO2, N2O). We calculated gross emissions of 147.2 ± 6.8 TgCO2eq yr-1 for 18 administrative units covering mainland Finland, using data representative of the period 2017-2025. Emissions from energy production, industrial processes, road traffic and other sources in artificial surfaces amounted to 45.7 ± 2.0 TgCO2eq yr-1. The loss of C in forest harvesting was the largest emission source in the LULUCF sector, in total 59.8 ± 3.3 TgCO2eq yr-1. Emissions from domestic livestock production, field cultivation and organic soils added up to 12.2 ± 3.5 TgCO2eq yr-1 from arable land. Rivers and lakes (13.4 ± 1.9 TgCO2eq yr-1) as well as undrained mires and peat production sites (14.7 ± 1.8 TgCO2eq yr-1) increased the total GHG fluxes. The C sequestration from the atmosphere was 93.2 ± 13.7 TgCO2eq yr-1. with the main sink in forest on mineral soil (79.9 ± 12.2 TgCO2eq yr-1). All sinks compensated 63% of total emissions and thus the net emissions were 53.9 ± 15.3 TgCO2eq yr-1, or a net GHG flux per capita of 9.8 MgCO2eq yr-1.

Modelling the regional potential for reaching carbon neutrality in Finland: Sustainable forestry, energy use and biodiversity protection

The EU aims at reaching carbon neutrality by 2050 and Finland by 2035. We integrated results of three spatially distributed model systems (FRES, PREBAS, Zonation) to evaluate the potential to reach this goal at both national and regional scale in Finland, by simultaneously considering protection targets of the EU biodiversity (BD) strategy. Modelling of both anthropogenic emissions and forestry measures were carried out, and forested areas important for BD protection were identified based on spatial prioritization. We used scenarios until 2050 based on mitigation measures of the national climate and energy strategy, forestry policies and predicted climate change, and evaluated how implementation of these scenarios would affect greenhouse gas fluxes, carbon storages, and the possibility to reach the carbon neutrality target. Potential new forested areas for BD protection according to the EU 10% protection target provided a significant carbon storage (426-452 TgC) and sequestration potential (- 12 to - 17.5 TgCO2eq a-1) by 2050, indicating complementarity of emission mitigation and conservation measures. The results of the study can be utilized for integrating climate and BD policies, accounting of ecosystem services for climate regulation, and delimitation of areas for conservation.

Risk for colorectal cancer after computed tomography verified acute diverticulitis: A retrospective cohort study with long-term follow-up

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) can mimic acute diverticulitis and can thus be misdiagnosed. Therefore, colonic evaluation is recommended after an episode of acute diverticulitis. The aim of this study was to analyze the risk of CRC after computed tomography (CT) verified uncomplicated and complicated acute diverticulitis in short-term and, particularly, long-term follow-up to ensure the feasibility of the primary CT imaging in separating patients with uncomplicated and complicated acute diverticulitis.

METHODS

A retrospective cohort study was conducted in patients with CT-verified acute diverticulitis in 2003-2012. Data on CT findings and colonic evaluations were analyzed. The patients were divided into those with uncomplicated and complicated acute diverticulitis. Patient charts were reviewed 9-18 years after the initial acute diverticulitis episode.

RESULTS

The study population consisted of 270 patients. According to CT scans, 170 (63%) patients had uncomplicated acute diverticulitis and 100 (37%) had complicated acute diverticulitis. Further colonic evaluation was made in 146 (54%) patients. In the whole study population, CRC was found in 7 (2.6%) patients, but CRC was associated with acute diverticulitis in only 4 (1.5%) patients. The short-term risk for CRC was 0.6% (1/170) in uncomplicated acute diverticulitis and 3.0% (3/100) in complicated acute diverticulitis. No additional CRC was found in patients with complicated acute diverticulitis during the long-term follow-up and three cases of CRC found after uncomplicated acute diverticulitis had no observable association with previous diverticulitis.

CONCLUSIONS

In short-term follow-up, the risk of underlying CRC is very low in CT-verified uncomplicated acute diverticulitis but increased in complicated acute diverticulitis. Long-term follow-up revealed no additional CRCs associated with previous acute diverticulitis, indicating that the short-term results remain consistent also in the long run. These long-term results confirm that colonoscopy should be reserved for patients with complicated acute diverticulitis or with persisting or alarming symptoms.

Appendiceal microbiome in uncomplicated and complicated acute appendicitis: A prospective cohort study

Background

Uncomplicated and complicated acute appendicitis seem to be two different forms of this common abdominal emergency. The contribution of appendiceal microbiota to appendicitis pathogenesis has been suggested, but differences between uncomplicated and complicated appendicitis are largely unknown. We compared the appendiceal microbiota in uncomplicated and complicated acute appendicitis.

Methods

This prospective single-center clinical cohort study was conducted as part of larger multicenter MAPPAC trial enrolling adult patients with computed tomography or clinically confirmed uncomplicated or complicated acute appendicitis. The microbial composition of the appendiceal lumen was determined using 16S rRNA gene amplicon sequencing.

Results

Between April 11, 2017, and March 29, 2019, 118 samples (41 uncomplicated and 77 complicated appendicitis) were available. After adjusting for age, sex, and BMI, alpha diversity in complicated appendicitis was higher (Shannon p = 0.011, Chao1 p = 0.006) compared to uncomplicated appendicitis. Microbial compositions were different between uncomplicated and complicated appendicitis (Bray-Curtis distance, P = 0.002). Species poor appendiceal microbiota composition with specific predominant bacteria was present in some patients regardless of appendicitis severity.

Conclusion

Uncomplicated and complicated acute appendicitis have different appendiceal microbiome profiles further supporting the disconnection between these two different forms of acute appendicitis.

Study registration

ClinicalTrials.gov NCT03257423.

Blood culture positivity in patients with acute appendicitis: A propensity score-matched prospective cohort study

BACKGROUND AND OBJECTIVE

The prevalence of bacteremia in acute appendicitis is unknown. We aimed to assess prevalence and predictive factors of bacteremia in adult patients with appendicitis.

METHODS

In this prospective propensity score-matched cohort study, patients were recruited as part of one single-center prospective observational study assessing appendicitis microbiology in concurrence with two randomized controlled trials on non-operative treatment of uncomplicated acute appendicitis. All patients evaluated for enrollment in these three trials between April 2017 and December 2018 with both a confirmed diagnosis of appendicitis and available blood culture on admission were included in this study. Potential predictive factors of bacteremia (age, sex, body mass index (BMI), body temperature, C-reactive protein (CRP), leukocyte count, comorbidities, symptom duration, and appendicitis severity) were assessed. Prevalence of bacteremia was determined by all available blood cultures followed by propensity score matching using sex, age, BMI, CRP, leukocyte count, and body temperature of the patients without available blood culture.

RESULTS

Out of the 815 patients with appendicitis, 271 patients had available blood culture and the prevalence of bacteremia was 12% (n = 33). Based on propensity score estimation, the prevalence of bacteremia in the whole prospective appendicitis cohort was 11.1%. Bacteremia was significantly more frequent in complicated acute appendicitis (15%; 29/189) compared with uncomplicated acute appendicitis (5%; 4/82) (p = 0.015). Male sex (p = 0.024) and higher body temperature (p = 0.0044) were associated with bacteremia.

CONCLUSIONS

Estimated prevalence of bacteremia in patients with acute appendicitis was 11.1%. Complicated appendicitis, male sex, and higher body temperature were associated with bacteremia in acute appendicitis.

OUP accepted manuscript

BACKGROUND

Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested.

METHODS

A double-blind, placebo-controlled, superiority RCT in adults with CT-confirmed uncomplicated acute appendicitis was designed to compare placebo with antibiotics (intravenous ertapenem followed by oral levofloxacin and metronidazole). The primary endpoint was treatment success (resolution resulting in discharge without appendicectomy within 10 days); secondary outcomes included pain scores, complications, hospital stay, and return to work.

RESULTS

From May 2017 to September 2020, 72 patients with a mean(s.d.) age of 37.5 (11.1) years were recruited at five hospitals. Six were excluded after randomization (5 early consent withdrawals, 1 randomization protocol violation), 35 were assigned to receive antibiotics, and 31 to receive placebo. Enrolment challenges (including hospital pharmacy resources in an acute-care surgery setting) meant that only the lowest sample size of three predefined scenarios was achieved. The 10-day treatment success rate was 87 (95 per cent c.i. 75 to 99) per cent for placebo and 97 (92 to 100) per cent for antibiotics. This clinical difference of 10 (90 per cent c.i. -0.9 to 21) per cent was not statistically different for the primary outcome (1-sided P = 0.142), and secondary outcomes were similar.

CONCLUSION

The lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis. Registration number: EudraCT 2015-003634-26 (https://eudract.ema.europa.eu/eudract-web/index.faces), NCT03234296 (http://www.clinicaltrials.gov).

Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study

BACKGROUND

Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT.

METHODS

This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis.

RESULTS

Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001).

CONCLUSION

Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.

Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial

BACKGROUND

Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation.

METHODS

Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method.

RESULTS

In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group (P = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99]; P = 0.01).

CONCLUSIONS

In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.

Validation of the low anterior resection syndrome score in finnish patients: preliminary results on quality of life in different lars severity groups

BACKGROUND AND AIMS

Low anterior resection syndrome is common after anterior resection for rectal cancer. Its severity can be tested with the low anterior resection syndrome score. We have translated the low anterior resection syndrome score to Finnish, and the aim of this study is to validate the translation.

MATERIALS AND METHODS

The translated Finnish low anterior resection syndrome score and European Organisation for Research and Treatment of Cancer quality-of-life questionnaire-C30 and QLQ-CR29 questionnaires were sent to 159 surviving patients operated with anterior resection for rectal adenocarcinoma between 2007 and 2014 in a tertiary referral center. Psychometric properties of the translation were evaluated in comparison to quality-of-life scales and in different risk factor groups.

RESULTS

In the study, 104 (65%) patients returned the questionnaires. Of these, 56 (54%) had major low anterior resection syndrome, 26 (25%) had minor low anterior resection syndrome, and 22 (21%) had no low anterior resection syndrome. Patients with major low anterior resection syndrome had a significantly lower quality of life and more defecatory symptoms as assessed with the European Organisation for Research and Treatment of Cancer questionnaires compared with those with no low anterior resection syndrome. Patients operated with total mesorectal excision had significantly higher low anterior resection syndrome scores compared with those operated with partial mesorectal excision (median/interquartile range 32/15 and 29/11, respectively, p = 0.037). The test-retest validity of the translation was good with an intraclass correlation coefficient of 0.77 (95% confidence interval 0.51-0.90).

CONCLUSIONS

The Finnish low anterior resection syndrome score is a valid test in the assessment of postoperative bowel function and its impact on the quality of life. It can be implemented to use during regular follow-up visits of Finnish-speaking rectal cancer patients.

Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial

IMPORTANCE

Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known.

OBJECTIVE

To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography-confirmed uncomplicated acute appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019.

INTERVENTIONS

Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days.

MAIN OUTCOMES AND MEASURES

The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference.

RESULTS

Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was -3.6% ([1-sided 95% CI, -9.7% to ∞]; P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin.

CONCLUSION AND RELEVANCE

Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03236961; EudraCT Identifier: 2015-003633-10.

Quality of Life and Patient Satisfaction at 7-Year Follow-up of Antibiotic Therapy vs Appendectomy for Uncomplicated Acute Appendicitis: A Secondary Analysis of a Randomized Clinical Trial

Importance

Long-term results support antibiotics for uncomplicated acute appendicitis as an alternative to appendectomy. To our knowledge, treatment-related long-term patient satisfaction and quality of life (QOL) are not known.

Objective

To determine patient satisfaction and QOL after antibiotic therapy and appendectomy for treating uncomplicated acute appendicitis.

Interventions

Open appendectomy vs antibiotics with intravenous ertapenem, 1 g once daily, for 3 days followed by 7 days of oral levofloxacin, 500 mg once daily, and metronidazole, 500 mg 3 times per day.

Design, Setting, and Participants

This observational follow-up of the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotics included 530 patients age 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis who were randomized to undergo appendectomy (273 [52%]) or receive antibiotics (257 [49%]). The trial was conducted from November 2009 to June 2012; the last follow-up was May 9, 2018. The data were analyzed in February 2019.

Main Outcomes and Measures

In this analysis, post hoc secondary end points of postintervention QOL (EQ-5D-5L) and patient satisfaction and treatment preference were evaluated.

Results

Of the 530 patients enrolled in the trial (appendectomy group: 273 [174 men (64%)] with a median age of 35 years; (antibiotic group: 257 [155 men (60%)] with a median age of 33 years), 423 patients (80%) were available for phone interview at a median follow-up of 7 years; 206 patients (80%) took antibiotics and 217 (79%) underwent appendectomy. Of the 206 patients taking antibiotics, 81 (39%) had undergone appendectomy. The QOL between appendectomy and antibiotic group patients was similar (median health index value, 1.0 in both groups; 95% CI, 0.86-1.0; P = .96). Patients who underwent appendectomy were more satisfied in the treatment than patients taking antibiotics (68% very satisfied, 21% satisfied, 6% indifferent, 4% unsatisfied, and 1% very unsatisfied in the appendectomy group and 53% very satisfied, 21% satisfied, 13% indifferent, 7% unsatisfied, and 6% very unsatisfied in the antibiotic group; P < .001) and in a subgroup analysis this difference was based on the antibiotic group patients undergoing appendectomy. There was no difference in patient satisfaction after successful antibiotic treatment compared with appendectomy (cumulative odds ratio [COR], 7.8; 95% CI, 0.5-1.3; P < .36). Patients with appendectomy or with successful antibiotic therapy were more satisfied than antibiotic group patients who later underwent appendectomy (COR, 7.7; 95% CI, 4.6-12.9; P < .001; COR, 9.7; 95% CI, 5.4-15.3; P < .001, respectively). Of the 81 patients taking antibiotics who underwent appendectomy, 27 (33%) would again choose antibiotics as their primary treatment.

Conclusions and Relevance

In this analysis, long-term QOL was similar after appendectomy and antibiotic therapy for the treatment of uncomplicated acute appendicitis. Patients taking antibiotics who later underwent appendectomy were less satisfied than patients with successful antibiotics or appendectomy.

Trial Registration

Clinicaltrials.gov Identifier: NCT01022567.

Correction to: Appendicolith appendicitis is clinically complicated acute appendicitis-is it histopathologically different from uncomplicated acute appendicitis

The authors regrets that a typo error found on their published paper. The correction are as follows.

Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

BACKGROUND AND AIMS

Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation.

METHODS

Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages.

RESULTS

A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes.

CONCLUSIONS

The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.

Risk of Appendiceal Neoplasm in Periappendicular Abscess in Patients Treated With Interval Appendectomy vs Follow-up With Magnetic Resonance Imaging: 1-Year Outcomes of the Peri-Appendicitis Acuta Randomized Clinical Trial

Importance

The step after conservative treatment of periappendicular abscess arouses controversy, ranging from recommendations to abandon interval appendectomy based on low recurrence rates of the precipitating diagnosis to performing routine interval appendectomy owing to novel findings of increased neoplasm risk at interval appendectomy. To our knowledge, there are no randomized clinical trials with sufficient patient numbers comparing these treatments.

Objective

To compare interval appendectomy and follow-up with magnetic resonance imaging after initial successful nonoperative treatment of periappendicular abscess.

Design, Setting, and Participants

The Peri-Appendicitis Acuta randomized clinical trial was a multicenter, noninferiority trial conducted in 5 hospitals in Finland. All patients between age 18 and 60 years with periappendicular abscess diagnosed by computed tomography and successful initial nonoperative treatment from January 2013 to April 2016 were included. Data analysis occurred from April 2016 to September 2017.

Interventions

Patients were randomized either to interval appendectomy or follow-up with magnetic resonance imaging; all patients underwent colonoscopy.

Main Outcomes and Measures

The primary end point was treatment success, defined as an absence of postoperative morbidity in the appendectomy group and appendicitis recurrence in the follow-up group. Secondary predefined end points included neoplasm incidence, inflammatory bowel disease, length of hospital stay, and days of sick leave.

Results

A total of 60 patients were included (36 men [60%]; median [interquartile range] age: interval appendectomy group, 49 [18-60] years; follow-up group, 47 [22-61] years). An interim analysis in April 2016 showed a high rate of neoplasm (10 of 60 [17%]), with all neoplasms in patients older than 40 years. The trial was prematurely terminated owing to ethical concerns. Two more neoplasms were diagnosed after study termination, resulting in an overall neoplasm incidence of 20% (12 of 60). On study termination, the overall morbidity rate of interval appendectomy was 10% (3 of 30), and 10 of the patients in the follow-up group (33%) had undergone appendectomy.

Conclusions and Relevance

The neoplasm rate after periappendicular abscess in this small study population was high, especially in patients older than 40 years. If this considerable rate of neoplasms after periappendicular abscess is validated by future studies, it would argue for routine interval appendectomy in this setting.

Trial Registration

ClinicalTrials.gov identifier: NCT03013686.

Prospective multicentre cohort trial on acute appendicitis and microbiota, aetiology and effects of antimicrobial treatment: study protocol for the MAPPAC (Microbiology APPendicitis ACuta) trial

INTRODUCTION

Based on the epidemiological and clinical data, acute appendicitis can present either as uncomplicated or complicated. The aetiology of these different appendicitis forms remains unknown. Antibiotic therapy has been shown to be safe, efficient and cost-effective for CT-confirmed uncomplicated acute appendicitis. Despite appendicitis being one of the most common surgical emergencies, there are very few reports on appendicitis aetiology and pathophysiology focusing on the differences between uncomplicated and complicated appendicitis. Microbiology APPendicitis ACuta (MAPPAC) trial aims to evaluate these microbiological and immunological aspects including immune response in the aetiology of these different forms also assessing both antibiotics non-responders and appendicitis recurrence. In addition, MAPPAC aims to determine antibiotic and placebo effects on gut microbiota composition and antimicrobial resistance.

METHODS AND ANALYSIS

MAPPAC is a prospective clinical trial with both single-centre and multicentre arm conducted in close synergy with concurrent trials APPendicitis ACuta II (APPAC II) (per oral (p.o.) vs intravenous+p.o. antibiotics, NCT03236961) and APPAC III (double-blind trial placebo vs antibiotics, NCT03234296) randomised clinical trials. Based on the enrolment for these trials, patients with CT-confirmed uncomplicated acute appendicitis are recruited also to the MAPPAC study. In addition to these conservatively treated randomised patients with uncomplicated acute appendicitis, MAPPAC will recruit patients with uncomplicated and complicated appendicitis undergoing appendectomy. Rectal and appendiceal swabs, appendicolith, faecal and serum samples, appendiceal biopsies and clinical data are collected during the hospital stay for microbiological and immunological analyses in both study arms with the longitudinal study arm collecting faecal samples also during follow-up up to 12 months after appendicitis treatment.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the Hospital District of Southwest Finland (Turku University Hospital, approval number ATMK:142/1800/2016) and the Finnish Medicines Agency. Results of the trial will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03257423.

Appendicolith appendicitis is clinically complicated acute appendicitis-is it histopathologically different from uncomplicated acute appendicitis

PURPOSE

Acute appendicitis may present as uncomplicated and complicated and these disease forms differ both epidemiologically and clinically. Complicated acute appendicitis has traditionally been defined as an appendicitis complicated by perforation or a periappendicular abscess, and an appendicolith represents a predisposing factor of complicated disease. There are histopathological differences between uncomplicated acute appendicitis and the previously established traditional forms of complicated acute appendicitis, but to our knowledge, the histopathological differences between uncomplicated acute appendicitis and complicated acute appendicitis presenting with an appendicolith have not yet been reported. The study purpose was to assess these differences with two prospective patient cohorts: (1) computed tomography (CT) confirmed uncomplicated acute appendicitis patients enrolled in the surgical treatment arm of the randomized APPAC trial comparing appendectomy with antibiotics for the treatment of uncomplicated acute appendicitis and (2) patients with CT-verified acute appendicitis presenting with an appendicolith excluded from the APPAC trial.

METHODS

The following histopathological parameters were assessed: appendiceal diameter, depth of inflammation, micro-abscesses, density of eosinophils, and neutrophils in appendiceal wall and surface epithelium degeneration.

RESULTS

Using multivariable logistic regression models adjusted for age, gender, and symptom duration, statistically significant differences were detected in the depth of inflammation ≤ 2.8 mm (adjusted OR 2.18 (95%CI: 1.29-3.71, p = 0.004), micro-abscesses (adjusted OR 2.16 (95%CI: 1.22-3.83, p = 0.008), the number of eosinophils and neutrophils ≥ 150/mm² (adjusted OR 0.97 (95%CI: 0.95-0.99, p = 0.013), adjusted OR 3.04 (95%CI: 1.82-5.09, p < 0.001, respectively).

CONCLUSIONS

These results corroborate the known clinical association of an appendicolith to complicated acute appendicitis.

Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial

BACKGROUND

The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years.

METHODS AND FINDINGS

This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy.

CONCLUSIONS

At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.

Optimising the antibiotic treatment of uncomplicated acute appendicitis: a protocol for a multicentre randomised clinical trial (APPAC II trial)

BACKGROUND

Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70-80%) or complicated (20-30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis.

METHODS

APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin.

DISCUSSION

To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.

A randomised placebo-controlled double-blind multicentre trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis: APPAC III trial study protocol

INTRODUCTION

Recent studies show that antibiotic therapy is safe and feasible for CT-confirmed uncomplicated acute appendicitis. Spontaneous resolution of acute appendicitis has already been observed over a hundred years ago. In CT-confirmed uncomplicated acute diverticulitis (left-sided appendicitis), studies have shown no benefit from antibiotics compared with symptomatic treatment, but this shift from antibiotics to symptomatic treatment has not yet been widely implemented in clinical practice. Recently, symptomatic treatment of uncomplicated acute appendicitis has been demonstrated in a Korean open-label study. However, a double-blinded placebo-controlled study to illustrate the role of antibiotics and spontaneous resolution of uncomplicated acute appendicitis is still lacking.

METHODS AND ANALYSIS

The APPAC III (APPendicitis ACuta III) trial is a multicentre, double-blind, placebo-controlled, superiority randomised study comparing antibiotic therapy with placebo in the treatment CT scan-confirmed uncomplicated acute appendicitis aiming to evaluate the role of antibiotics in the resolution of uncomplicated acute appendicitis. Adult patients (18-60 years) with CT scan-confirmed uncomplicated acute appendicitis (the absence of appendicolith, abscess, perforation and tumour) will be enrolled in five Finnish university hospitals.Primary endpoint is success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without surgical intervention within 10 days after initiating randomised treatment (treatment efficacy). Secondary endpoints include postintervention complications, recurrent symptoms after treatment up to 1 year, late recurrence of acute appendicitis after 1 year, duration of hospital stay, sick leave, treatment costs and quality of life. A decrease of 15 percentage points in success rate is considered clinically important difference. The superiority of antibiotic treatment compared with placebo will be analysed using Fisher's one-sided test and CI will be calculated for proportion difference.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee of Turku University Hospital and the Finnish Medicines Agency (FIMEA). The findings will be disseminated in peer-reviewed academic journals.

TRIAL REGISTRATION NUMBER

NCT03234296; Pre-results.

Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up

PURPOSE

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.

METHODS

A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3-4) rectal cancer with APE in 2004-2009 were compared to patients with similar tumors operated with ELAPE in 2009-2016.

RESULTS

Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.

CONCLUSIONS

We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial

BACKGROUND

An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial.

METHODS

The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012.

RESULTS

Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models.

CONCLUSION

Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.

A Simple Dynamic Model of Soil Test Phosphorus Responses to Phosphorus Balances

Soil test P (STP) concentration indicates whether annual P applications can be expected to give yield increases and can also indicate an elevated risk of P mobilization and potential for P transfer to surface waters and groundwater from a particular field. Changes in STP with time thus project agronomic benefits and environmental risks of different P use strategies. To predict STP changes with time, we constructed a simple dynamic model for which the input variables are P balance and initial STP. The model parameters (soil type-specific constants) were fitted using data originating from 44 P fertilizer experiments with different P rates. Model performance was evaluated using independent data sets that either had reasonably accurate input values ( = 103) or were obtained from farmers through interviews ( = 638). The simulations were in agreement with measured STP changes for both evaluation data sets when fittings were performed separately for four main soil types (clays, silts, coarse mineral soils, and organic soils). Statistical analysis confirmed that the model captured the trends in STP (NHOAc test) with acceptable accuracy and precision, with of 0.83 and 0.66 for the data with more accurate input and for farmer interview data, respectively; the corresponding model efficiency statistics were 0.88 and 0.66. The model is not restricted to use with one soil test, as fittings for several different types of soil tests can be generated. In this study, we fitted the model for Olsen P data retrieved from the literature. Agronomic use of the model includes evaluation of P use strategies, e.g., when a certain STP level is targeted or when long-term economy of P use is calculated. In an environmental context, the model can be used to predict STP changes with time under variable P balance regimes, which is essential for realistic assessment of changes in the potential for dissolved P losses.

Randomized multicenter study of multiple plastic stents vs. covered self-expandable metallic stent in the treatment of biliary stricture in chronic pancreatitis

BACKGROUND AND STUDY AIMS

The use of covered self-expandable metallic stents (cSEMS) in benign biliary indications is evolving. The aim of the study was to assess the safety and feasibility of cSEMS compared with multiple plastic stents in the treatment of benign biliary stricture (BBS) caused by chronic pancreatitis.

PATIENTS AND METHODS

This was a prospective, multicenter, randomized study of 60 patients with BBS caused by chronic pancreatitis. All patients received an initial plastic stent before randomization. At randomization, the stent was replaced either with a single cSEMS or three plastic stents. After 3 months, the position of the cSEMS was checked or another three plastic stents were added. At 6 months after randomization, all stents were removed. Clinical follow-up including abdominal ultrasound and laboratory tests were performed at 6 months and 2 years after stent removal.

RESULTS

Two patients dropped out of the cSEMS group before stent removal. In April 2014, the median follow-up was 40 months (range 1 - 66 months). The 2-year, stricture-free success rate was 90 % (95 % confidence interval [CI] 72 % - 97 %) in the plastic stent group and 92 % (95 %CI 70 % - 98 %) in the cSEMS group (P = 0.405). There was one late recurrence in the plastic stent group 50 months after stent removal. Stent migration occurred three times (10 %) in the plastic stent group and twice in the cSEMS group (7 %; P = 1.000).

CONCLUSION

A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747).

Accuracy of 18F-FDG PET/CT, Multidetector CT, and MR Imaging in the Diagnosis of Pancreatic Cysts: A Prospective Single-Center Study

Accurate diagnosis of the nature of pancreatic cysts is challenging but more important than ever, in part because of the increasing number of incidental cystic findings in the pancreas. Preliminary data suggest that (18)F-FDG PET/CT may have a significant influence on clinical decision making, although its role is still evolving. Our aim was to prospectively compare the accuracy of combined (18)F-FDG PET and contrast-enhanced CT ((18)F-FDG PET/CT), multidetector CT (MDCT), and MR imaging in differentiating malignant from benign pancreatic cysts.

METHODS

Thirty-one consecutive patients with pancreatic cysts were enrolled in the study. They underwent a protocol including (18)F-FDG PET/CT, MDCT, and MR imaging combined with MR cholangiopancreatography, all of which were evaluated in a masked manner. The findings were confirmed macroscopically at surgery or histopathologic analysis (n = 22) or at follow-up (n = 9).

RESULTS

Of the 31 patients, 6 had malignant and 25 had benign lesions. The diagnostic accuracy was 94% for (18)F-FDG PET/CT, compared with 77% and 87% for MDCT (P < 0.05) and MR imaging, respectively. (18)F-FDG PET/CT had a negative predictive value of 100% and a positive predictive value of 75% for pancreatic cysts. The maximum standardized uptake value was significantly higher in malignant (7.4 ± 2.6) than in benign lesions (2.4 ± 0.8) (P < 0.05). When the maximum standardized uptake value was set at 3.6, the sensitivity and specificity were 100% and 88%, respectively. Furthermore, when compared with MDCT and MR imaging, respectively, (18)F-FDG PET/CT altered the clinical management of 5 and 3 patients, respectively.

CONCLUSION

(18)F-FDG PET/CT is an accurate imaging modality for differentiating between benign and malignant pancreatic cysts. We recommend the use of (18)F-FDG PET/CT in the evaluation of diagnostically challenging pancreatic cysts.

Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

BACKGROUND

The definition of a "difficult" cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP).

AIMS

To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis.

PATIENTS AND METHODS

Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure.

RESULTS

The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02-94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%.

CONCLUSIONS

If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Understanding biorefining efficiency--the case of agrifood waste

The aim of this study was to determine biorefining efficiency according to the choices made in the entire value chain. The importance of the share of biomass volume biorefined or products substituted was investigated. Agrifood-waste-based biorefining represented the case. Anticipatory scenarios were designed for contrasting targets and compared with the current situation in two Finnish regions. Biorefining increases nutrient and energy efficiency in comparison with current use of waste. System boundaries decisively influence the relative efficiency of biorefining designs. For nutrient efficiency, full exploitation of biomass potential and anaerobic digestion increase nutrient efficiency, but the main determinant is efficient substitution for mineral fertilisers. For energy efficiency, combustion and location of biorefining close to heat demand are crucial. Regional differences in agricultural structure, the extent of the food industry and population density have a major impact on biorefining. High degrees of exploitation of feedstock potential and substitution efficiency are the keys.

[Palliative surgery of the gastrointestinal tract]

Palliative surgery refers to surgical procedures that alleviate the symptoms of a patient having incurable cancer and in many cases also improve the quality of life. Regrettably often gastrointestinal cancers have progressed beyond curative surgical therapy at the time of diagnosis. Palliative surgery aims to provide a patient having an incurable cancer good-quality days of life by using treatment methods that are putting as little strain as possible on the patient. In addition to clinical expertise, communication skills are an essential part of palliative surgery know-how.

How to cannulate? A survey of the Scandinavian Association for Digestive Endoscopy (SADE) in 141 endoscopists

Cannulation of the papilla vateri represents an enigmatic first step in endoscopic retrograde cholangiopancreaticography (ERCP). In light of falling numbers of (diagnostic) ERCP and novel techniques, e.g. short-wire system, we were interested in the approach novice and experienced endoscopist are taking; especially, what makes a papilla difficult to cannulate and how to approach this. We devised a structured online questionnaire, sent to all endoscopists registered with SADE, the Scandinavian Association for Digestive Endoscopy. A total of 141 responded. Of those, 49 were experienced ERCP-endoscopists (>900 ERCPs). The first choice of cannulation is with a sphincterotome and a preinserted wire. Both less experienced and more experienced endoscopists agreed on the criteria to describe a papilla difficult to cannulate and both would choose the needle-knife sphincterotomy (NKS) to get access to the bile duct. The less experienced used more "upward" NKS, whereas the more experienced also used the "downward" NKS technique. This survey provides us with a database allowing now for a more differentiated view on cannulation techniques, success, and outcome in terms of pancreatitis.

Quality of life after surgery for rectal cancer with special reference to pelvic floor dysfunction

AIM

Conventional outcomes such as survival, tumour recurrence and complication rates after surgery for rectal cancer have been rigorously assessed, but the importance of maintaining quality of life (QOL) after surgery for rectal cancer has received less attention. The aim of the current study was to analyse QOL and the occurrence of pelvic dysfunction after the surgical treatment of rectal cancer.

METHOD

Between May 2005 and May 2008, 150 patients with rectal cancer underwent abdominoperineal resection (APR) or anterior resection (AR). Seventy-four answered two preoperative questionnaires. At a follow up of 1 year, 65 were alive without sign of recurrence and answered the same questionnaires: (a) validated RAND 36-item health survey QOL questionnaire; and (b) self-administered disease-related questionnaire with special reference to anorectal and urogenital function.

RESULTS

The postoperative general QOL was similar after surgery, and mental functioning was better (P < 0.001). Problems with physical functions were associated with anal dysfunction after AR (P < 0.001) and problems with social functioning were associated with urinary dysfunction (P = 0.038). At 1 year after surgery, urinary incontinence was worse (P = 0.026) after all operations, and the incidence of dysuria was higher after APR than AR (P = 0.001). Male sexual function also worsened (P = 0.060). Anorectal dysfunction caused more inconvenience among patients who underwent AR (P = 0.028). Preoperative radiation was associated with postoperative ejaculation problems (P = 0.028) and anal incontinence (P = 0.012).

CONCLUSION

Factors affecting QOL and pelvic floor function should be taken into account when making treatment decisions in rectal cancer.

[Fibrin glue in gastrointestinal fistulas]

Gastrointestinal fistulas are relatively uncommon, and therefore difficult to diagnose. They occur after surgical procedures and result from various diseases or injuries. The diagnosis is usually based on contrast-enhanced computed tomography. When occurring, these fistulas are associated with considerable morbidity and even mortality. One third of the fistulas heal spontaneously, while the rest have usually been operated with varying success. During the last years, gastrointestinal fistulas have been successfully treated endoscopically with fibrin glue.

Patient's age should not play a key role in clinical decisions on surgical treatment of rectal cancer

BACKGROUND AND AIMS

Recent advances in surgical techniques and adjuvant treatments have decreased morbidity and mortality in patients with rectal cancer. The aim of this study was to clarify the effects of aging on the choice, feasibility and safety of various treatment modalities in patients with rectal cancer.

PATIENTS AND METHODS

During 2003-2006, a total of 274 rectal cancers were diagnosed at Turku University Central Hospital. Patient and tumor characteristics, treatment modalities chosen, and complications were recorded, and patients were followed up prospectively for 1-3 years after treatment. Patients were then divided into two groups: under 75 (n=181) and 75 years or older (n=93) at the moment of diagnosis. Patient data in the two age groups were analysed and compared with each other.

RESULTS

Of the total of 274 patients with rectal cancer, 243 (89%) underwent surgery. The percentage of patients operated was higher (p=0.03) in the younger (92%) than in the older group (83%). The main reasons for non-operative or palliative treatment were severe concomitant diseases and metastasized cancer. Preoperative radiation therapy was given more often (p<0.01) to young (72%) than old (27%) patients. With these selections, there was no difference in 30-day postoperative mortality (1% vs 1%, ns) or postoperative complications (22% vs 34%, ns) between two groups.

CONCLUSION

With preoperative selection, patients over 75 with rectal cancer are suitable for major surgery, as morbidity and mortality rates are comparable to those in younger patients.

Thromboprophylaxis following Surgery for Colorectal Cancer — Is it Worthwhile after Hospital Discharge?

Background:

The efficacy of low-molecular-weight heparin (LMWH) in preventing venous thromboembolism (VTE) after surgery for colorectal cancer is well documented, but the optimal duration of postoperative thromboprophylaxis is not known. The aim of this retrospective study was to assess the occurrence of symptomatic VTE after surgery for colorectal cancer in patients in whom LMWH was continued only until hospital discharge.

Methods:

During 2003–2006 a total of 494 patients underwent abdominal surgery for colorectal cancer at our institution. Enoxaparin (Klexane® 40mg s.c.) prophylaxis was started 12 hours before surgery and continued once a day until hospital discharge. The median duration of thromboprophylaxis was 11 days. The follow-up data were collected retrospectively from electronic archives and analyzed up to three months after the operation.

Results:

Only three (0.6%) symptomatic VTEs occurred during the follow-up period. One patient presented with pulmonary embolism, while the remaining two had proximal deep-vein thrombosis. The 30-day-mortality was 1.6%. None of the deaths were obviously associated with VTE.

Conclusion:

LMWH given for a median of 11 days until hospital discharge seems to provide sufficient thromboprophylaxis after surgery for colorectal cancer combined with the use of graded compression stockings and early mobilization.

Biochemical and clinical approaches in evaluating the prognosis of colon cancer

BACKGROUND

Colorectal adenocarcinoma is a common malignant neoplasm in the Western world. To achieve optimal treatment results, the risk estimation of recurrence should be as accurate as possible.

MATERIALS AND METHODS

Tissue material from tumour and normal mucosa was taken from six patients and was analysed to screen aberrantly expressed genes using cDNA microarray. Selected up-regulated genes were chosen for further analysis by immunohistochemistry. For this purpose a tissue array material of 114 colorectal cancer patients was obtained. In addition to the routinely used proliferation marker Ki-67, the analysed proteins included securin and CDC25B.

RESULTS

Processes such as cellular defense, cell structure, motility and cell division were found to be notably represented among the most deregulated genes. A significant portion of the overexpressed genes included those functioning in the cell cycle. Immunohistochemical stainings of securin and CDC25B showed a consistent expression pattern with that of cDNA microarray analysis. There was no statistical association between the studied proliferation markers and survival. Instead, there was a significant association between the Dukes' class and the histological grade (p=0.04), but not between histological grade and survival. The survival of Dukes' B patients was significantly poorer if no regional lymph nodes were studied compared with the Dukes' B patients with even a single lymph node was studied (p=0.04, hazard ratio 2.7).

CONCLUSION

Tumour stage is superior in estimating the prognosis of patients with colonic cancer compared with the grading of cell cycle regulators or histological grade of the cancer. The study of regional lymph nodes is essential to identify the patients who would benefit from adjuvant chemotherapy.

Needle-knife assisted ERCP

BACKGROUND

During endoscopic retrograde cholangiopancreatography (ERCP), incising through the wall of the major papilla with an electrocautery needle-knife is a method for achieving access into the bile duct. This procedure, often referred to as a "precut," may be used when cannulation attempts via the orifice of the papilla are unsuccessful. Potential complications include hemorrhage, duodenal perforation, and acute pancreatitis.

METHODS

The 172 patients who underwent an attempt of a needle-knife assisted ERCP during the years 1997-2003 at our institution were retrospectively evaluated.

RESULTS

A selective bile duct cannulation was achieved after needle-knife incision in 148 out of 172 patients (86%) at the primary session. In 10 additional patients (6%), a repeated procedure proved successful for cannulation. In the remaining 14 patients (8%), the biliary cannulation failed and was not attempted again. Complications after needle-knife assisted ERCP occurred as follows: three patients (2%) presented with late bleeding after the ERCP and three patients (2%) developed acute pancreatitis. None of the patients required operative treatment for complications. There was no mortality.

CONCLUSION

The use of the needle-knife markedly improves the success rate of selective biliary cannulation in ERCP without increasing the rate of complications.

Surgically treated adenocarcinomas of the right side of the colon during a ten year period: a retrospective study

BACKGROUND AND AIMS

Colon cancer is one of the most common malignancies in Finland. The purpose of the current study was to analyse the results of surgical treatment of right-sided colon cancers operated in the 1980s at Turku University Central Hospital. In addition, we compared the results to those reported from earlier decades.

MATERIAL AND METHODS

One hundred and fifty-three patients with primary proximal colon cancer were operated in 1981-1990. The results were analysed retrospectively from patient records.

RESULTS

The crude five-year survival rate of the patients was 48%. The most crucial factor affecting survival was the stage of spreading of the tumour. Obstructive tumours had a poorer prognosis than non-obstructive ones.

CONCLUSIONS

The results of surgical treatment of proximal colon cancer were satisfactory at Turku University Central Hospital and slightly better compared to earlier reports.

Surgically treated adenocarcinomas of the right side of the colon during a ten year period: a retrospective study

BACKGROUND AND AIMS

Colon cancer is one of the most common malignancies in Finland. The purpose of the current study was to analyse the results of surgical treatment of right-sided colon cancers operated in the 1980s at Turku University Central Hospital. In addition, we compared the results to those reported from earlier decades.

MATERIAL AND METHODS

One hundred and fifty-three patients with primary proximal colon cancer were operated in 1981-1990. The results were analysed retrospectively from patient records.

RESULTS

The crude five-year survival rate of the patients was 48%. The most crucial factor affecting survival was the stage of spreading of the tumour. Obstructive tumours had a poorer prognosis than non-obstructive ones.

CONCLUSIONS

The results of surgical treatment of proximal colon cancer were satisfactory at Turku University Central Hospital and slightly better compared to earlier reports.

Immune response after laparoscopic and conventional Nissen fundoplication

OBJECTIVE

To compare the changes in the immune responses of patients undergoing laparoscopic or conventional Nissen fundoplication.

DESIGN

Prospective randomised clinical study.

SETTING

University hospital, Finland.

SUBJECTS

20 patients undergoing Nissen fundoplication for symptomatic erosive oesophagitis.

INTERVENTION

Laparoscopic Nissen fundoplication (n = 10) or conventional open Nissen fundoplication (n = 10).

MAIN OUTCOME MEASURES

Leucocyte and differential counts; percentages of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD20 positive lymphocytes); and monocytes (CD 14); phytohemagglutinin, concanavalin A and pokeweed mitogen-induced and unstimulated proliferation of separated lymphocytes; plasma interleukin-6 (IL-6), serum C-reactive protein (CRP), albumin, and cortisol concentrations; and group II phospholipase A2 (PLA2) activity.

RESULTS

Laparoscopic fundoplication was associated with less tissue damage (IL-6, and CRP concentrations) than the conventional open operation. However, although there were pronounced changes in immune responses over time, there were no differences between the groups.

CONCLUSION

Laparoscopic fundoplication seemed to cause less tissue damage than the conventional open operation, but this difference was not reflected in patients' immune responses.

Diagnosis of acute pancreatitis

There is no golden standard for the diagnosis of acute pancreatitis (AP). The diagnosis is currently based on clinical presentation, measurement of released pancreatic enzymes and imaging studies. Serum/urinary amylase, lipase and trypsinogen-2 dipstick are the most applicable methods in the clinical practice largely because of their simple, rapid, inexpensive and readily available assay methods. In addition to the clinical picture, inflammatory markers (CRP) or contrast enhanced CT can be used to assess the severity of acute pancreatitis. Multifactorial scoring systems (Ranson's prognostic signs, APACHE II, MOF-score) may be too cumbersome for clinical practice. Patient history, determination of AST, bilirubin and alkaline phosphatase levels as well as imaging studies such as ultrasonography and ERCP can be used to distinguish between biliary and non-biliary origin of the disease.

Hyperamylasemia after cardiopulmonary bypass: pancreatic cellular injury or impaired renal excretion of amylase?

BACKGROUND

Postoperative hyperamylasemia and even acute pancreatitis are associated with coronary artery bypass grafting (CABG). The mechanism of hyperamylasemia and pancreatic acinar cell damage was studied in 20 patients undergoing CABG.

METHODS

Serial blood and urine samples at eight time points before, during, and 24 hours after the CABG were collected. Salivary and pancreatic isoamylases, the fractional clearance of isoamylases (i.e., relative to creatinine clearance), pancreatic phospholipase A2 (a specific serum marker of pancreatic acinar cell injury), and cystatin C (a sensitive marker of glomerular filtration rate) were measured.

RESULTS

Mild serum hyperamylasemia (300 to 1000 units/L) was found in 11 of 20 (55%) and severe (> 1000 units/L) in 6 of 20 (30%) patients with no signs of clinical acute pancreatitis. Hyperamylasemia occurred from 6 to 24 hours after the CABG and was mainly caused by pancreatic isoamylase. Serum pancreatic phospholipase A2 concentration remained unchanged, which excludes acinar cell damage. Although renal glomerular filtration was normal during CABG as measured by serum cystatin C and creatinine clearance, the fractional clearance of isoamylases decreased.

CONCLUSIONS

The decreased rate of excretion into urine, rather than pancreatic cellular damage, is the major source of hyperamylasemia after CABG.

Catalytic activity of phospholipase A2 in serum in experimental fat embolism in pigs

OBJECTIVE

To investigate the catalytic activity of phospholipase A2 in serum during the early phase of experimental fat embolism.

DESIGN

Randomised controlled experimental study.

SETTING

Animal laboratory, Finland.

SUBJECTS

18 domestic pigs weighing 25-31 kg.

INTERVENTIONS

Allogeneic bone marrow suspension at a dose of 100 mg/kg was infused intracavally in 9 anaesthetised, mechanically ventilated, and haemodynamically monitored pigs; 9 control pigs received saline.

MAIN OUTCOME MEASURES

Central haemodynamics, blood gases, catalytic activity of phospholipase A2.

RESULTS

In the fat embolism group, there were significant increases in mean pulmonary arterial pressure (p < 0.001), pulmonary vascular resistance (p < 0.001) and pulmonary shunting (p < 0.05) and simultaneously, systemic oxygenation was significantly impaired. The animals with fat embolism developed gradual fever and leucocytosis, whereas the catalytic activity of phospholipase A2 remained relatively unchanged.

CONCLUSION

In this experimental model the measurement of serum phospholipase A2 activity does not provide a useful tool for the early detection of experimental fat embolism.

Group II phospholipase A2 in serum after knee surgery and intramedullary nailing of tibial shaft fracture

This prospective study investigates the effect of injury and surgery of cartilage and bone on serum group II phospholipase A2 (PLA2-II) and C-reactive protein (CRP) levels. Serum concentrations of PLA2-II and CRP were measured before and after the operation in nine patients with closed tibial shaft fractures treated by nailing, 11 patients with fractures of lateral tibial plateau treated by bone grafting, and 19 patients with ruptured anterior cruciate ligament treated by reconstruction. The postoperative PLA2-II and CRP values were statistically significantly higher than the pre-operative values in the tibial plateau fracture and ligament rupture groups, whereas the increase in the PLA2-II values in the tibial fracture group was not statistically significant. The highest values of both parameters were found on the second postoperative day. The changes in the PLA2-II and CRP values were parallel in the lateral condyle fracture and in anterior cruciate ligament rupture groups. PLA2-II behaves as an acute phase reactant in the serum of patients undergoing acute and elective knee surgery.