Quality-of-care initiative in patients treated surgically for perforated peptic ulcer.

BACKGROUND: Mortality and morbidity are considerable after treatment for perforated peptic ulcer (PPU). Since 2003, a Danish nationwide quality-of-care (QOC) improvement initiative has focused on reducing preoperative delay, and improving perioperative monitoring and care for patients with PPU. The present study reports the results of this initiative. METHODS: This was a nationwide cohort study based on prospectively collected data, involving all hospitals caring for patients with PPU in Denmark. Details of patients treated surgically for PPU between September 2004 and August 2011 were reported to the Danish Clinical Register of Emergency Surgery. Changes in baseline patient characteristics and in seven QOC indicators are presented, including relative risks (RRs) for achievement of the indicators. RESULTS: The study included 2989 patients. An increasing number fulfilled the following four QOC indicators in 2010-2011 compared with the first 2 years of monitoring: preoperative delay no more than 6 h (59·0 versus 54·0 per cent; P = 0·030), daily monitoring of bodyweight (48·0 versus 29·0 per cent; P < 0·001), daily monitoring of fluid balance (79·0 versus 74·0 per cent; P = 0·010) and daily monitoring of vital signs (80·0 versus 68·0 per cent; P < 0·001). A lower proportion of patients had discontinuation of routine prophylactic antibiotics (82·0 versus 90·0 per cent; P < 0·001). Adjusted 30-day mortality decreased non-significantly from 2005-2006 to 2010-2011 (adjusted RR 0·87, 95 per cent confidence interval 0·76 to 1·00), whereas the rate of reoperative surgery remained unchanged (adjusted RR 0·98, 0·78 to 1·23). CONCLUSION: This nationwide quality improvement initiative was associated with reduced preoperative delay and improved perioperative monitoring in patients with PPU. A non-significant improvement was seen in 30-day mortality.

The Peptic Ulcer Perforation (PULP) score: a predictor of mortality following peptic ulcer perforation. A cohort study.

BACKGROUND: Accurate and early identification of high-risk surgical patients with perforated peptic ulcer (PPU) is important for triage and risk stratification. The objective of the present study was to develop a new and improved clinical rule to predict mortality in patients following surgical treatment for PPU. DESIGN: nationwide cohort study based on prospectively collected data. SETTING: thirty-five hospitals in Denmark. PATIENTS: a total of 2668 patients surgically treated for gastric or duodenal PPU between 1 February 2003 and 31 August 2009. OUTCOME MEASURE: 30-day mortality. RESULTS: We derived a new clinical prediction rule for 30-day mortality and evaluated and compared its prognostic performance with the American Society of Anaesthesiologists (ASA) and Boey scores. A total of 708 patients (27%) died within 30 days of surgery. The Peptic Ulcer Perforation (PULP) score - comprised eight variables with an adjusted odds ratio of more than 1.28: 1) age > 65 years, 2) active malignant disease or AIDS, 3) liver cirrhosis, 4) steroid use, 5) time from perforation to admission > 24 h, 6) pre-operative shock, 7) serum creatinine > 130 µM, and 8) the four levels of the ASA score (from 2 to 5). The score predicted mortality well (area under receiver operating characteristics curve (AUC) 0.83). It performed considerably better than the Boey score (AUC 0.70) and better than the ASA score alone (AUC 0.78). CONCLUSION: The PULP score accurately predicts 30-day mortality in patients operated for PPU and can assist in risk stratification and triage.

Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation.

BACKGROUND: Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU. METHODS: This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls. RESULTS: The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38). CONCLUSION: The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment. REGISTRATION NUMBER: NCT00624169 (http://www.clinicaltrials.gov).

Splenic injury after colonoscopy.

Splenic injury is a rare and serious complication of colonoscopy. The most likely mechanism is tension on the splenocolic ligament and adhesions. Eight cases were identified among claims for compensation submitted to the Danish Patient Insurance Association during the period 1992-2006, seven of which were reported after 2000. The total number of colonoscopies in Denmark in 2004 was 39 067. Seven of the eight patients were aged 65 years or over. Loops causing difficulties during the colonoscopy had been reported in four patients. All the patients had a symptom-free interval after the colonoscopy, ranging from 4 hours to 7 days, before presenting with signs of splenic injury. In all cases the spleen was torn, and the amount of blood in the peritoneal cavity ranged from 1500 mL to 5000 mL. Two patients died postoperatively. The number of cases reported after 2000 indicates that this potentially lethal complication might be more common than was previously assumed, and it is possibly under-reported. Preventive measures include good colonoscopic technique to avoid loop formation and the use of excessive force; and it is possible that emerging endoscopic technologies will lead to a reduced risk of splenic injury. The information given to patients both before and after the procedure should include information on the signs of this complication, and patients should be also informed that these signs can develop after a symptom-free interval.

Diagnostic performance of computed tomography colonography and colonoscopy: a prospective and validated analysis of 231 paired examinations.

BACKGROUND: Detection of colorectal tumors with computed tomography colonography (CTC) is an alternative to conventional colonoscopy (CC), and clarification of the diagnostic performance is essential for cost-effective use of both technologies. PURPOSE: To evaluate the diagnostic performance of CTC compared with CC. MATERIAL AND METHODS: 231 consecutive CTCs were performed prior to same-day scheduled CC. The radiologist and endoscopists were blinded to each other's findings. Patients underwent a polyethylene glycol bowel preparation, and were scanned in prone and supine positions using a single-detector helical CT scanner and commercially available software for image analysis. Findings were validated (matched) in an unblinded comparison with video-recordings of the CCs and re-CCs in cases of doubt. RESULTS: For patients with polyps >/=5 mm and >/=10 mm, the sensitivity was 69% (95% CI 58-80%) and 81% (68-94%), and the specificity was 91% (84-98%) and 98% (93-100%), respectively. For detection of polyps >/=5 mm and >/=10 mm, the sensitivity was 66% (57-75%) and 77% (65-89%). A flat, elevated low-grade carcinoma was missed by CTC. One cancer relapse was missed by CC, and a cecal cancer was missed by an incomplete CC and follow-up double-contrast barium enema. CONCLUSION: CC was superior to CTC and should remain first choice for the diagnosis of colorectal polyps. However, for diagnosis of lesions >/=10 mm, CTC and CC should be considered as complementary methods.

Cost-effectiveness of computed tomographic colonography: a prospective comparison with colonoscopy.

PURPOSE: To estimate the cost-effectiveness of detecting colorectal polyps with computed tomographic colonography (CTC) and subsequent polypectomy with primary colonoscopy (CC), using CC as the alternative strategy. MATERIAL AND METHODS: A marginal analysis was performed regarding 103 patients who had had CTC prior to same-day CC at two hospitals, H-I (n = 53) and H-II (n = 50). The patients were randomly chosen from surveillance and symptomatic study populations (148 at H-I and 231 at H-II). Populations, organizations, and procedures were compared. Cost data on time consumption, medication, and minor equipment were collected prospectively, while data on salaries and major equipment were collected retrospectively. The effect was the (previously published) sensitivities of CTC and CC for detection of colorectal polyps > or = 6 mm (H-I, n = 148) or > or = 5 mm (H-II, n = 231). RESULTS: Thirteen patients at each center had at least one colorectal polyp > or = 6 mm or > or = 5 mm. CTC was the cost-effective alternative at H-I (euro187 vs. euro211), while CC was the cost-effective alternative at H-II (euro239 vs. euro192). The cost-effectiveness (costs per finding) mainly depended on the sensitivity of CTC and CC, but the depreciation of equipment and the staff's use of time were highly influential as well. CONCLUSION: Detection of colorectal polyps > or = 6 mm or > or = 5 mm with CTC, followed by polypectomy by CC, can be performed cost-effectively at some institutions with the appropriate hardware and organization.

Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients.

PURPOSE: To evaluate the effectiveness and safety of percutaneous radiologic gastrostomy (PRG) under ultrasonographic (US) and fluoroscopic guidance using a simplified gastropexy technique. MATERIAL AND METHODS: One hundred and fifty-four (154) patients (mean age 73, range 22-93 years) were referred for PRG. Indication for PRG was neurologic disease, head/neck cancer, and other disease in 73%, 15%, and 12%, respectively. Initially, the stomach was filled with 300-500 cm3 of tap water via a nasogastric tube. The fluid-filled stomach was punctured under US guidance. A guidewire and a single T-fastener were introduced. Under fluoroscopic guidance, the tract was dilated over the guidewire until a 16F dilator with a peel-away sheath could be introduced. During dilatation, the external suture string to the T-fastener was held tight to fixate the gastric wall. A 14F balloon-retained gastrostomy tube was introduced and inflated. The T-fastener was then released, and the gastrostomy tube was retracted gently to affix the gastric wall to the abdominal wall (tube gastropexy). Technical success was assured by aspiration of gastric fluid and fluoroscopically by injection of a water-soluble contrast medium. RESULTS: The primary technical success rate was 98%. At 30-day follow-up, 3.2% had major complications and 14% minor complications. Three patients (1.9%) died of complications related to the procedure. Thirteen cases (8%) of simple tube displacement without other complications occurred. CONCLUSION: PRG guided by US and fluoroscopy is a relatively safe technique with a high success rate, provided the stomach can be properly distended with fluid. However, tube gastropexy alone does not seem to protect against early dislodgement.

Missed lesions and false-positive findings on computed-tomographic colonography: a controlled prospective analysis.

BACKGROUND AND STUDY AIMS: The aim of the present study was to analyze the reasons for false findings on computed-tomographic (CT) colonography. PATIENTS AND METHODS: A total of 100 consecutive CT colonography examinations were carried out before conventional colonoscopies scheduled on the same day. Before the study, an experienced radiologist received training in analyzing CT colonographies. The radiologists and endoscopists were blinded to each others' findings. The patients received standard polyethylene glycol bowel preparation and were scanned in the prone and supine positions using a helical CT scanner and commercially available software for image analysis. Each pair of examinations was later followed by an unblinded analysis, comparing the CT colonographies with video recordings of the conventional colonographies in order to determine the reasons for tumors being missed or false-positive diagnoses arising on CT colonography. RESULTS: Ninety polyps were detected in 41 patients. For patients with tumors > or = 5 mm and > or = 10 mm, the sensitivity was 67 % and 75 %, respectively, and the specificity was 84 % and 95 %, respectively. The most important reasons for the 38 false findings of tumors > or = 5 mm were perception errors (21 of 38) and misinterpretation of flat lesions in particular, including a high-grade dysplasia and a flat elevated Dukes A carcinoma. Residual stool was frequently the reason for misinterpreting lesions > or = 10 mm (four of 10). CONCLUSIONS: Perception errors were the main reason for false findings of lesions > or = 5 mm, including one flat malignant lesion. Residual stool caused four of 10 false findings for lesions > or = 10 mm. Reading CT colonographies requires a high level of expertise, and conventional colonography is still regarded as the gold standard for detecting colorectal lesions.

A comparative study of skills in virtual laparoscopy and endoscopy.

BACKGROUND: The present study was designed to investigate whether there is a correlation between manual skills in laparoscopic procedures and manual skills in flexible endoscopy. METHODS: In a prospective study using laparoscopy and endoscopy simulators (MIST-VR, and GI-Mentor II), 24 consecutive subjects (gastrointestinal surgeons, novice and experienced gastroenterologists, and untrained subjects) were asked to perform laparoscopic and endoscopic tasks. Their performance was assessed by the simulators' software and by observers blinded to the levels of subjects' experience. Performance in experienced vs inexperienced subjects was compared. Score pairs of three parameters--time, errors, and economy of movement--were also compared. RESULTS: Experienced subjects performed significantly better than inexperienced subjects on both tasks in terms of time, errors, and economy of movement (p < 0.05). All three performance parameters in laparoscopy and endoscopy correlated significantly (p < 0.02). CONCLUSION: Both simulators can distinguish between experienced and inexperienced subjects. Observed skills in simulated laparoscopy correlate with skills in simulated flexible endoscopy. This finding may have an impact on the design of training programs involving both procedures.

Relationship between nocturnal hypoxaemia, tachycardia and myocardial ischaemia after major abdominal surgery.

BACKGROUND: Episodic hypoxaemia, cardiac arrhythmias, and myocardial ischaemia may be related after major abdominal surgery. METHODS: We studied 52 patients on the second and third nights after major abdominal operations, using continuous pulse oximetry and Holter ECG. We recorded the amount of time spent with oxygen saturation values less than 90, 85, and 80% during the night, and noted episodes of hypoxaemia, tachycardia, bradycardia, and ST-segment changes. RESULTS: In 87 study nights there were 2403 (individual range 1-229) episodes of hypoxaemia, 3509 (individual range 1-234) episodes of tachycardia, and 265 (individual range 1-73) episodes of ST segment deviation. Of the 52 patients, 50 had episodes of hypoxaemia and tachycardia, and 19 patients had one or more episodes of ST segment deviation. For 38% of the episodes of ST deviation, there was an episode of hypoxaemia at the same time and in 16% there was an episode of tachycardia. ST deviation was only noted in 4% of the episodes of hypoxaemia and in 1% of the episodes of tachycardia. CONCLUSION: Episodes of hypoxaemia and tachycardia frequently occur together after surgery but are rarely associated with ST deviation. Hypoxaemia or tachycardia is often present at the same time as ST deviation occurs.

Preoperative routine magnetic resonance cholangiopancreatography before laparoscopic cholecystectomy: a prospective study.

OBJECTIVES: To assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct stones in the preoperative investigation of patients electively referred for gallstone disease, to find out the incidence of asymptomatic common duct stones, and to correlate clinical symptoms and history and liver function tests (LFT) with the actual occurrence of common duct stones. DESIGN: Prospective study. SETTING: General hospital, Denmark. PATIENTS: 180 consecutive non-jaundiced patients referred with symptomatic gallstones for elective cholecystectomy. INTERVENTIONS: LFT, abdominal ultrasonography, MRCP, endoscopic retrograde cholangiopancreatography (ERCP), questionnaire. MAIN OUTCOME MEASURES: Positive and negative predictive values and accuracy of MRCP, number of patients with asymptomatic stones, and correlation of symptoms with the presence of stones. RESULTS: 26/180 patients had common duct stones (14%). Only one (<1%) had an asymptomatic stone. For detection of such stones, MRCP's positive predictive value was 0.95 (95% confidence interval (CI): 0.86 to 1.00), negative predictive value 0.96 (0.93 to 0.99), and accuracy 0.85 (0.93 to 0.99). MRCP missed 5 stones 1-4 mm in size in 5 patients; 17/64 patients with raised LFTs had stones (27%). The probability of stones was highest when the patients had both raised LFTs and a dilated common (>7 mm) bile duct (82%). There were no readmissions with ductal stones in the 6-month postoperative period. CONCLUSIONS: The predicive values of MRCP were fairly good, but MRCP misses some small stones <5 mm in size. Asymptomatic stones in the common duct are not common in this population and should not be screened for. The probability of stones increases with the number of predictive factors. Patients should be questioned carefully about signs of biliary obstruction, and only be offered preoperative MRCP should they have a suspicious history, raised LFTs, or a dilated common duct.

Completeness and accuracy of voluntary reporting to a national case registry of laparoscopic cholecystectomy.

OBJECTIVE: To validate completeness and accuracy of registry data reported from three randomly chosen departments contributing to The Danish National Registry of Laparoscopic Cholecystectomy, covering all departments offering chole cystectomy. DATA SOURCES: A total of 431 case reports representing cases of laparoscopic cholecystectomy in a 2-year period in three surgical departments. DESIGN: Comparison of case reports with reported data in The Danish National Registry of Laparoscopic Cholecystectomy. MAIN OUTCOME MEASURES: Rates of discrepancies, comparison of complication rates for cases in the registry and cases not reported to the registry. RESULTS: Completeness of registration was 69%, 80% and 99% respectively. A significantly higher degree of completeness was found in the only department with a formalized registration procedure. Inaccuracies were found in 28-49% of the cases, but none regarding serious complications such as bile duct injury or perioperative death. CONCLUSIONS: The information in the national registry may be accurate if the present findings can be extrapolated to the remaining departments in the country. The number of non-reported cases should be minimized by introducing a formalized procedure of handling and forwarding information to the registry. Continuous validation through external visits by registry staff to contributing departments may also be advisable.

Timing of adoption of laparoscopic cholecystectomy in Denmark and in The Netherlands: a comparative study.

Laparoscopic cholecystectomy (LC) has diffused rapidly in most industrialised countries. The aim of this study has been to analyse the impact of different hospital characteristics on the hospital adoption of LC in Denmark and The Netherlands. Data on the timing of the adoption of LC and hospital characteristics (hospital size, teaching status and location) were retrieved in both countries. Proportional hazard regression was used to analyse different multivariate models. A total of 59 Danish and 109 Dutch hospitals adopting LC were identified. The multivariate analyses showed that increased hospital size was associated with relatively early adoption of LC in Denmark. Neither this nor other hospital characteristics influenced the timing of adoption in The Netherlands. As in other countries studied, hospital size is identified as an important factor in hospital adoption, whereas teaching status and location play a more limited role. The study shows that a multivariate method, such as the proportional hazard regression, can be used to elucidate differences among countries of the impact of different factors on the adoption of medium-ticket technologies like LC. Such multinational comparisons provide valuable information for health policy and planning.