The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter?

BACKGROUND AND AIMS: To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience. MATERIAL AND METHODS: Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups. RESULTS: Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1-97.8) and 95.9% (95% confidence interval, 93.2-97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. CONCLUSION: The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

Adoption of single incision laparoscopic cholecystectomy in small-volume hospitals: initial experiences of 51 consecutive procedures.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy (LC) via three or four ports has been the standard operation for gallstone disease. Recently, the development of multichannel port devices has allowed LCs to be performed through a single fascial incision in the umbilicus. Here, we report our experiences of the adoption of the single incision laparoscopic cholecystectomy (SILC) in two small-volume community hospitals. MATERIAL AND METHODS: From January until July 2010, 51 consecutive patients (41 females and 10 males, the mean age 44 (21-75) years, BMI 26 (18-35)) underwent elective SILC for symptomatic gallstone disease in Salo (n = 29) and Loimaa (n = 22) hospitals. RESULTS: Of the 51 operations, 42 (82%) were accomplished without additional troacars. Seven (14%) procedures were converted to multiple-port technique and two (4%) to open cholecystectomy. In 25 (49%) operations, transabdominal retraction sutures through the gallbladder were used to maintain a good view of the triangle of Calot. The mean operative time was 74 (31-155) min. No major intraoperative complications occurred. The mean hospital stay was 0.6 (0-3) days. During a mean follow up of 4 (1-7) months, five (10%) patients had wound infection, and one (2%) had hematoma and prolonged pain in the insertion site of the retraction suture. One (2%) patient was reoperated for continuous pain in umbilical wound without findings at operation but with good results. One (2%) patient had subphrenic abscess seven months postoperatively. CONCLUSIONS: Our initial experiences indicate that SILC can be adopted without major complications in small-volume hospitals but the rate of wound infections seems to increase with the introduction of SIL.

Treatment of biliary complications after laparoscopic cholecystectomy.

The incidence of iatrogenic bile duct injury remains high despite increased awareness of the problem. This major complication following laparoscopic cholecystectomy (LC) has a significant impact on patient's well-being and even survival despite seemingly adequate therapy. The management of bile duct injury (BDI) includes education to avoid the insult, proper and early diagnosis and preferably early treatment. It is of utmost importance to involve experienced hepatobiliary surgeon early enough to perform corrective reconstruction or to plan other therapies with a multidisciplinary team including interventional radiologist and advanced endoscopist. The selection of correct therapy at the earliest possible phase has significant effect on patient outcome. The treatment options are surgery and endoscopy, either immediately or delayed. By constant and continuous analysis of the problem and information to the surgical community it should be possible to decrease the prevalence of iatrogenic BDI and even to avoid it.

Elective laparoscopic cholecystectomy without routine intraoperative cholangiography: a retrospective analysis of 1101 consecutive cases.

BACKGROUND: Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not? PATIENTS AND METHODS: We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992-2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15-89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database. RESULTS: IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36-144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case. CONCLUSIONS: According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Mesh repair of common abdominal hernias: a review on experimental and clinical studies.

Results on hernia surgery from numerous centers confirm that tensionless repair with various meshes reduces the complication rates and the frequency of recurrences. Some evidence on incisional hernias suggests, however, that the use of mesh seems to transfer the onset of recurrences by several years. Persistent pain and other discomfort is also an unpleasant complication of otherwise successful surgery in a number of patients. Thus, improved, slowly degrading, mesh materials, with strong connective tissue-inducing action, might be more optimal for hernia surgery. Accumulating evidence also suggests that recurrent hernias appear in patients having inherited weakness of connective tissues. Numerous tissue specific collagens, in addition to the classical fibrillar I-III collagens and numerous substrate specific matrix proteinases, have recently been described in biochemical literature, and their roles as possible causes of tissue weakness are discussed.

Splanchnic and pancreatic tissue perfusion in experimental acute pancreatitis.

BACKGROUND: Gut hypoperfusion has a major role in the pathogenesis of multiple organ failure, which is the main cause of death in severe acute pancreatitis. The effects of experimental acute pancreatitis on splanchnic and pancreatic perfusion and oxygenation were studied to find out whether gut hypoperfusion occurs already at the same time as changes in pancreatic perfusion. METHODS: Twenty-four domestic pigs weighing 21-27 kg were randomized to severe or mild acute pancreatitis or control groups. Eight anaesthetized and mechanically ventilated pigs were intraductally infused with taurocholic acid to induce severe acute pancreatitis and eight received intraductal saline to induce mild acute pancreatitis. Eight pigs served as controls. RESULTS: Intraductally infused taurocholic acid rapidly induced severe necrotizing acute pancreatitis as assessed macroscopically and histologically. Histological changes of mild acute pancreatitis were seen in animals after intraductal saline infusion. After the induction, pancreatic tissue oxygen tension decreased promptly in severe acute pancreatitis and increased in mild acute pancreatitis. Laser-Doppler red cell flux decreased in severe acute pancreatitis. Gut pH gap and pCO2 gap decreased in 2 h after the induction of severe acute pancreatitis. Central haemodynamics were fairly stable throughout the study period in all groups. CONCLUSION: In experimental severe acute pancreatitis, splanchnic malperfusion seems to begin with pancreatic hypoperfusion before disturbances in gut microcirculation.

Source of group II phospholipase A2 in gastric juice.

Gastric juice contains both pancreatic group I phospholipase A2 (PLA2-I) and synovial-type group II phospholipase A2 (PLA2-II), which may play a crucial role in Helicobacter pylori infection and gastric mucosal injury. PLA2-I present in gastric juice is derived from pancreatic acinar cells. The cellular source of PLA2-II found in gastric juice is unknown. A specific cell type of the intestinal mucosa, the Paneth cell, is known to secrete PLA2-II. The purpose of the present study was to define the source of PLA2-II present in gastric juice. For this purpose, gastric juice was collected from 29 individuals during gastroscopy, and mucosal biopsies were taken from the antrum and body of the stomach and from the duodenum as well as from the jejunum of individuals with resected stomach, for immunohistochemical detection of PLA2-II. The concentration of bilirubin in the gastric juice samples was determined to identify duodenogastric regurgitation. The PLA2-II content was significantly higher in bilirubin-positive than in bilirubin-negative gastric juice samples. PLA2-II was localized by immunohistochemistry in Paneth cells in three patients with areas of intestinal metaplasia of the gastric mucosa and in Paneth cells of duodenal and jejunal mucosa in all patients, but not in any other epithelial cell type of the mucosa of the stomach or the small intestine. Inflammatory cells did not contain PLA2-II. The current results suggest that PLA2-II found in gastric juice is derived from the Paneth cells of the small intestinal mucosa.

Do normal leucocyte count and C-reactive protein on admission to hospital exclude a life-threatening attack of acute pancreatitis?

BACKGROUND AND AIMS: The early severity assessment of an attack of acute pancreatitis is clinically of utmost importance. The aim of the present work was to study the role of leucocyte count and C-reactive protein (CRP) measurements on admission to hospital in assessing the severity of an attack of acute pancreatitis. In particular, patients with a life-threatening attack of acute pancreatitis but a normal leucocyte count and CRP level were sought. MATERIAL AND METHODS: A total of 1050 attacks of acute pancreatitis were treated at Turku University Central Hospital during the years 1995-1999. Leucocyte count and C-reactive protein (CRP) value were determined on admission to hospital. There were 58 life-threatening attacks of acute pancreatitis (group A). Fifty-eight consecutive mild attacks served as controls (group B). The number of patients with both values normal, only leucocyte count raised, only CRP level raised and both values raised were calculated in the groups A and B. RESULTS: Both leucocyte count and CRP level were significantly (P < 0.001 in both comparisons) higher on admission to hospital in patients with a life-threatening disease (group A) than in those with a mild disease (group B). Group A contained no patients with both values in the normal range. In group B, one fifth of the patients had both values normal. CONCLUSION: It is very unlikely that acute pancreatitis proves to be a life-threatening one when both the leucocyte count and CRP are normal on admission to hospital. In the present 1050 acute pancreatitis there were no patients with life-threatening disease but normal laboratory values on admission.

Do normal leucocyte count and C-reactive protein value exclude acute appendicitis in children?

UNLABELLED: The present study aimed to determine the role of leucocyte count and C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis in children. In particular, children with acute appendicitis but normal leucocyte count and CRP level were sought. The present study protocol was identical to those used in earlier studies on adult patients with suspected acute appendicitis. The mean preoperative leucocyte count and CRP value in 100 consecutive children with an uninflamed appendix at appendicectomy (group A) and in 100 consecutive patients with acute appendicitis (group B) were calculated. The numbers of patients with (i) both values normal, (ii) only leucocyte count raised, (iii) only CRP level raised, and (iv) both values raised were calculated in both groups A and B. Leucocyte count effectively (p < 0.001) separated children with uninflamed appendix (mean +/- SEM 10.2 +/- 0.4 x 10(9) l(-1)) from those with acute appendicitis (15.0 +/- 0.4 x 10(9) l(-1)), but the CRP value was of no use in this respect (p = 0.866; 31 +/- 4 mg l(-1) and 30 +/- 4 mg l(-1)). The most conspicuous finding was that in children with acute appendicitis, both values were normal in 7 out of 100 patients. CONCLUSION: Contrary to adult patients, normal leucocyte count and CRP value do not effectively exclude acute appendicitis in children.

A non-icteric cholecystectomized patient with recurrent attacks of right epigastric pain and dilated common bile duct--do liver function tests predict bile duct stones?

Cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct are a clinical challenge. In a number of these patients dilatation of the common bile duct is explained as a normal postoperative state following cholecystectomy and the recurrent pain attacks are of origin other than bile disorder, but in some cases dilatation of the common bile duct and attacks are caused by bile duct stones. The aim of the present work was to study the value of common plasma liver function tests in predicting bile duct stones in the group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. The study population comprised 24 consecutive non-icteric cholecystectomized patients admitted for elective endoscopic retrograde cholangiopancreatography because of attacks of right epigastric pain and dilated common bile duct in ultrasonography. All the liver function tests seemed to assist in separating patients with bile duct stones (n=11) from those without (n=13). Alanine aminotransferase levels were significantly higher (p=0.05) in patients with bile duct stones than in those without, but also alkaline phosphatase (p=0.07), gamma-glutamyl transferase (p=0.09) and bilirubin (p=0.09) levels seemed to be higher in patients with bile duct stones than in those without, although the differences in these values did not reach statistical significance. In conclusion, common plasma liver function tests assist in separating patients with bile duct stones from those without in this small but clinically important group of non-icteric cholecystectomized patients with recurrent attacks of right epigastric pain and with dilated common bile duct. However, the actual value of these measurements is limited in clinical decision making since overlapping of values occured.

Pancreatic tissue perfusion in experimental acute pancreatitis.

OBJECTIVE: To investigate pancreatic tissue perfusion and oxygenation in severe and mild experimental acute pancreatitis in pigs. DESIGN: Randomised controlled experiment. SETTING: Animal laboratory, Finland. ANIMALS: 24 domestic pigs weighing 21-27 kg. INTERVENTIONS: 24 pigs were randomised into severe acute pancreatitis, mild acute pancreatitis and control groups (n = 8 in each). The pancreatic duct of eight anaesthetised and mechanically ventilated pigs was cannulated and taurocholic acid was infused into the pancreatic duct to induce severe acute pancreatitis. Eight animals received intraductally infused saline and developed mild acute pancreatitis. Eight pigs had their ducts cannulated alone, and served as controls. MAIN OUTCOME MEASURES: Pancreatic tissue oxygenation, laser Doppler red cell flux, central haemodynamics. RESULTS: Intraductally infused taurocholic acid rapidly induced macroscopically and histologically proven severe necrotising acute pancreatitis. Histological changes characterising mild acute pancreatitis were seen in animals after intraductal saline infusion. Pancreatic tissue oxygen tension decreased in the severe group and increased in the mild group during the six-hour study period. Laser Doppler red cell flux decreased in the severe group. Central haemodynamics, arterial blood gases, and acid base balances were stable throughout the study period in all groups. CONCLUSION: The present model of severe acute pancreatitis significantly impairs pancreatic oxygenation in the early phase. In mild acute pancreatitis, pancreatic oxygenation increases.

Effect of the diameter of the common bile duct on the incidence of bile duct stones in patients with recurrent attacks of right epigastric pain after cholecystectomy.

OBJECTIVE: To study the relationship between the diameter of the common bile duct and the incidence of bile duct stones in non-jaundiced patients with recurrent attacks of right epigastric pain after cholecystectomy. DESIGN: Retrospective study. SETTING: University hospital, Finland. SUBJECTS: 57 consecutive, non-jaundiced patients admitted for elective endoscopic retrograde cholangiopancreatography (ERCP) because of attacks of right epigastric pain after cholecystectomy. INTERVENTIONS: Measurement of maximum diameter of the common bile duct and presence or absence of bile duct stones. MAIN OUTCOME MEASURES: Diameter of bile duct (10 mm or less was regarded as normal) and presence or absence of stones. RESULTS: 33 patients had normal-sized bile ducts and in 24 they were widened. Only 2/33 patients with normal-sized ducts (6%) had stones, compared with 11/24 (46%) with wide ducts (p = 0.0008). However, the degree of ductal dilatation did not seem to have any influence on the presence or absence of stones. CONCLUSION: Bile duct stones are unlikely after cholecystectomy in patients who are not jaundiced and have a normal-sized common bile duct. However, nearly half of the patients with a wide common bile duct had stones, but the degree of dilatation was not important.

Roles of secretory phospholipases A(2) in inflammatory diseases and trauma.

Six distinct secretory small molecular weight phospholipases A(2) (PLA(2)) have been cloned and characterized from human tissues. Two of them, pancreatic group IB PLA(2) (PLA(2)-IB) and synovial-type group IIA PLA(2) (PLA(2)-IIA) have been studied as to their association to various inflammatory diseases. PLA(2)-IB is a digestive enzyme synthesized by pancreatic acinar cells. In acute pancreatitis, which is characterized by destruction of pancreatic tissue, PLA(2)-IB is released into the circulation, but its role in pancreatic and other tissue damage is still hypothetical. The concentration of PLA(2)-IIA increases in blood plasma in generalized inflammatory response resulting from infections, chronic inflammatory diseases, acute pancreatitis, trauma and surgical operations. PLA(2)-IIA is synthesized in a number of gland cells and is present in cellular secretions on mucosal surfaces including Paneth cells of intestinal mucosa, prostatic gland cells and seminal plasma, and lacrimal glands and tears. PLA(2)-IIA is expressed in hepatoma-derived cells in vitro and hepatocytes in vivo. PLA(2)-IIA is regarded as an acute phase protein and seems to function as an antibacterial agent especially effective against Gram-positive bacteria. Other putative functions in the inflammatory reaction include hydrolysis of cell membrane phospholipids and release of arachidonic acid for prostanoid synthesis.

Phospholipase A2 in acute pancreatitis: new biochemical and pathological aspects.

Phospholipase A2 has been implicated in the pathogenesis and pathophysiology of acute pancreatitis. The initial enthusiasm concerning pancreatic group I phospholipase A2 as an enzyme responsible for pancreatic necrosis and systemic manifestations of acute pancreatitis has gradually waned, as the mechanisms of the pathogenesis and the pathophysiology of acute pancreatitis have been revealed. The overactive systemic inflammatory response associated with the activation of different cascade systems and increased levels of inflammatory mediators as seen in severe acute pancreatitis, closely resembles that associated with other severe inflammatory diseases such as septic shock. The critical role of the non-pancreatic secretory group II phospholipase A2 in the chain of inflammatory mediators has been emphasized recently, as new detection methods for the enzyme have become available.

A fertile-aged woman with right lower abdominal pain but unelevated leukocyte count and C-reactive protein. Acute appendicitis is very unlikely.

BACKGROUND AND AIMS: An uninflamed appendix at appendectomy represents a misdiagnosis. In fertile-aged women, the diagnostic accuracy in acute appendicitis is usually lower than 60%. We studied the role of preoperative leukocyte count and C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis in fertile-aged women with a clinical suspicion of acute appendicitis. In particular, what is the clinical value of unelevated leukocyte count and CRP in excluding acute appendicitis in these patients? METHODS: We calculated the mean leukocyte count and CRP values in (1) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis but with an uninflamed appendix found at appendectomy, and (2) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis and acute appendicitis found at appendectomy. The percentages of patients with (1) both values unelevated, (2) only leukocyte count elevated, (3) only CRP value elevated, or (4) both values elevated were calculated within the groups A (uninflamed appendix) and B (acute appendicitis). RESULTS: The mean leukocyte value was significantly (P<0.001) higher in patients with acute appendicitis (13.7x10(9)/l) than in those with an uninflamed appendix (10.6x10(9)/l). Similarly, the mean CRP value was significantly (P<0.05) higher in patients with acute appendicitis (42 mg/l) than in those with an uninflamed appendix(29 mg/l). Taken together, 24 patients were operated on for a clinical suspicion of acute appendicitis, although preoperative leukocyte count and CRP values were unelevated. An uninflamed appendix was found in all these patients at appendectomy. CONCLUSION: Although clinical symptoms and signs indicated acute appendicitis, unelevated leukocyte count and CRP values excluded it, with a 100% predictive value in the current study of fertile-aged women. In our patients, 24% (24 of 100) of unnecessary appendectomies could have been avoided by trusting in this finding.

Bactericidal/permeability-increasing protein in colonic mucosa in ulcerative colitis.

BACKGROUND/AIMS: Increased mucosal concentration of bactericidal/permeability-increasing protein (BPI) has been shown in inflammatory bowel diseases. The purpose of the present study was to investigate the relationship between the mucosal concentration of BPI and the grade of mucosal inflammation in ulcerative colitis. METHODOLOGY: Samples of colonic mucosa from 12 patients with ulcerative colitis and from 8 control patients were studied. The concentration of BPI in tissue extracts was measured by a time-resolved fluoroimmunoassay. The concentration of BPI was compared between samples with histological inflammatory changes of different severity. BPI was localized in tissue sections by immunohistochemistry. RESULTS: The concentration of BPI was higher (p < 0.001) in samples of colonic mucosa from patients with ulcerative colitis (median: 3.2 micrograms/g, range: 0.3-22.6 micrograms/g) than in control samples (0.4 microgram/g, 0.1-0.6 microgram/g,). Moreover, the concentration of BPI was higher (p = 0.015) in samples with severe inflammation (2.5 mu/g, 0.3-22.6 micrograms/g) than in those with mild inflammation (0.5 mu/g, 0.3-2.5 micrograms/g). The concentration of BPI in mucosal samples correlated well with the degree of histological inflammation (Spearman R = 0.70, p = 0.01). BPI was localized in polymorphonuclear leukocytes in the mucosa and stroma of the colonic wall. CONCLUSIONS: The concentration of BPI is increased in the colonic mucosa of patients with ulcerative colitis. The increase in the concentration of BPI in colonic mucosa seems to be closely associated with the inflammatory activity of ulcerative colitis.

Mortality in acute pancreatitis in Turku University Central Hospital 1971-1995.

BACKGROUND/AIMS: The role of surgical procedures in the treatment of acute pancreatitis is still unclear. The aim of the present study was to analyze the mortality in acute pancreatitis in Turku University Central Hospital during the last quarter century with special reference to the prevailing surgical treatment trends. METHODOLOGY: A total of 3921 patients with acute pancreatitis were treated 1971-1995. We analyzed the mortality in acute pancreatitis and the number of patients treated in the intensive care unit as well as the number of various surgical procedures used in the treatment of acute pancreatitis in each year 1971-1995. RESULTS: The most conspicuous finding was that the mortality in acute pancreatitis has not decreased any more during the last 15 years. Neither pancreatic resections nor peritoneal lavages seem to decrease the mortality. CONCLUSIONS: We conclude that despite various surgical procedures used in the treatment of acute pancreatitis the mortality in acute pancreatitis has not decreased any more during the last 15 years. Because of the retrospective nature of the current study the present results do not justify drawing any strict conclusions concerning the treatment of acute pancreatitis. However, the present results support the view that conservative treatment in the intensive care unit is justified as an initial therapy even in the fulminant attacks of acute pancreatitis.