Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results.

PURPOSE: The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR. METHODS: This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain. RESULTS: Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm3, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019). CONCLUSION: Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions. CLINICAL TRIAL NUMBER: NCT02542085.

Surgery cancelation on the day of surgery in same-day admission in a Finnish hospital.

BACKGROUND AND AIMS: Surgery cancelations cause inappropriate use of hospital resources and additional financial and psychological stress to patients. Cancelation rates have been described to be even more than 10% of scheduled cases. Preoperative anesthesia evaluation clinics have been initialized to decrease cancelation rates. At Hyvinkää hospital, 95% of elective surgical patients are admitted on the morning of operation, and only 25% of these patients visit preoperative anesthesia evaluation clinic prior to surgery. Cancelation rate in Finnish hospitals has not been described. MATERIAL AND METHODS: We studied retrospectively 12,205 scheduled elective same-day admission surgical cases at Helsinki and Uusimaa Hospital District, Hyvinkää hospital for a period of 2 years. Obstetric cases, emergency cases, and a few inpatient cases were excluded. A case was considered as canceled if surgery was canceled after the finalization of operation room schedule for the next day. Cancelation rates among different specialties and reasons for cancelation were analyzed. RESULTS: A total of 12,205 surgeries were scheduled during the study period, and 551 (4.5%) of these were canceled. The highest cancelation rate was in hand surgery, with 8.2% of scheduled cases, followed by orthopedic surgery with 5.4%, and pediatric surgery with 5.1% cancelation rate. Endocrinology had no cancelations, and breast, urology, and vein surgery also had less than 2% of canceled cases. Patient-related issues caused 72.4% of cancelations, and operation no longer being necessary caused 26% of all cancelations. CONCLUSIONS: Day of surgery cancelation rate was low in same-day admission, although it varied between specialties. Specialties having explicit surgery indications had fewer cancelations than specialties having surgery indications based on more subjective diagnostic. Process improvements need to be considered continuously to further decrease cancelation rate.

From Home To Operation (FHTO)--a new surgical admission centre: does the comprehensive initialisation of a new process harm surgery outcome?

BACKGROUND AND AIMS: FHTO - From Home To Operation is a same day admission -model developed at Finland Hyvinkää Hospital from as early as year 2000. In September 2006, a new FHTO centre was opened, through which surgical patients walk into the operation room. This article describes how an extensive FHTO process transition effects patients operation outcome. METHODS: The data was collected of all elective surgical patients between March and May in 2006 and in 2007, six months before and after the new FHTO centre was opened. Patient demographics and surgery outcome measurements were reported and analysed between the two study periods. One month postoperative follow-up was recorded. RESULTS: Overall 1206 patients were included, 592 in 2006 and 614 in 2007. Before the extensive process change in 2006 54% of patients were admitted through old limited FHTO unit, and 46% through surgical ward. Six months after FHTO centre opening in 2007 same figures were 90,5% and 9,5% respectively. The baseline statistics differed statistically in kidney failure, that increased in 2007. Two deaths were recorded during postoperative follow-up each year. CONCLUSIONS: FHTO process transition included different surgical specialities and did not have negative impact on surgery outcome. Preoperative process should be debated thoroughly in every public hospital. The preoperative process transition from preoperative hospital stay to same day admission through new centre can be accomplished without harming surgery outcome.

The effect of 4% icodextrin solution on adhesiolysis surgery time at the Hartmann's reversal: a pilot, multicentre, randomized control trial vs lactated Ringer's solution.

OBJECTIVE: A pilot randomized controlled clinical multicentre trail was established to compare intraperitoneal 4% icodextrin (ID) solution with lactated Ringer's solution (LRS) on adhesion formation after Hartmann's procedure. The adhesiolysis surgery time during Hartman's reversal was used as a marker of the severity of adhesions. METHOD: Patients scheduled for Hartmann's resection were randomized at surgery to either of the two study solutions used as an irrigant during the operation and instilled (1000 ml) at the end of surgery. During the reversal procedure, the time for small bowel adhesiolysis was recorded. RESULTS: On completion of 17 eligible patients, an interim analysis was performed. There were no complications following the use of 4% ID solution. The mean (SD) total adhesiolysis times in patients treated with 4% ID solution and LRS were 30.8 (18.0) min and 47.6 (45.7) min, respectively. The mean reduction of 16.8 min, although greater than expected, was not statistically significant (P = 0.33) because of the large variance in adhesiolysis times. Further statistical analysis showed that to achieve significance for the observed differences and variance, a minimum of 240 patients in each group would be required. CONCLUSION: Icodextrin treatment resulted in a decreasing trend in adhesiolysis time. The use of 4% ID solution in peritonitis patients seemed to be safe. Because of larger than expected variations in adhesiolysis times, this pilot study was underpowered to meet the study end-point and further statistical modelling estimated that significance cannot be reached within a reasonable time scale. Other models should be used to evaluate the efficacy of anti-adhesive agents.

Economic evaluation comparing From Home To Operation same day admission and preoperative admission one day prior to the surgery process: a randomized, controlled trial of laparoscopic cholecystectomy.

OBJECTIVE: A novel preoperative procedure From Home To Operation (FHTO) seeks to combat increasing operation and infection rates. This is the first prospective randomized controlled trial (RCT) comparing the cost-effectiveness and cost-utility of FHTO and conventional ward procedures for standardized Laparoscopic Cholecystectomy (LC). RESEARCH DESIGN AND METHODS: During 12/2004-7/2005, 47 patients with symptomatic gallstones were randomized to receive LC in the FHTO (28 patients) or in a conventional manner (19 patients) in a Finnish hospital setting. The 15D quality of life tool was administered at the baseline and 1 month after. MAIN OUTCOME MEASURES: A stochastic approach over a month interval for hospital costs, length of postoperative stay, infection rate and Quality-Adjusted Life Years (QALY) was employed. RESULTS: Baseline group characteristics were similar. The mean health care costs with FHTO (1695 EUR) were significantly lower (p < 0.001) than in the conventional arm (2234 EUR). The number of patients discharged on the first postoperative day was 27 (96.4%) and 15 (78.9%) with two (7.1%) infections in the FHTO and four (21.1%) in the conventional arm. A difference in QALYs gained (0.0174; p = 0.030) favouring FHTO was observed. According to a cost-effectiveness acceptability curve, the probability of FHTO being cost-effective was 99%. The results were robust to probabilistic sensitivity analyses. CONCLUSIONS: FHTO can introduce substantial cost savings and have a positive impact on both clinical measures and quality of life. Studies with larger numbers of patients are needed to assess whether conventional ward procedure can be a source of infections, which can be avoided with FHTO. CLINICAL TRIAL REGISTRY: ICJME-qualified registry of the Hospital District of Helsinki and Uusimaa (number 217849).

Service comparison between vascular and general surgery in the treatment of chronic venous insufficiency with special reference to preoperative Doppler techniques.

AIMS: To compare the ability of vascular and general surgical services to abolish reflux in superficial venous system with a special reference to preoperative use of Doppler techniques. MATERIALS AND METHODS: 68 lower limbs operated on for venous insufficiency based on either preoperative Duplex evaluation and Doppler marking in a vascular surgical unit (Vascular Surgical Service, VSS: 33 limbs, clinical class C2-C6) or clinical findings in a general surgical unit (General Surgical Service, GSS: 35 limbs, clinical class C2-C4) were re-examined clinically and with duplex scanning for reflux some three years postoperatively. RESULTS: Marked superficial or perforator vein reflux was observed in 27 of 68 (39.7 %) operated limbs, thirteen of which in VSS and fourteen in GSS. However, axial reflux at saphenofemoral or thigh level was observed significantly less in VSS compared to GSS (3 vs 13, p = 0,006). CONCLUSION: Total ablation of any reflux appeared difficult irrespective of the preoperative assessment. Preoperative Duplex examination, however, aided in identifying and treating axial reflux at thigh level.

Quantitative comparison of growth-associated protein-43 and substance P in ulcerative colitis.

The aim of this study was to compare immunoreactivities for substance P with other enteric neuropeptides and GAP-43, a general marker for enteric nerves, in normal human colon and in different stages of ulcerative colitis. Tissue samples from normal colon and regions of ulcerative colitis colon were obtained at surgery and immunostained for substance P, vasoactive intestinal polypeptide (VIP), somatostatin, calcitonin gene-related peptide (CGRP), enkephalin, galanin, GAP-43, and neuron-specific enolase (NSE). Visual examination and semiquantitative analysis revealed a clear increase in the immunoreactivity for substance P in ulcerative colitis, whereas no differences were observed in the distribution of the other peptides. Therefore, quantitative analysis was performed only for substance P immunoreactivity in the lamina propria, circular muscle layer, and myenteric ganglia. In the lamina propria, the score of total intensity of substance P immunoreactivity was 0.55 +/- 0.15 (mean +/- SEM) in normal colon, 1.30 +/- 0.35 (p = 0.087) in least affected colon, and 2.22 +/- 0.28 (p < 0.001) in moderately affected colon, whereas no significant differences were observed in immunoreactivities for GAP-43. Similar results were obtained for the mean substance P- or GAP-43-immunoreactive area. In the circular muscle layer, the number, density, total intensity, and perimeter of substance P- and GAP-43-immunoreactive fibers were essentially similar in normal colon, and in mild or moderately affected colon. We conclude that ulcerative colitis does not change the density of gut innervation as a whole. However, the density of substance P-containing nerves is specifically increased, probably due to increased peptide synthesis leading to better visibility of the fibers.

Functional results after restorative proctocolectomy complicated by pouchitis.

UNLABELLED: This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P < 0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P > 0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.

Substance P- and vasoactive intestinal polypeptide-immunoreactive innervation in normal and inflamed pouches after restorative proctocolectomy for ulcerative colitis.

Recent studies suggest that the intestinal polypeptides substance P (SP) and vasoactive intestinal polypeptide (VIP) play a role in the bowel inflammatory processes. The aim of this study was to evaluate the distribution of SP and VIP immunoreactivities in the ileal pouch of the patients with ulcerative colitis (UC). Thirty-six patients underwent clinical evaluation, endoscopy, and histological examinations. Samples were taken from normal ileum (N = 9), ileum of UC patients (N = 9), normal ileal pouch (N = 9) and pouchitis (N = 9). SP- and VIP-containing nerve fibers were visualized in sections processed for immunofluorescence microscopy. The number and intensity of SP and VIP immunoreactivities were subjected to quantitative scoring. On samples from all groups lamina propria contained fibers showing bright immunofluorescence for SP and VIP. The number and intensity of SP immunoreactive nerve fibers were markedly increased in pouchitis as compared to normal pouch (P < 0.005), to ileum of UC patients (P < 0.001), and to normal ileum (P < 0.05). The number and intensity of VIP-immunoreactive nerve fibers in the lamina propria were markedly increased in pouchitis patients and in those having a normal pouch as compared to pooled values of ileum of UC patients and normal ileum (P < 0.05). The results suggest that SP, which may play a role in mediating inflammatory processes, is increased in pouchitis and that VIP, which may contribute to the regulation of intestinal motility, is increased in the pouch.

Substance P--an underlying factor for pouchitis? Prospective study of substance P- and vasoactive intestinal polypeptide-immunoreactive innervation and mast cells.

Recent studies suggest that substance P (SP), vasoactive intestinal polypeptide (VIP), and mast cells play a role in inflammatory processes of the bowel. The aim of this study was to evaluate the distribution of SP and VIP immunoreactivities and to count mast cells in the ileal pouch of patients, who had pouchitis after restorative proctocolectomy performed for treatment of ulcerative colitis (UC), and to compare the findings in the same patients after a follow-up period. Nine patients with pouchitis underwent clinical evaluation, endoscopy of the pouch, and histological examination, which were repeated after the follow-up period of 14 months on average. The number and intensity of SP- and VIP-immunoreactive nerve fibers were visualized by immunofluorescence microscopy and subjected to quantitative scoring, and the number of mast cells per unit area was counted. The results were compared to the histological findings and the clinical status. Lamina propria contained fibers showing bright immunofluorescence for SP and VIP. The mean fluorescence intensity score of SP-immunoreactive nerve fibers in the lamina propria remained similar after the follow-up period (2.99 +/- 0.79 and 2.06 +/- 0.82, NS). SP-immunoreactive innervation correlated with the grade of acute (R2 = 0.5396, P = 0.0242) and chronic inflammation (R2 = 0.4561, P = 0.0459), while SP and VIP immunoreactivity, mast cell count, and histological changes did not correlate with the clinical status. The present study demonstrates an increase in the density of SP-immunoreactive nerve fibers in inflamed ileal pouch mucosa of clinically asymptomatic pouchitis patients. These results raise the possibility of therapeutic interference of SP-related processes in treatment of pouchitis.

Changes in substance P-immunoreactive innervation of human colon associated with ulcerative colitis.

The amount of colonic substance P and substance P-receptors is increased in ulcerative colitis, which may denote that substance-P is involved as a neurogenic mediator in the inflammatory process of ulcerative colitis. We studied the anatomical distribution of elevated colonic substance P in ulcerative colitis and assessed morphometrically whether the changes in substance P correlate with alterations in colonic innervation. Full-thickness specimens of colonic wall were obtained from normal human colons (N = 9) and the most and least affected regions of ulcerative colitis colons (N = 10) and immunostained for substance P. Substance P immunoreactivity index was calculated by multiplying each intensity value by the number of pixels exhibiting this intensity value. The numbers of substance P-immunoreactive nerve fibers in the lamina propria were markedly increased, and their fluorescence intensity was enhanced in ulcerative colitis. The longitudinal muscle layer contained substance P-immunoreactive nerve fibers in ulcerative colitis, but not in the controls. The substance P-immunoreactive index (= number x intensity of nerve fibers) was 3.42 +/- 1.49 in controls, 21.19 +/- 7.79 in mild ulcerative colitis regions (P < 0.05), and 29.68 +/- 9.81 in severe ulcerative colitis regions (P < 0.01). Increase in the number of substance P nerve fibers is in accordance with the hypothesis that substance P contributes to neurogenic mediation of inflammation in ulcerative colitis.

Co-localization of NADPH diaphorase reactivity and vasoactive intestinal polypeptide in human colon.

Nitric oxide-containing nervous structures were localized in the human colon using NADPH diaphorase activity and nitric oxide synthase immunoreactivity. We found some, solitary NADPH diaphorase-reactive and nitric oxide synthase-immunoreactive neurons in the submucous plexus, while the myenteric plexus contained several neurons, often arranged in clusters, and nerve fibers showing these markers. The circular muscle layer contained a dense plexus of NADPH diaphorase-reactive nerves, which was greater than that in the longitudinal muscle layer. We report on co-localization of NADPH diaphorase activity and VIP immunoreactivity in several neurons of the myenteric ganglia. Such co-localization has not been reported previously for human colon. Localization of nitric oxide synthase and VIP in the myenteric plexus and in the nerves of circular muscle layer raises the possibility that nitric oxide contributes to the regulation of motility in the human colon.

Peptic ulcer surgery in the nineties: patient profile, immediate results and clinical findings.

The decreasing frequency of elective ulcer surgery and the persisting frequency of emergency surgery for peptic ulcer diseases has often been reported. The reason for the divergent epidemiological behaviour of the two subgroups of surgical candidates is not clear. The present cross-sectional, population-based analysis of patients undergoing peptic ulcer surgery evaluates the mode of preoperative therapy in elective and emergency cases. It also assesses the present frequency of peptic ulcer surgery, ulcer complications, and the immediate results of ulcer surgery in a target population. The evaluation concerned 117 adult patients (F/M ratio 1/1.1, mean age 58.7 +/- 1.8 years) operated on for peptic ulcer disease in Helsinki City between March 1990 and February 1991. The annual frequency of elective surgery was 8.3 and of emergency surgery 20.7 per 10(5) residents in Helsinki. 30% of the patients treated surgically had no preoperative symptoms or antiulcer medication; the others were on on-demand type H2-receptor antagonist therapy. Whereas there was no mortality from the elective surgery the mortality rate for the emergency surgery was 10%, mainly due to cardiopulmonary reasons among elderly, high-risk patients. In conclusion, since our previous report for 1987 for the same target population in Helsinki, the incidence of emergency surgery has additionally increased, while the incidence of elective surgery has continuously decreased.