Surgical Management of Toxic Megacolon.

BACKGROUND/AIMS: Toxic megacolon carries still a substantial mortality and the decision when to per form emergent colectomy needs precise predictors outcome. METHODOLOGY: Thirty-two patients with toxic megacolon were identified from a computer database, and their clinical variables were analysed both univariate and multivariate analysis. RESULTS: 30-day mortality was 16%, being 17% for the patients with Clostridium difficile colitis and 13% for the patients with inflammatory bowel diseases. Diabetes, MPI class II, ASA classes 4-5, increase serum creatinine level, fever over 39 degrees, renal failure, gangrenous bowel and vasopressor requirement significantly associated with in univariate analysis, but only MPI class II and ASA classes 4-5 were independent predictors of mortality. Major complications occurred in 53% of the patients and they associated with respiratory failure, development of shock and vasopressor requirement. Surgical intensive care was needed by the patients who developed respiratory failure, shock or anaemia the hospital treatment was longer in patients with Clostridium difficile colitis. CONCLUSION: Development of signs of organ failures or shock are associated with poorer outcome in patients with toxic megacolon and the patients should be urgently operated, when these signs occur.

Surgical treatment of colorectal cancer in patients aged over 80 years.

PURPOSE: The aim of this study was to identify the clinical factors and tumour characteristics that predict the outcome in patients older than 80 years with colorectal cancer. PATIENTS AND METHODS: One hundred and four patients with colorectal cancer aged over 80 years were identified from a computer database, and their clinical variables were analysed by both univariate and multivariate analyses. RESULTS: All 104 patients underwent resective surgery, 87% radical and 13% palliative resection. Postoperative mortality was 5%, being associated with a number of coexisting diseases and the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 33%, the median survival was 31 months and the cancer-specific 5-year survival was 36%. The recurrence rate after radical surgery was 30%, being 13%, 25%, 44% and 100% in the Union for International Cancer Control stages I, II, III and IV. Kaplan-Meier estimates indicated that age, number of underlying diseases, radicality of operation, Dukes' staging, size of tumour, number of lymph node metastasis, metastasised disease, venous invasion and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion was an independent prognostic factor of survival. CONCLUSIONS: Low mortality and acceptable survival can be achieved even in very elderly patients with colorectal cancer. Venous invasion is an independent predictor of survival.

Clinicopathological features of colorectal cancer in patients over 70 years of age.

OBJECTIVE: The aim was to identify the clinical factors and tumor characteristics that predict mortality and survival in patients older than 70 years with colorectal adenocarcinoma. MATERIAL AND METHODS: One hundred and ninety-four patients with colorectal cancer aged over 70 years were identified from a computer database and their clinical variables were analyzed by both univariate and multivariate analyses. RESULTS: All patients underwent resective surgery, 79% radical and 21% palliative resection, and postoperative mortality was 6% being associated with the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 38%, the median survival 35 months, and the cancer-specific 5-year survival 48% and this did not differ significantly between the age groups. The recurrence rate after radical surgery was 30%, being 12, 22, 56, and 100% in Dukes classes A, B, C, and D. Kaplan-Meier estimates indicated that gender, Dukes staging, grade of tumor, number of lymph node metastasis, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion and recurrent disease were independent prognostic factors of survival. CONCLUSIONS: Low mortality and acceptable survival can be achieved in elderly patients with colorectal cancer. Venous invasion and recurrent cancer are independent predictors of survival.

[Treatment of sigmoid diverticulitis]. / Koolonin divertikuliitin hoitolinjat.

Most patients, up to 75-80 percent, with anatomical diverticulosis will remain uncomplicated with a few symptoms. They might benefit of increasing their fruit and vegetable fibre intake and active movement. Advancing age of the Finnish population and decreasing daily consumption of dietary fibre led at the end of 1990' to increasing incidence of diverticle perforations. The annual mortality associated with diverticle perforation is as high as that following hip fracture. It has earlier been recommended that the patients aged under 50 years should be operated after recovery from one acute diverticulitis. However, at present younger patients seem not to be at an increased risk of complications. Elective operation after acute diverticulitis should be made on a case-by-case basis and operations should be restricted to the most symptomatic patients.

Spectrum of disease and outcome among patients with acute diverticulitis.

BACKGROUND: This study was designed to evaluate the natural history of patients admitted for acute diverticulitis. METHODS: Nine hundred and seventy-seven patients admitted to Oulu University Hospital for acute symptoms of diverticular disease during the 20-year period from 1986 to 2005 were identified using a database. RESULTS: Six hundred and ninety-five patients were admitted for uncomplicated diverticulitis and 282 for complicated diverticulitis. The patients admitted for uncomplicated diverticulitis were younger than the others and 66% of them were admitted only once. The number of admissions preceding perforation was higher in the 1980s, and the number of admissions was unrelated to the degree of perforation or the outcome of the patients. The annual prevalence of sigmoid diverticular perforation increased from 2.6/100,000 in 1986 to 4.2/100,000 in 2005. Seventy (10%) of the 695 patients admitted for the first time for acute diverticulitis underwent urgent surgery during the same admission and 66 (9%) had elective surgery during a later admission. Overall hospital mortality was 2.3%, being 1% among those admitted for acute diverticulitis and 5.5% among those admitted for diverticular perforation. Two hundred and thirty-four (42%) of the 555 nonoperated patients with acute diverticulitis developed a recurrent episode of diverticulitis. The course of recurrent disease was similar to the primary episode. CONCLUSION: Two or more preceding admissions for acute diverticulitis do not warrant sigmoid resection after diverticulitis. Young patients do not have a greater risk of complicated diverticulitis than older ones.

[Prevention of complications of thyroid and parathyroid surgery]. / Kilpi- ja lisäkilpirauhaskirurgian komplikaatioiden välttäminen--embryologisia ja anatomisia näkökohtia.

The knowledge of parathyroid and thyroid anatomy helps a surgeon to localize important details and lessen complications, especially laryngeal palsy and hypoparathyroidism. The ligament of Berry and tuberculum Zuckerkandl cover the recurrent laryngeal nerve in the upper part of the thyroid lobes. The recurrent laryngeal nerve or its branches are exposed during the mobilization of these structures during total thyreoidectomy. The upper parathyroid gland can be found on the upper part of the tuberculum Zuckerkandl behind the recurrent laryngeal nerve, whereas the lower parathyroid gland can be found in front of the nerve on the under surface of the thyroid lobe or in the thymus below. The tertiary branches of blood vessels are cut preserving the function of the parathyroid glands. If the parathyroid has lost its blood circulation, it is made into pieces and transplanted into the pockets of sternocleidomastoideus muscle. Exposing the recurrent laryngeal nerve during operation seems to decrease permanent recurrent laryngeal nerve injury. The role of neuromonitoring is during parathyroid and thyroid surgery still controversial.

Clinicopathological features of colorectal cancer in patients under 40 years of age.

OBJECTIVE: The aim was to identify the clinical factors and tumour characteristics that predict survival in patients younger than 40 years with colorectal adenocarcinoma. MATERIAL AND METHODS: Fifty-nine patients with colorectal cancer aged under 40 years were identified from a computer database, and their clinical variables were analysed. The factors predicting long-term survival were compared by both univariate and multivariate analysis. RESULTS: The prevalence of positive family history of cancer was 27%, and predisposing factors were present in 31% of the patients. All patients underwent resective surgery, 76% radical and 24% palliative resection, and their 5-year survival was 59% and mean survival +/-75 months. The recurrence rate after radical resection was 38% being 14%, 30%, 78% and 100% in Dukes classes A, B, C and D. The cumulative 5-year survival of men, 45%, was significantly worse than that of women, 73%, and this phenomenon was closely related to more distended lymphatic and venous invasion of cancer in men. Kaplan-Meier estimates showed that gender, Dukes staging, grade of tumour, lymphatic invasion, the number of lymph nodes with metastases, venous invasion and size of tumour were significant predictors of survival, but in Cox regression model, only venous invasion was the independent prognostic factor of survival. CONCLUSIONS: Young men with colorectal cancer in Northern Finland have poorer prognosis than women. Venous invasion is an independent predictor of survival.

Acute sigmoid diverticulitis in young patients.

BACKGROUND/AIMS: The natural history of young patients admitted for acute diverticulitis in terms of the virulence of the disease and the need for surgical treatment has remained controversial. METHODOLOGY: One thousand eighty-one patients with acute diverticulitis admitted to our hospital from 1986 to 2006 were identified from a computer database and their clinical course was analysed Patients under or over 50 years of age were compared regarding uncomplicated and complicated diverticulitis, the number of admissions, operative procedures performed, morbidity, mortality and recurrence of diverticulitis. RESULTS: Eighty-one percent of the patients aged under 50 years were admitted for uncomplicated diverticulitis, whereas 36 % of the patients aged over 50 years were admitted for complicated diverticulitis (p = 0.001). Sixty-eight percent of the patients with uncomplicated diverticulitis and 79% of those admitted for diverticular perforation were admitted only once to our hospital. The male/female ratios of patients presenting with uncomplicated diverticulitis were 114/106 for patients aged under 50 years and 181/336 for patients aged over 50 years. The respective ratios for complicated diverticulitis were 36/17 and 111/179. Overall mortality for all the admitted patients was 2%, being 0% for patients aged under 50 years, 3% for patients aged over 50 years and 5% for those admitted for diverticular perforation. Recurrent symptoms of diverticulitis developed in 34% of the patients admitted the first time for acute diverticulitis and diverticular perforation occurred in 20% of the cases. CONCLUSIONS: Young patients are more often admitted for uncomplicated diverticulitis than older patients. The course of the disease in patients aged less than 50 years is not more aggressive than in older patients.

Elective surgery for recurrent diverticulitis.

BACKGROUND/AIMS: After two documented episodes of uncomplicated diverticulitis, elective colon resection is recommended to prevent complications of the disease but the nature of symptoms in non-operated patients requires specification. METHODOLOGY: A detailed questionnaire concerning clinical variables was mailed to two hundred and sixty patients admitted into our hospital for symptoms of acute sigmoid diverticulitis between 1981 and 2002. One hundred and seventy-one patients (70 percent) answered the questions adequately. Based on the clinical symptoms reported by the patients on the questionnaires, three patient groups set up, i.e. patients treated non-operatively or operatively for recurrent diverticulitis and patients operated on for diverticular perforation. The results of the patients treated non-operatively were analyzed with special reference to readmissions and age. RESULTS: The need for treatment by a physician, the need for hospital treatment, the presence of abdominal cramps, the presence of febrile left lower abdominal pain, the need for antibiotics and the need for NSAIDs were more common in the patients treated non-operatively for recurrent diverticulitis. When the patients treated non-operatively for recurrent diverticulitis were compared in a logistic regression model in relation to the number of admissions, the need for treatment by a physician and the presence of left lower abdominal pain were significantly more common in the patients admitted twice or more often. The same variables remained significantly different when the patients admitted once or twice were compared. Age did not correlate with any of the variables tested. CONCLUSIONS: On the basis of our results, we recommend that patients with recurrent uncomplicated diverticulitis should be operated on after two documented episodes to reduce the symptoms of the patients.

Computed tomography severity index and C-reactive protein values predicting mortality in emergency and intensive care units for patients with severe acute pancreatitis.

BACKGROUND: Severe acute pancreatitis is a multisystem disease in which various local and systemic complications lead to high mortality. We retrospectively examined the clinical and biochemical factors that may influence the risk of mortality on admission to emergency and intensive care units (ICUs). METHODS: Sixty-eight patients were admitted into our hospital for acute pancreatitis and treated in our ICU for computed tomography-proven severe acute pancreatitis during the years 1997 to 2004. The clinical, biochemical, and radiologic data were reviewed from the computerized database, radiologic films, and patient records. RESULTS: The mortality rate during the ICU stay was 18% (12/68) and that during the whole period of hospitalization 26% (18/68). A C-reactive protein (CRP) value over 150 was the only independent predictor of mortality on admission into the emergency unit, whereas the computed tomography severity index and the elevated CRP value over 150 predicted significantly and independently mortality on admission into the ICU. Linear backward regression analysis showed that high CRP values and respiratory failure on ICU admission correlate with longer ICU stay. Men's ICU stays were longer than those of women. CONCLUSIONS: A high computed tomography severity index and CRP values over 150 on admission into the ICU are valuable predictors of the mortality risk. High CRP, renal and respiratory failure, and male gender are associated with longer ICU stay.

Early cytokine responses after percutaneous magnetic resonance imaging guided laser thermoablation of malignant liver tumors.

An early systemic response induced by magnetic resonance imaging (MRI)-guided interstitial percutaneous laser thermoablation was analyzed in 13 consecutive patients with malignant liver tumors by serum interleukin (IL)-1beta, IL-6, IL-10, tumor necrosis factor (TNF)-alpha, its receptor TNFRI, and C-reactive protein (CRP) levels up to 72h after the procedures. Only IL-6 (p=0.033) and TNFRI (p<0.001) increased statistically significantly after ablation, while the TNF-alpha, IL-1 beta, and IL-10 levels remained unchanged. The peak median CRP response was 92mg/l. There was a dose-dependent correlation between the energy used and the maximum CRP values (tau=0.68, p=0.013). MRI-guided laser thermoablation induced an early systemic inflammatory reaction with statistically significantly elevated IL-6, TNFRI, and CRP levels but not TNF-alpha or IL-10 levels and without procedure-related complications, favoring this procedure as a safe therapeutic alternative for well-selected patients with liver tumors.

Acute cholecystitis in the elderly.

BACKGROUND/AIMS: The population of Finland is ageing fast, and acute cholecystitis is common among elderly people. Because the treatment options have changed greatly since the late 1980's, we wanted to find out whether the active treatment policy nowadays used in our hospital has some effects on operability, morbidity, mortality and the duration of the in-patient period. The numerous serious illnesses of elderly people that cause considerable morbidity and mortality underlines the importance of risk stratification, and clinical variables were therefore also tested for their ability to predict the probability of morbidity and mortality. METHODOLOGY: Two hundred and eighteen patients aged over 75 years, 92 patients during the 5-year period 1988-1992 (Period I) and 126 patients during the 5-year period 1998-2002 (Period II) had been admitted into our hospital for acute cholecystitis, and they were identified from a computer database. During these two periods, different treatment strategies were used. The clinical data were reviewed from the database and the patient records. RESULTS: The active use of ERCP and percutaneous cholecystostomy during Period II decreased the number of all operations and emergency operations. Only six of the 43 patients who underwent early cholecystostomy were later scheduled for cholecystectomy. Postoperative morbidity did not differ between the two periods, and stepwise logistic regression analysis showed obesity to be an independent predictor of morbidity. Overall mortality was 8% during period I and 6% during period II, and of the clinical variables, underlying lung disease, malnutrition, pericholecystic fluid collection in ultrasound and perforation of the gallbladder were independent predictors of mortality in stepwise logistic regression analysis. Neither the primary in-patient period nor the total in-patient period were significantly shorter during Period II. CONCLUSIONS: Active treatment of acute cholecystitis in the elderly may decrease the need for emergency surgery. Malnutrition and perforation of the gallbladder are the most important predictors of mortality in this patient group.

Prognostic factors of perforated sigmoid diverticulitis in the elderly.

BACKGROUND: The Finnish population is aging fast and the prevalence of perforated sigmoid diverticulitis is simultaneously increasing in northern Finland. The fact that an increasing number of elderly patients, with their age-specific problems, are subjected to emergency surgery for acute diverticulitis underlines the importance of risk stratification. METHODS: One hundred and seventy-two patients admitted to Oulu University Hospital because of diverticular perforation from 1983 to 2002 were identified from the computer database. The clinical variables were evaluated as prognostic indicators of postoperative complications, mortality and time of hospitalization. RESULTS: The resection rate was 91%; 64 primary anastomoses, 93 Hartmann's procedures and two covering colostomies were performed. The overall complication rate was 33%. In patients under 70 years, a stepwise logistic regression analysis showed that the Mannheim Peritonitis Index (MPI) score and American Society of Anesthesiologists (ASA) score were independent prognostic factors. None of factors predicted morbidity in patients over 70 years. Overall mortality rate was 8%, without any significant difference between the procedures. Of the clinical variables, MPI score, ASA score, Hinchey classes and malnutrition correlated with mortality. All patients who died presented with ASA scores of III-IV, and 12 out of 14 patients had an MPI score of II. In a stepwise logistic regression analysis, only the MPI score seemed to be an independent predictor of mortality. CONCLUSIONS: Mortality is related to age but age alone is not an independent predictor of mortality. The MPI score is useful in predicting the risk of death in patients with perforated diverticulitis.

Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis.

PURPOSE: To identify the risk factors for anastomotic leakage after left-sided colorectal resections with rectal anastomosis. METHODS: Forty-four patients with anastomotic leakage identified from a computer-generated database were compared with 44 control patients standardized for gender, age, and operative indication. RESULTS: The mean hospital stay was significantly prolonged in the leakage group, which resulted in a higher total cost of hospital treatment. The preoperative variables significantly associated with anastomotic leakage included malnutrition, weight loss, hypoalbuminemia, cardiovascular disease, two or more underlying diseases, and use of alcohol. The surgery-related factors that turned out to be significant were The American Society of Anesthesiologists physical status, operation time greater than two hours, multiple blood transfusions, intraoperative contamination of the operative field, and a short distance of the anastomosis to the anal verge. Obesity, body mass index, diabetes, smoking, serum hemoglobin, serum creatinine, serum bilirubin, bowel preparation, mode of antibiotic prophylaxis, type of anastomosis, technique of stapling, size of stapler used, and use of drain were nonsignificant variables. Malnutrition, weight loss, use of alcohol, intraoperative contamination, long operation time, and multiple blood transfusions remained significant in logistic regression model. Eighty-six percent of the patients with three or more risk factors of anastomotic leakage belonged to the leakage group. CONCLUSIONS: Patients with multiple risk factors have higher risk for anastomotic leakage. When patients have three or more risk factors, the creation of a protective stoma should be considered in cases with a low rectal anastomosis, and all these patients should be carefully monitored postoperatively for signs of possible leak.

Prognostic factors after surgery in patients younger than 50 years old with colorectal adenocarcinoma.

BACKGROUND/AIMS: The factors predicting recurrence and survival were evaluated using a computer-generated database to identify the independent predictors of survival of colorectal cancer in patients under 50 years of age. METHODOLOGY: One hundred and two patients under the age of 50 years with colorectal cancer who had been admitted into our hospital during the 20-year period of 1980-1999 were identified from a computer database. The factors possibly predicting recurrence were compared by bivariate analysis and the predictors of long-term survival by both univariate and multivariate analysis. RESULTS: A family history of colorectal cancer was present in 14% of all patients and in 15% of the patients aged under 40 years. Overall 5-year survival after radical resection was 59% and median survival 47 months. The recurrence rate after radical resection was 40%, being 13%, 35%, 55% and 80% in Dukes classes A, B, C and D, respectively. The risk of recurrence was most closely related to lymphatic invasion, vascular invasion and Dukes stage. Kaplan-Meier estimates showed that Dukes stage, grade of tumor, venous invasion, lymphatic invasion, perineural invasion and radicality of resection were the best predictors of survival, but in multivariate analysis only the radicality of operation, venous invasion and tumor grade retained their significance. CONCLUSIONS: Young age is not a poor prognostic marker in colorectal cancer. In addition to radical operation, venous invasion and tumor grade are good predictors of survival in patients under the age of 50 years.

Prevalence of perforated sigmoid diverticulitis is increasing.

INTRODUCTION: The population of Finland is aging fast, and dietary fiber consumption has decreased during the past few decades; the prevalence of sigmoid diverticular perforation can therefore be anticipated to increase. This study presents our experience concerning the outcome of 133 patients admitted to a university hospital for diverticular perforation during a 15-year period. METHODS: One hundred thirty-three patients admitted into our hospital for sigmoid diverticular perforation during the 15-year period from 1986 to 2000 were identified using a computer database. Clinical data were reviewed from the database and the patients' records. RESULTS: The annual prevalence of perforated sigmoid diverticulitis is increasing. It was 2.4 per 100,000 in the year 1986 and 3.8 per 100,000 in the year 2000. The resection rate was 90 percent; after resection, 45 primary anastomoses, 75 Hartmann's colostomies, and 1 covering colostomy were performed. The overall complication rate was 32 percent, without any significant difference between the procedures. Of the clinical variables, the Mannheim Peritonitis Index scores (P = 0.0088) and the number of previous hospital treatments (P = 0.035) correlated with postoperative complications. Overall mortality was 9 percent, without any significant difference between the procedures. Of the clinical variables, the Mannheim Peritonitis Index scores correlated with mortality. Of the 12 patients who died, 11 had Mannheim Peritonitis Index scores of 21 or more (P = 0.0001). Forty-five percent of the colostomies have been closed. CONCLUSIONS: The prevalence of perforated sigmoid diverticulitis is increasing in northern Finland. Mannheim Peritonitis Index score can be used in predicting the outcome of patients admitted for perforated sigmoid diverticulitis.

Factors that predict morbidity and mortality in patients with perforated peptic ulcers.

BACKGROUND: The demographic changes of perforated peptic ulcer disease were assessed in a well-defined population in northern Finland. The high mortality from perforated peptic ulcer underlines the importance of risk stratification, and clinical variables and three scoring systems were therefore tested for their ability to predict the probability of morbidity and mortality. METHODS: Two hundred and eighty patients admitted to a university hospital with peptic ulcer perforation during the 22-year period 1979-2000 were identified using a computer database, and their clinical data were reviewed from the database and patient records. RESULTS: The annual operation rate for ulcer perforation has varied from 2.7/100,000 in 1979 to 6.2 in 1985 and 3.6 in 2000 without any significant changes during the examination period. More operations have been performed for duodenal (157) than for gastric (123) ulcer perforations, but their incidence rates were quite similar at the beginning and the end of the period. Of the clinical variables, two or more associated illnesses, duration of symptoms for more than 24 hours, the amount of abdominal liquid, and low albumin concentration predicted morbidity, while a long duration of symptoms and the amount of abdominal liquid were independent risk factors for mortality. The MPI score correctly predicted 96% of postoperative complications and all the three scores, i.e. the Boey score, the MPI score and the ASA score, were good predictors of mortality. CONCLUSION: The incidence of peptic ulcer perforation has not changed during the 22-year period in northern Finland. All the three scores, i.e. the Boey score, the MPI score and the ASA score, predict mortality in patients with peptic ulcer perforation and are suitable for risk stratification preoperatively in the surgical ward.