Clinical trial: the incidence and early mortality after peptic ulcer perforation, and the use of low-dose aspirin and nonsteroidal anti-inflammatory drugs.

BACKGROUND: It is not clear whether the incidence or early mortality related to peptic ulcer perforation has changed. AIM: To evaluate the incidence and mortality related to peptic ulcer perforation while considering the intake of low-dose aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: We recorded the numbers and details of all patients presenting in our region of Scotland with perforation between 1997 and 2006 including demography, drug usage and 30-day mortality. RESULTS: In subjects aged >65 years, the annual incidence of perforation was 32.7 per 10(5) of the age-specific population, of whom 10.7 per 10(5) were taking low-dose aspirin and 12.0 taking NSAIDs. These were all significantly higher (P < 0.001) than the corresponding incidence in subjects aged < or =65 years (6.6 per 10(5) overall, 1.1 taking aspirin and 2.5 taking NSAIDs). There was an increasing trend with time in the number of patients taking NSAIDs (chi(2) = 4.57, P = 0.03). Using univariate analysis, 30-day mortality was associated with aspirin [odds ratio, 2.32 (95% C.I., 1.20-4.47), P = 0.01] but not with NSAIDs. The strongest predictors of mortality were increasing age and comorbidity. CONCLUSIONS: Perforation remains common in elderly patients including users of NSAIDs and aspirin. Early mortality is also noted in association with increasing age and comorbidity, but not independently with drug intake.

Comparison of P-POSSUM and O-POSSUM in predicting mortality after oesophagogastric resections.

BACKGROUND: P-POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) predicts mortality and morbidity in general surgical patients providing an adjunct to surgical audit. O-POSSUM was designed specifically to predict mortality and morbidity in patients undergoing oesophagogastric surgery. AIM: To compare P-POSSUM and O-POSSUM in predicting surgical mortality in patients undergoing elective oesophagogastric cancer resections. METHODS: Elective oesophagogastric cancer resections in a district general hospital from 1990 to 2002 were scored by P-POSSUM and O-POSSUM methods. Observed mortality rates were compared to predicted mortality rates in six risk groups for each model using the Hosmer-Lemeshow goodness-of-fit test. The power to discriminate between patients who died and those who survived was assessed using the area under the receiver-operator characteristic (ROC) curve. RESULTS: 313 patients underwent oesophagogastric resections. 32 died within 30 days (10.2%). P-POSSUM predicted 36 deaths (chi2 = 15.19, df = 6, p = 0.019, Hosmer-Lemeshow goodness-of-fit test), giving a standardised mortality ratio (SMR) of 0.89. O-POSSUM predicted 49 deaths (chi2 = 16.51, df = 6, p = 0.011), giving an SMR of 0.65. The area under the ROC curve was 0.68 (95% confidence interval 0.59 to 0.76) for P-POSSUM and 0.61 (95% confidence interval 0.50 to 0.72) for O-POSSUM. CONCLUSION: Neither model accurately predicted the risk of postoperative death. P-POSSUM provided a better fit to observed results than O-POSSUM, which overpredicted total mortality. P-POSSUM also had superior discriminatory power.

The relationship between patient physiology and cancer-specific survival following curative resection of colorectal cancer.

The impact of patient physiology on cancer-specific survival is poorly documented. Patient physiology predicted overall, cancer-specific (Physiology Score>30; HR 8.64 (95% CI 3.00-24.92); P=0.0005) and recurrence-free survival (Physiology Score >30; HR 7.44 (95% CI 1.99-27.73); P=0.003) independent of Dukes stage following potentially curative surgery for colorectal cancer. This independent negative association with survival is a novel observation.

Oesophagitis and bile reflux gastritis--clinical and histological assessments.

BACKGROUND AND AIMS: Little is known concerning the relationship between oesophagitis and bile reflux (chemical) gastritis despite the numerous studies on gastritis related to Helicobacter pylori. Given the importance of bile in the pathogenesis of both gastric and oesophageal disorders, we aimed at assessing the chemical gastritis score in patients with or without oesophagitis. METHODS: Chemical/bile reflux gastritis score and bile reflux index were assessed in gastric biopsies taken from patients with oesophagitis and gastric surgery (group 1, n=9), gastric surgery without oesophagitis (group 2, n= 11), and oesophagitis without gastric surgery (group 3, n= 10). Endoscopic oesophageal damage was also graded on a 0-5 scale. RESULTS: Group 1 had a median (interquartile range) chemical score of 6 (4-9) compared with 8 (6-10) in group 2, and 1 (0-2) in group 3 (p=0.001; Kruskal-Wallis test for multiple group comparisons). Both the reflux gastritis score and bile reflux index were lowest in patients with intact stomachs. However, the oesophageal scores were 2 (1-2) in group 1 compared with 3 (2-5) in group 3 (p=0.01). CONCLUSION: Patients with post-surgical stomachs have similar chemical and related scores regardless of the presence or absence of oesophagitis. Despite the higher chemical gastritis scores, patients with gastric surgery, exposed mainly to bile reflux, have milder oesophagitis than those with intact stomachs, exposed to both gastric acid and bile.

Reflux and Barrett's oesophagitis after gastric surgery--long-term follow-up and implications for the roles of gastric acid and bile in oesophagitis.

BACKGROUND: The role of gastric acid is difficult to separate from that of bile in oesophageal reflux, and the complications of this can take many years to develop. Gastric surgery patients provide a good model for both significant bile reflux and marked gastric acid inhibition. AIM: To study the oesophageal abnormalities in gastric surgery patients undergoing long-term follow-up, compared with patients with intact stomachs. METHODS: Two hundred and forty adult patients were endoscoped regardless of their age, sex or type of surgical procedure. Oesophageal damage was graded on a scale of 0-5, and biopsies were taken to exclude neoplasia, to diagnose Barrett's oesophagus and to identify Helicobacter pylori. RESULTS: Of the 240 patients studied, 140 had undergone gastric surgery 27 years (19-31 years) [median (interquartile range)] prior to endoscopy, and these patients had milder oesophageal scores and fewer cases of Barrett's oesophagitis. Of the 119 patients with post-surgical bile reflux gastritis, 31 (26%) had oesophagitis, two (1.7%) had Barrett's oesophagitis and oesophageal scores of 0 (0-1) were found. These results compared with corresponding values of 37 (37%; P = 0.11), 11 (11%; P = 0.007) and 0 (0-2) (P = 0.046), respectively, in 100 patients with intact stomachs. In addition, of the 83 patients with vagotomy, 19 had oesophagitis (23%; P = 0.05), none had Barrett's oesophagitis and lower oesophageal scores (P = 0.02) were found. CONCLUSIONS: The prevalence and severity of reflux and Barrett's oesophagitis are not increased in patients with a long history of gastric surgery, particularly after vagotomy, and despite being at risk of bile reflux.

Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: a randomized trial.

In a randomized controlled trial, 299 patients were sent a symptoms questionnaire 1 year after laparoscopic (n = 151) or minilaparotomy (n = 148) cholecystectomy for symptomatic cholelithiasis. The response rate to the questionnaire from contactable patients was 86 per cent. In both groups, at least 90 per cent of patients reported that their symptoms were improved, and at least 93 per cent rated the success of their operation as 'excellent', 'good', or 'fair'. However, over half the patients reported abdominal pain, a quarter reported flatulence, and a quarter dyspepsia. The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy reported heartburn (35 per cent versus 19 per cent, P = 0.005). Patients who reported a 'poor' outcome were more likely to have suffered a postoperative complication, had lower quality of life scores, and higher anxiety and depression scores. Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis.

Value of oral antibiotic prophylaxis in colorectal surgery.

A total of 169 patients undergoing colorectal surgery were randomly allocated to receive either gentamicin plus metronidazole or oral ciprofloxacin plus metronidazole as prophylaxis; they were also allocated to receive cover for 1 or 3 days. Twenty-eight patients (17 per cent) developed postoperative wound infections. The proportion of patients with wound infections and other infective complications was significantly less (P < 0.02) in those receiving oral ciprofloxacin. Cover for 3 days was no better than that for only 1 day. Oral ciprofloxacin for prophylaxis may offer advantages in efficacy and ease of administration compared with parenteral antibiotics.

Oral ciprofloxacin as prophylaxis in gastroduodenal surgery.

One hundred and fifty patients undergoing gastroduodenal surgery were randomly allocated to receive intravenous (iv) cefuroxime, iv ciprofloxacin or oral ciprofloxacin as prophylaxis. There were no differences in the incidence of postoperative infection complications or duration of stay among the three groups. Oral ciprofloxacin offers obvious advantages in terms of ease of administration and cost.

Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial.

Although laparoscopic cholecystectomy has rapidly become routine practice in the UK, there has been no rigorous comparison of it with open cholecystectomy. In our trial, 302 patients were randomised to laparoscopic or minilaparotomy cholecystectomy. Recovery after surgery was assessed by length of hospital stay, outpatient review at 10 days and 4 weeks, and patient questionnaires 1, 4, and 12 weeks after surgery. The mean operation time was 14 min shorter for minilaparotomy, while median post-operative hospital stay was 2 days shorter after laparoscopic cholecystectomy. The hospital costs were about 400 pounds greater for the laparoscopic procedure. Laparoscopic patients returned to work in the home sooner; at 1 week, they had better physical and social functioning, were less limited by physical problems, and had less pain and depression. At 4 weeks, only physical functioning and depression scores were better in the laparoscopic group, and by 3 months there were no differences. Laparoscopic patients were more satisfied with the appearance of their scars. The incidence of complications after both procedures was 20%. Compared to minilaparotomy cholecystectomy, laparoscopic cholecystectomy results in shorter hospital stay, less postoperative dysfunction, and quicker return to normal activities, but is more costly.

The value of oral antibiotic prophylaxis in biliary tract surgery.

In this study the relationship between the presence or absence of organisms in bile or on closing wound swabs and the subsequent development of wound sepsis was confirmed. There was no significant difference in the incidence of septic complications among three treatment groups in which cefuroxime (iv) and ciprofloxacin (iv or oral) were administered. Consideration of costs attributable to the choice of antibiotic prophylaxis suggests that oral ciprofloxacin in biliary tract surgery may offer significant advantages.

Examination of cardiorespiratory changes during upper gastrointestinal endoscopy. Comparison of monitoring of arterial oxygen saturation, arterial pressure and the electrocardiogram.

Critical events including hypoxaemia, arrhythmias and myocardial ischaemia may occur more frequently during endoscopic procedures than during anaesthesia. A study was undertaken to assess the cardiovascular changes and to evaluate suitable monitoring techniques to detect critical events during sedation and endoscopy. Twenty patients scheduled to undergo a prolonged endoscopic procedure which required deep sedation were studied. Continuous recordings of electrocardiogram, heart rate and arterial oxygen saturation were made and arterial pressure was recorded at one-minute intervals. The study commenced immediately before administration of sedatives, continued for the duration of the examination and for one hour following the examination. Oxygen saturation decreased in all patients during the examination to a mean of 82.9% (SD 11.9), and remained below baseline for the duration of the examination and into the recovery period. Statistically significant increases and reductions of systolic arterial pressure and rate-pressure product were found during the procedures compared with baseline values recorded before administration of sedatives. Sixteen of the 20 patients developed tachycardia during the examination. Ten patients developed ectopic foci which were supraventricular, ventricular or both in origin. Electrocardiogram changes resolved during the recovery period. Myocardial ischaemia was assessed by S-T segment depression and a significant correlation was found between S-T segment depression and hypoxaemia, although the magnitude of the S-T depression was small and may not have been detected clinically. No correlation was found between S-T segment depression and arterial pressure, heart rate or rate-pressure product.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial oxygen saturation during upper gastrointestinal endoscopy: the effects of a midazolam/pethidine combination.

This study was performed to assess the severity and duration of hypoxia during and after prolonged upper gastrointestinal endoscopy. Twenty patients were studied using a non-invasive pulse oximeter. Significant reductions in oxygen saturation were noted during endoscopy and remained below the preexamination level during the one hour period after the examination. This study indicates that pulse oximetry is a useful monitor for detection of hypoxia during and after endoscopy.

Pancreatic and biliary pressure changes during ERCP.

Injection of contrast is a prerequisite for endoscopic retrograde cholangiopancreatography. Such injection into the biliary and pancreatic duct systems may require considerable force. This paper reports the changes in pressure that result within the duct systems and highlights the significant pressure rise that occurs within the pancreatic duct.

Acute pancreatitis and non-Hodgkin's lymphoma.

We report two patients presenting with acute pancreatitis, the aetiology of which was subsequently proven to be non-Hodgkin's lymphoma. Histological confirmation of tumour-associated pancreatitis is essential so that appropriate therapy can be planned.

Postoperative pain and pulmonary complications: comparison of three analgesic regimens.

In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05).