Leakage after Surgery for Rectum Cancer: Inconsistency in Reporting to the Danish Colorectal Cancer Group.

Purpose. Anastomotic leakage accounts for up to 1/3 of all fatalities after rectal cancer surgery. Evidence suggests that anastomotic leakage has a negative prognostic impact on local cancer recurrence and long-term cancer specific survival. The reported leakage rate in 2011 in Denmark varied from 7 to 45 percent. The objective was to clarify if the reporting of anastomotic leakage to the Danish Colorectal Cancer Group was rigorous and unequivocal. Methods. An Internet-based questionnaire was e-mailed to all Danish surgical departments, who reported to Danish Colorectal Cancer Group (DCCG) in 2011. There were 23 questions. Four core questions were whether pelvic collection, fecal appearance in a pelvic drain, rectovaginal fistula, and "watchfull" waiting patients were reported as anastomotic leakage. Results. Fourteen out of 17 departments, who in 2011 according to DDCG performed rectal cancer surgery, answered the questionnaire. This gave a response rate of 82%. In three of four core questions there was disagreement in what should be reported as anastomotic leakage. Conclusion. The reporting of anastomotic leakage to the Danish Colorectal Cancer Group was not rigorous and unequivocal. The reported anastomotic leakage rate in Danish Colorectal Cancer Group should be interpreted with caution.

Systematic review of thromboprophylaxis in colorectal surgery -- an update.

OBJECTIVE: The incidence of thromboembolism after colorectal surgery is higher than after general surgery. The aim of this paper is to update a systematic review addressing thrombosis prophylaxis in connection with colorectal surgery. METHODS: MEDLINE, EMBASE, LILACS, abstract books and reference lists from reviews were searched without language restrictions for randomized controlled trials or clinical controlled trials comparing prophylactic interventions and/or placebo up til August 2003. Five hundred and fifty-eight studies were identified of which 19 fulfilled the inclusion criteria. Data extraction was done by at least two of the authors. Outcome was deep venous thrombosis and/or pulmonary embolism diagnosed by various methods. RESULTS: Any kind of heparin is better than no treatment or placebo (11 studies) with a Peto Odds ratio (POR) at 0.32 (95% CI 0.20-0.53). Unfractionated heparin and low molecular weight heparin (4 studies) were equally effective POR 1.01 (95% CI 0.67-1.52). The combination of graduated compression stockings and LMWH is better than LMWH alone (2 studies) with a POR at 4.17 (95% CI 1.37-12.70). CONCLUSION: The optimal thromboprophylaxis in colorectal surgery is the combination of graduated compression stockings and low-dose unfractionated heparin or low molecular weight heparin.

Heparins and mechanical methods for thromboprophylaxis in colorectal surgery.

BACKGROUND: Colorectal surgery implies higher risk of postoperative thromboembolic complications as deep venous thrombosis (DVT) and pulmonary embolism (PE) than general surgery. The best prophylaxis in general surgery is heparin and graded compression stockings. No systematic review on combination prophylaxis or on thrombosis prophylaxis in colorectal surgery has been published. OBJECTIVES: To compare the incidence of postoperative thromboembolism after colorectal surgery using prophylactic methods focussing on heparins and mechanical methods alone and in combinations. SEARCH STRATEGY: Electronic searches was performed in PUBMED, EMBASE, LILACS and the Cochrane Library. Abstract books from major congresses were handsearched as were reference lists from previously performed reviews. SELECTION CRITERIA: RCT or CCT comparing prophylactic interventions and/or placebo. Outcomes were ascending venography, 125 I-fibrinogen uptake test, ultrasound methods, pulmonary scintigraphy. Studies, using thermographic methods, other isotopic methods, plethysmographic methods, and purely clinical methods as the only diagnostic measure were excluded. 558 studies were identified - 477 were excluded. Only 3 of the identified studies focused exclusively on colorectal surgery. Studies of general surgery contain considerable numbers of colorectal patients. The authors of 66 studies in general and/or abdominal surgery were contacted for retrieving the results from the colorectal patients. Answers were received from very few. 19 studies entered this review. DATA COLLECTION AND ANALYSIS: All studies and all data extraction were performed by at least two of the authors. Outcome was deep venous thrombosis and/or pulmonary embolism. Analysis of bleeding complications were unfeasible. 12 meaningful outcomes were analysed by means of the fixed effects model with Peto Odds Ratios. MAIN RESULTS: Heparins versus no treatment: Any kind of heparincompared to no treatment or placebo (comparison 07.03, 11 studies). Heparin is better in preventing DVT and/or PE with a Peto Odds ratio at 0.32 (95% Confidence Interval 0.20-0.53) Unfractionated heparin versus low molecular weight heparin (comparison 08.03, 4 studies). The two treatments were found equally effective in preventing DVT and/or PE with a Peto Odds ratio 1.01 (95% Confidence Interval 0.67-1.52). Mechanical methods (comparison 10.3, 2 studies). The combination of graded compression stockings and LDH is better than LDH alone in preventing DVT and/or PE with a Peto Odds ratio at 4.17 (95% Confidence Interval 1.37-12.70). REVIEWER'S CONCLUSIONS: The optimal prophylaxis in colorectal surgery is the combination of graduated compression stockings and low-dose unfractionated heparin. The unfractionated heparin can be replaced with low molecular weight heparin.

Heparins and mechanical methods for thromboprophylaxis in colorectal surgery.

BACKGROUND: Colorectal surgery implies higher risk of postoperative thromboembolic complications as deep venous thrombosis (DVT) and pulmonary embolism (PE) than general surgery. The best prophylaxis in general surgery is heparin and graded compression stockings. No systematic review on combination prophylaxis or on thrombosis prophylaxis in colorectal surgery has been published. OBJECTIVES: To compare the incidence of postoperative thromboembolism after colorectal surgery using prophylactic methods focussing on heparins and mechanical methods alone and in combinations. SEARCH STRATEGY: Electronic searches was performed in MEDLINE, EMBASE back to 1970. Abstract books from major congresses were handsearched as were reference lists from previously performed reviews. SELECTION CRITERIA: RCT or CCT comparing prophylactic interventions and/or placebo. Outcomes were ascending venography, 125 I-fibrinogen uptake test, ultrasound methods, pulmonary scintigraphy. Studies, using thermographic methods, other isotopic methods, plethysmographic methods, and purely clinical methods as the only diagnostic measure were excluded. 558 studies were identified - 477 were excluded. Only 3 of the identified studies focused exclusively on colorectal surgery. Studies of general surgery contain considerable numbers of colorectal patients. The authors of 66 studies in general and/or abdominal surgery were contacted for retrieving the results from the colorectal patients. Answers were received from very few. 19 studies entered this review. DATA COLLECTION AND ANALYSIS: All studies and all data extraction were performed independently by at least two of the authors. Outcome was deep venous thrombosis and/or pulmonary embolism. Analysis of bleeding complications were unfeasible. 12 meaningful outcomes were analysed by means of the fixed effects model with Peto Odds Ratios. MAIN RESULTS: Heparins versus no treatment: Any kind of heparincompared to no treatment or placebo (comparison 07.03, 11 studies). Heparin is better in preventing DVT and/or PE with a Peto Odds ratio at 0.32 (95% Confidence Interval 0.20-0.53) Unfractionated heparin versus low molecular weight heparin (comparison 08.03, 4 studies). The two treatments were found equally effective in preventing DVT and/or PE with a Peto Odds ratio 1.01 (95% Confidence Interval 0.67-1.52). Mechanical methods (comparison 10.3, 2 studies). The combination of graded compression stockings and LDH is better than LDH alone in preventing DVT and/or PE with a Peto Odds ratio at 4.17 (95% Confidence Interval 1.37-12.70). REVIEWER'S CONCLUSIONS: The optimal prophylaxis in colorectal surgery is the combination of graduated compression stockings and low-dose unfractionated heparin. The unfractionated heparin can be replaced with low molecular weight heparin.

Preoperative prediction model of outcome after cholecystectomy for symptomatic gallstones.

BACKGROUND: After cholecystectomy for symptomatic gallstone disease 20%-30% of the patients continue to have abdominal pain. The aim of this study was to investigate whether preoperative variables could predict the symptomatic outcome after cholecystectomy. METHODS: One hundred and two patients were referred to elective cholecystectomy in a prospective study. Median age was 45 years; range, 20-81 years. A preoperative questionnaire on pain, symptoms, and history was completed, and the questions on pain and symptoms were repeated 1 year postoperatively. Preoperative cholescintigraphy and sonography evaluated gallbladder motility, gallstones, and gallbladder volume. Preoperative variables in patients with or without postcholecystectomy pain were compared statistically, and significant variables were combined in a logistic regression model to predict the postoperative outcome. RESULTS: Eighty patients completed all questionnaires. Twenty-one patients continued to have abdominal pain after the operation. Patients with pain 1 year after cholecystectomy were characterized by the preoperative presence of a high dyspepsia score, 'irritating' abdominal pain, and an introverted personality and by the absence of 'agonizing' pain and of symptoms coinciding with pain (P < 0.000001). In a constructed logistic regression model 15 of 18 predicted patients had postoperative pain (PVpos = 0.83). Of 62 patients predicted as having no pain postoperatively, 56 were pain-free (PVneg = 0.90). Overall accuracy was 89%. CONCLUSION: From this prospective study a model based on preoperative symptoms was developed to predict postcholecystectomy pain. Since intrastudy reclassification may give too optimistic results, the model should be validated in future studies.

Human gallbladder pressure and volume: validation of a new direct method for measurements of gallbladder pressure in patients with acute cholecystitis.

Increased gallbladder (GB) pressure is probably a part of the pathogenesis of acute cholecystitis, and measurements of GB pressure might therefore be of interest. The aim of this study was to validate a microtip pressure transducer for intraluminal GB pressure measurements. In vitro precision and accuracy was within 0.2 mmHg, (SD) and 0.6 +/- 0.1 mmHg (mean +/- SD), respectively. Pressure rise rate was 24.8 +/- 5.5 mmHg s-1. Zero drift was in the range 0.3 +/- 0.4 to 0.8 +/- 0.9 mmHg (mean +/- SD). GB pressure was investigated in 16 patients with acute cholecystitis treated with percutaneous ultrasonically guided cholecystostomy. Basal intraluminal GB pressure was 8.9 mmHg (2.1-12.2 mmHg; n = 9, open cystic duct) and 1.8 and 5.8 mmHg (n = 2, closed cystic duct). There was no significant difference between two different measurements in the same patients (n = 5). The pressure was significantly influenced by respiration (n = 8) and the pressure seems to be higher in the sitting position than in the supine position (n = 5). Cystic duct opening pressure was 10.4, 11.2 and 16.8 mmHg (n = 3). Pressure-volume responses showed that the GB up to a certain volume could accommodate increases in intraluminal volume with only slight changes in intraluminal pressure (n = 4). Except for the zero drift, this piece of equipment seemed to fulfil the requirements of being able to measure pressure in the GB. In vivo measurements showed a good clinical reproducibility of the method, and also that respiration and patient posture influenced the pressure measurements. Further, a GB pressure-volume relationship was demonstrated, and the possibility of a cystic duct opening pressure was described.

Cholescintigraphy in patients with acute cholecystitis before and after percutaneous gallbladder drainage.

OBJECTIVE: To investigate gallbladder function by use of cholescintigraphy in patients with acute cholecystitis before and after percutaneous gallbladder drainage. DESIGN: A cholescintigraphy was performed in 40 patients with acute cholecystitis before and after the performance of percutaneous gallbladder drainage. During the post-drainage cholescintigraphies, a cholecystokinin stimulation was performed to investigate gallbladder emptying in 12 selected patients. Gallbladder pressure and volume were measured before drainage in another group of 12 patients with acute cholecystitis. RESULTS: As expected, no gallbladder activity was observed in the cholescintigraphies before drainage, except in a patient with an occluding stone in the common bile duct. Cystic duct patency and gallbladder activity were seen in 80% of patients in cholescintigraphies performed after drainage but before any other treatment. Post-drainage cholescintigraphy revealed a mean gallbladder ejection fraction of 24%, which is significantly lower than the corresponding value in normal individuals and gallstone patients without cholecystitis (n = 12). Gallbladder pressure and volume were markedly increased compared with normal values. CONCLUSION: The relief of increased gallbladder pressure and volume appears to be important for the re-establishment of gallbladder function.

[Disease classification--how are bladder tumors registered? A questionnaire]. / Sygdomsklassifikation--hvordan registreres blaeretumorer? Et rundspørge.

Sixty-one surgical departments in Denmark were asked how they used the three possible diagnoses: carcinoma in situ vesicae urinariae (D09.0), neoplasma benignum vesicae urinariae (D30.3) and neoplasma malignum vesicae urinariae (C67.9) for bladder tumours with specific reference to different stages and grades of the tumour. The answers from 59 departments demonstrated great variation in the classification of the same bladder tumour. This variation results in a registration of data which is not valid for a statistical outcome of the real incidence of benign and malignant bladder tumours in Denmark. A consensus from the Danish Bladder Cancer Committee, which will be published in 1996, concerning the criteria for the use of the different diagnoses for bladder tumours, should however in the future make it possible for all departments to make a uniform classification.

Evaluation of pancreatic tissue fluid pressure measurements intraoperatively and by sonographically guided fine-needle puncture.

The aim of the present study was to evaluate the needle method for pancreatic tissue fluid pressure measurements. Clinical evaluation was performed in 24 patients with chronic pancreatitis, comparing repeated pressure measurements via sonographically guided fine-needle puncture and intraoperative pressure measurements by direct puncture of pancreatic tissue and duct. In patients with chronic pancreatitis we found small week-to-week variations in sonographically guided percutaneous pressure measurements and good agreement between preoperative percutaneous pressure measurements and intraoperative pressure measurements via direct puncture. Furthermore, no significant difference was seen between pancreatic duct and tissue fluid pressure. The technical evaluation was performed by repeated pressure measurements in human pancreatic autopsy specimens and living rats in a pressure chamber at various external pressure levels. The basic calibration of the method evaluated by means of this pressure chamber study showed sufficient precision and accuracy of the needle technique for clinical and investigative purposes. In conclusion, our results suggest that pancreatic tissue fluid pressure can be reliably assessed by the needle technique.

Pancreatic tissue fluid pressure during drainage operations for chronic pancreatitis.

Pancreatic tissue fluid pressure was measured in 10 patients undergoing drainage operations for painful chronic pancreatitis. The pressure was measured by the needle technique in the three anatomic regions of the pancreas before and at different stages of the drainage procedure, and the results were compared with preoperative endoscopic retrograde cholangiopancreatography (ERCP) morphology. The preoperatively elevated pressure decreased in all patients but one, to normal or slightly elevated values. The median pressure decrease was 50% (range, 0-90%; p = 0.01). The drainage anastomosis (a pancreaticogastrostomy) was made in the body of the pancreas, but the pressure decrease in this region was not significantly different from that in the head and tail. The pressure decrease was independent of findings during ERCP (stone, total duct obstruction, or major ductal stenosis). In conclusion, the results showed a decrease in pancreatic tissue fluid pressure during drainage operations for pain in chronic pancreatitis. Regional pressure decrease were apparently unrelated to ERCP findings.

Pancreatic tissue fluid pressure in chronic pancreatitis. Relation to pain, morphology, and function.

The relation between pancreatic tissue fluid pressure and pain, morphology, and function was studied in a cross-sectional investigation. Pressure measurements were performed by percutaneous fine-needle puncture. Thirty-nine patients with chronic pancreatitis were included, 25 with pain and 14 without pain. The pressure was higher in patients with pain than in patients without pain (p = 0.000001), and this was significantly related to a pain score from a visual analogue scale (p less than 0.001). Patients with pancreatic pseudocysts had both higher pressure and higher pain score than patients without (p = 0.004 and p = 0.0003, respectively). The pressure was significantly related (inversely) to pancreatic duct diameter only in the group of 19 patients with earlier pancreatic surgery (R = -0.57, p = 0.02). The pressure was not related to functional factors or the presence of pancreatic calcifications. In conclusion, pancreatic tissue fluid pressure is a valuable indicator of pain in chronic pancreatitis.

Comparison of regional pancreatic tissue fluid pressure and endoscopic retrograde pancreatographic morphology in chronic pancreatitis.

The relation between pancreatic tissue fluid pressure measured by the needle method and pancreatic duct morphology was studied in 16 patients with chronic pancreatitis. After preoperative endoscopic retrograde pancreatography (ERP) the patients were submitted to a drainage operation. The predrainage pressures were higher in the tail of the pancreas (29 mm Hg; range, 16-37 mm Hg) than in the head (18 mm Hg; range, 2-30 mm Hg; p = 0.02). The regional pressure differences were significantly greater in four patients who had previously undergone pancreatic surgery than in the 12 patients without previous surgery. A stone, total obstruction, or major stenosis in the pancreatic duct at ERP was related to a downstream pressure gradient significantly higher than found in a non-obstructed pancreatic main duct, but the relation was not uniform. Generally, there was no significant relation between pancreatic duct diameter and pressure, but in each individual patient, the regional pressure tended to be highest in the region with the largest duct diameter. In conclusion, the study shows considerable regional pressure differences in chronic pancreatitis and indicates that the intraoperative pressure measurements give important information supplementary to ERP about the pathologic process in patients with chronic pancreatitis.

Effect of portal hypertension and duct ligature on pancreatic fluid pressures in cats.

In two groups of cats recordings were performed, during laparotomy, of pancreatic tissue fluid pressure measured by a needle technique, interstitial fluid pressure measured by micropipette technique, pancreatic intraductal pressure, and portal vein pressure. In one group of cats the pressures were measured before and after acutely induced portal hypertension; in the other group of cats the pressures were measured after an overnight ligature of the pancreatic main duct. At rest the needle pressure was equal to duct pressure but significantly lower than interstitial fluid pressure and portal pressure. Acute portal hypertension caused no significant changes in micropipette, needle, or duct pressures. Pancreatic duct ligature increased duct pressure, interstitial fluid pressure, and needle pressure. We conclude that the fluid pressure in the pancreas is probably influenced by the production/drainage relation of the pancreatic juice rather than by haemodynamic conditions.

Evaluation of pancreatic tissue fluid pressure and pain in chronic pancreatitis. A longitudinal study.

Pancreatic tissue fluid pressure and pain were compared in a longitudinal study in nine patients undergoing drainage operations for pain in chronic pancreatitis. Pressure measurements were performed percutaneously before the operation, intraoperatively before and after the drainage procedure, and percutaneously at follow-up study 1 year after the operation. The pressures were compared with 2-week pain scores. The median predrainage pressures were increased (27 mm Hg; range, 19-34 mm Hg; normal, 7 mm Hg; range, 2-13 mm Hg). The drainage operations led to a 45% pressure decrease (range, 0-77%). At 1-year follow-up study the pressure was increased in the patients with recurrent pain, and there was a significant relation between pressure and pain (R = 0.85, p less than 0.02). Furthermore, patients with an intraoperative pressure decrease greater than 10 mm Hg had a pain-free postoperative period. The duration of the pain-free period was significantly related to the size of the intraoperative pressure decrease (R = 0.79, p less than 0.03). These results further suggest that there is a causal relationship between pancreatic tissue fluid pressure and pain in chronic pancreatitis and that the success of the drainage procedure may be predicted by intraoperative pancreatic tissue fluid pressure measurements.

Pancreatic tissue pressure and pain in chronic pancreatitis.

Pancreatic tissue pressure (PTP) was measured peroperatively by the needle technique in 14 patients with chronic pancreatitis undergoing drainage operations for pseudocysts (six patients) or dilated ducts (eight patients). All patients suffered from severe abdominal pain before the operation, and a pain evaluation was made at discharge and after 8-18 months of observation. PTP was increased in all patients and was not different in the two groups. PTP decreased significantly in both groups after drainage. Pain relief at discharge was good or fair in 12 patients and poor in one (one patient died postoperatively). During observation, pain returned in four patients. Long-term pain relief was not related to PTP decrease, PTP after operation, type of operation, or patency of anastomosis as seen by endoscopic retrograde pancreaticography.