A randomized trial comparing percutaneous endoscopic gastrostomy (PEG) and radiologically inserted percutaneous gastrostomy (RIG).

BACKGROUND AND OBJECTIVE: At present, percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in establishing a permanent feeding tube in patients with chronic severe dysphagia. This is the first prospective randomized study in adults comparing PEG with radiologically inserted gastrostomy (RIG). METHODS: Randomization of 106 patients, eligible for both techniques, to PEG (pull method) or RIG. The groups were comparable in terms of age, body mass index, and underlying diseases. Adverse events were reported 10 and 30 days after the operative procedure, and mortality was up until 6 months. The validated European Quality of life 5 Dimensions 3 level version (EQ-5D) questionnaire was used for health status measurements. RESULTS: The procedures were successfully completed in all patients. The median operative time was 10 min for PEG and 20 min for RIG (p < 0.001). The overall rate of adverse events was lower for PEG (22%) than for RIG (51%, p = 0.002), mostly due to less local self-limiting stoma reactions and tube problems. The 30-day mortality was lower after PEG (2% versus 14%, p = 0.020). Patient-scored health status remained low for the entire cohort, with an EQ-5D utility index of 0.164. Self-rated health was low but improved in the RIG group (52.5 from 41.1, out of 100). CONCLUSION: PEG can be recommended as the primary procedure in patients in need of a feeding gastrostomy, mainly due to a lower frequency of tube complications. However, as the two techniques complement each other, RIG is also a valid alternative method. CLINICAL TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number ISRCTN17642761. https://doi.org/10.1186/ISRCTN17642761.

Less Pain 1 Year After Total Extra-peritoneal Repair Compared With Lichtenstein Using Local Anesthesia: Data From a Randomized Controlled Clinical Trial.

OBJECTIVE: The aim was to compare long-term postoperative pain after inguinal hernia surgery using 2 techniques that have shown favorable long-term outcome in previous randomized studies: Lichtenstein using local anesthesia (LLA) and endoscopic total extra-peritoneal repair (TEP) under general anesthesia. BACKGROUND: Patients often experience pain after inguinal hernia surgery. These 2 methods in their optimal state have not yet been sufficiently compared. METHODS: A randomized controlled trial was conducted to detect any difference in long-term postoperative inguinal pain. Altogether 384 patients were randomized and operated using either TEP under general anesthesia (n = 193) or LLA (n = 191). One year postoperatively, patients were examined by an independent surgeon and requested to complete the Inguinal Pain Questionnaire (IPQ), a validated questionnaire for the assessment of postoperative inguinal pain. RESULTS: Three hundred seventy-five (97.7%) patients completed follow-up at 1 year. In the TEP group, 39 (20.7%) patients experienced pain, compared with 62 (33.2%) patients in the LLA group (P = 0.007). Severe pain was reported by 4 patients in the TEP group and 6 patients in the LLA group (2.1% and 3.2%, respectively, P = 0.543). Pain in the operated groin limited the ability to exercise for 5 TEP patients and 14 LLA patients (2.7% and 7.5%, respectively, P = 0.034). CONCLUSIONS: Patients operated with TEP experienced less long-term postoperative pain and less limitation in their ability to exercise than those operated with LLA. The present data justify recommending TEP as the procedure of choice in the surgical treatment of primary inguinal hernia.

TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial.

BACKGROUND: Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain. METHODS: Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)]. RESULTS: A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups. CONCLUSIONS: Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

Effectiveness of antibiotic prophylaxis in cholecystectomy: a prospective population-based study of 1171 cholecystectomies.

BACKGROUND: The aim of this study was to assess the benefit from antibiotic prophylaxis (AP) during cholecystectomy in a population-based cohort study. METHODS: All cholecystectomies performed in Uppsala County, 2003-2005, were registered prospectively according to a standardized protocol. High-risk procedures (HP) were defined as operations for acute cholecystitis and procedures including exploration of the common bile duct. Infections requiring surgical or percutaneous drainage and non-surgical infections that prolonged hospital stay were defined as major infectious complications (IC). RESULTS: Altogether 1171 patients underwent cholecystectomy. AP was given to 130 of 867 (15%) of the patients undergoing low-risk procedures (LP) and 205 of 304 (67%) of those undergoing H-R P. Major IC were seen in 6 of 205 (3%) of the patients undergoing H-R P with AP and 1 of 99 of the patients undergoing H-R P without AP. No major IC was seen after L-R P. Minor IC were seen after 5 of 205 (2%) HP with AP, 1 of 99 (1%) HP without AP, 0 of 130 (0%) LP with AP, and 2 of 737 (0.3%) LP without AP. In univariate logistic analysis, the overall risk for IC was found to be higher with AP (p < 0.05), but the increase did not remain significant if adjusting for age, gender, ASA class, H-R P/L-R P and surgical approach or limiting the analysis to major IC. CONCLUSION: There is no benefit from AP in uncomplicated procedures. The effectiveness of antibiotic prophylaxis in complicated cholecystectomy must be evaluated in randomized controlled trials.

Validation of Gastrointestinal Quality of Life Index in Swedish for assessing the impact of gallstones on health-related quality of life.

OBJECTIVE: The aim of the present study was to validate a Swedish translation of the Gastrointestinal Quality of Life Index (GIQLI) questionnaire in patients with gallstone disease. METHODS: Sensitivity to change, internal consistency, and test-retest stability were tested in 187 consecutive patients who underwent planned cholecystectomy. Construct validity was assessed by comparing the GIQLI score with the bodily pain scale of SF-36 and four single-item questions in a separate group of 104 patients. RESULTS: A significant increase in all five domains as well as in the overall GIQLI score 6 months after surgery (all P < 0.05) was seen. All five domains correlated significantly with other measures of gallstone-related symptoms except one single-item question. Intraclass correlations ranged from 0.62 to 0.87. Cronbach's alpha ranged from 0.77 to 0.89. CONCLUSION: The Swedish translation of GIQLI has a high validity and reliability for assessing the impact of gallstones on quality of life.

Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure.

PURPOSE: To retrospectively compare the outcome of transcatheter arterial embolization (TAE) and surgery as salvage therapy of upper gastrointestinal bleeding after failed endoscopic treatment. MATERIALS AND METHODS: From January 1998 to December 2005, 658 patients were referred to diagnostic/therapeutic emergency endoscopy and diagnosed with upper gastrointestinal bleeding. Ninety-one of these 658 patients (14%) had repeat bleeding or continued to bleed. Forty of those 91 patients were treated with TAE and 51 were treated with surgery. From the medical records, the following variables were recorded: demographic data, endoscopic diagnoses, comorbidities, lowest hemoglobin levels, total transfusion requirements, lengths of hospitalization stays, postprocedure complications, and mortality rates. The relative survival rate was calculated, and survival probability was calculated with the Kaplan-Meier technique. RESULTS: Patients treated with TAE were older (mean age, 76 years; age range, 40-94 years) and had slightly more comorbidities compared to patients who underwent surgery (mean age, 71 years; age range, 45-89 years). The 30-day mortality rate in patients treated with TAE was one of 40 (3%) compared to seven of 51 (14%) in patients treated with surgery (P < .07). Most repeat bleeding could be effectively treated with TAE, both in the surgical and TAE groups. CONCLUSIONS: The results of this study suggest that, after failure of therapeutic endoscopy for upper gastrointestinal bleeding, TAE should be the treatment of choice before surgery and that TAE can also be used to effectively control bleeding after failed surgery or TAE. There was a clear trend to lower 30-day mortality with use of TAE instead of surgery.

Inflammatory response in patients with malignant obstructive jaundice.

OBJECTIVE: Surgery in patients with malignant obstructive jaundice is associated with increased risks for postoperative septic complications. The aim of this study was to investigate the inflammatory and the local cellular immune response in patients accepted for surgery because of tumours in the hepatic-pancreatic-biliary (HPB) tract. MATERIAL AND METHODS: Patients with obstructive jaundice (group HPB(+)) were compared with those without (HPB(-)). Patients undergoing surgery for benign abdominal disorders served as controls. Obstructive jaundice was present in 18 out of 33 HPB patients. Preoperatively, blood was analysed for bacteria, endotoxins and cytokines (TNF-alpha, IL-6 and IL-10). At operation, mesenteric lymph nodes (MLNs) were excised for bacterial cultures using standard microbiological techniques, and immunohistochemistry, using antibodies CD4 and CD8 (mainly staining T lymphocytes), CD68 (macrophages), and anti-caspase-3 (to determine the rate of apoptosis). RESULTS: Bacterial translocation was not demonstrated in any of the patients. Increased preoperative concentrations of endotoxins were found in group HPB(+). The number of macrophages and the rate of apoptosis in MLNs were increased in jaundiced patients, while the number of T lymphocytes was decreased. CONCLUSIONS: Malignant obstructive jaundice causes increased blood concentrations of endotoxins and cytokines, an increased number of macrophages in MLNs, a higher rate of apoptosis in MLNs, but a decreased number of T lymphocytes in MLNs. The lymphocyte depletion is probably due to the increased rate of apoptosis, and might reduce the ability of jaundiced patients to eradicate infection.

Influence of cyclooxygenase inhibitors on gut immune cell distribution and apoptosis rate in experimental sepsis.

The aim of this study was to determine if cyclooxygenase (COX) inhibitors influence immune cell distribution in the small intestinal mucosa and mesenteric lymph nodes (MLNs), the grade of mucosal damage, and the rate of apoptosis in septic rats. The effects induced by a selective COX-2 inhibitor (SC-236) were compared with those of a nonselective COX-1 and -2 inhibitor (indomethacin). Cecal ligation and puncture (CLP), CLP + SC-236 p.o, and CLP + indomethacin p.o, were evaluated. Animals were harvested 6 and 24 h after CLP, respectively. The concentration of proinflammatory cytokines was higher in ascitic fluid than in blood. CLP + SC-236 attenuated IL-6 in plasma and in ascitic fluid and CLP + indomethacin augmented TNF-alpha in ascitic fluid compared with CLP at 6 h. CLP + SC-236 gave a lesser degree of mucosal damage compared with CLP alone or with indomethacin at 6 and 24 h (P < 0.05). Untreated CLP had significant reductions in the number of T lymphocytes in the villi and increases of macrophages in the mucosa and MLNs compared with controls (P < 0.05). CLP + indomethacin decreased T lymphocytes in the villi and MLNs. CLP caused an enhanced apoptosis in the mucosa compared with controls (P < 0.05), pretreatment with COX inhibitors did not significantly change this. Both COX inhibitors enhanced apoptosis in MLNs and attenuated the increase of macrophages in mucosa and MLNs (P < 0.05). It is proposed that the increased apoptosis and the decrease in T cells in the mucosa may be causally related. Apoptosis of lymphocytes may impair the immunologic defense in sepsis. Furthermore, loss of intestinal epithelial cells may compromise bowel wall integrity and facilitate translocation.

[Arterial embolization can often substitute surgery in bleeding ulcer. When endoscopic hemostasis is not successful an alternative emergency treatment is needed]. / Artärembolisering kan ofta ersätta kirurgi vid blödande ulkus. När endoskopisk hemostas inte lyckas behövs alternativ akut behandling.

Peptic ulcer disease is the most common cause of acute haemorrhage from the upper gastrointestinal tract. Despite therapeutical improvements, the mortality rate remains high. Massive bleeding may, if haemostasis is not achieved by endoscopic treatment, require surgery. Often these patients are elderly with high comorbidity and, hence, are poor surgical candidates. We have therefore used angiography and selective arterial embolisation as an alternative option in 18 patients with massive ulcer bleeding. 13 patients were treated after failed endoscopic treatment, and 5 patients were treated for recurrent bleeding after previous emergency operations for bleeding ulcers. Embolisation of the arterial branch supplying the ulcer was possible in all patients. Permanent haemostasis was achieved in all but one patient, in whom the bleeding was controlled at an emergency operation. Our opinion is that angiographic embolisation is an effective way to control massive bleeding from peptic ulcers. In this way emergency operations in poor surgical candidates can be avoided.

Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers.

OBJECTIVE: We have tried angiography and selective arterial embolisation as a complement or another option in patients with massive bleeding from peptic ulcers who were considered poor candidates for surgery. DESIGN: Prospective, descriptive study. SETTING: University hospital, Sweden. PATIENTS: Since 1998, 18 patients (11 women) with a median age of 78 years (range 53-94) had selective arterial embolisation for uncontrollable bleeding from peptic ulcers. INTERVENTION: Superselective angiographic catheterisation and embolisation of the arterial branch that was supplying the ulcer. MAIN OUTCOME MEASURES: The success rate of haemostasis and the overall outcome. RESULTS: 13 patients were treated after failed endoscopic treatment to stop bleeding or to control recurrent bleeding after initial arrest, while 5 patients were treated for recurrent bleeding after emergency operations for bleeding ulcers. Most of the ulcers were in the duodenum. The patients were haemodynamically unstable and had a median haemoglobin concentration of 72 g/L (50-98). Embolisation of the arterial branch that was supplying the ulcer was feasible in all patients. Permanent haemostasis was achieved in all but one patient, although two patients needed a second embolisation for recurrent bleeding. One patient had the bleeding controlled at an emergency operation, but eventually died of respiratory complications. There were no serious complications of embolisation. CONCLUSION: Angiographic embolisation may be an effective way to stop massive bleeding from gastroduodenal ulcers. Emergency operations in poor surgical candidates can therefore be avoided.