Anatomical and functional changes to the pelvic floor after robotic versus laparoscopic ventral rectopexy: a randomised study.

INTRODUCTION AND HYPOTHESIS: To compare the effect of laparoscopic and robot-assisted ventral rectopexy for posterior compartment procidentia on the pelvic floor anatomy and function. METHODS: A prospective randomised single-centre study was carried out of 29 female patients, who underwent robot-assisted or laparoscopic ventral mesh rectopexy for external or internal rectal prolapse with symptoms of obstructive defecation and/or faecal incontinence. Anatomical changes were measured by Pelvic Organ Prolapse Quantification (POP-Q) and magnetic resonance defecography. Functional changes were evaluated using symptom questionnaires before and 3 months after surgery. RESULTS: After rectopexy, changes in POP-Q measurements were statistically significant for points Ap, Bp, C, D and Ba. The descent of the anorectum and cervix/vaginal cuff during straining were significantly reduced with regard to the reference line (mean, -10.4 ± 14.9 mm, p = 0.001) and (-13.3 ± 18.1 mm, p < 0.001) respectively. Pelvic organ mobility (POM) was reduced statistically significantly for the posterior (mean, -16.6 ± 20.8 mm, p < 0.001) and apical compartments (mean, -13.1 ± 14.8, p < 0.001). The PFDI-20, PFIQ-7 and PISQ-12 questionnaires showed statistically significant improvement of symptoms and sexual function. No significant differences were observed between the robot-assisted and laparoscopic techniques in terms of anatomical or functional parameters. CONCLUSION: Ventral mesh recto-colpo-sacropexy effectively corrects the anatomy of the posterior compartment, elevates the vaginal apex and reduces pelvic organ mobility of the posterior and middle compartments. The robot-assisted and laparoscopic techniques had similar anatomical and functional outcomes.

The role of low CRP values in the prediction of the development of acute diverticulitis.

PURPOSE: Computed tomography (CT) is the most appropriate imaging modality for the assessment of acute diverticulitis at the emergency unit. The aim of this study was to determine the clinical outcome of the patients presented first time with symptoms of acute diverticulitis and low CRP values. METHODS: Two-hundred patients, who presented with the symptoms of acute diverticulitis and had CRP values under 150 mg/L, underwent abdominal CT examination on admission to Oulu University Hospital. The clinical parameters and radiological findings were compared in relation to clinical outcome both by means of univariate and multivariate analyses. RESULTS: Seventy-one (35.5 %) of the 200 patients presented on admission with complicated diverticulitis. CRP values between 100 and 150 mg/L predicted complicated disease, but the mean values of CRP between uncomplicated disease, 89 mg/L ± 39, and complicated disease, 101 mg/L ± 39, did not differ significantly. Free intra-abdominal fluid in CT was the only independent risk factor of the need for interventional therapy and treatment in the intensive care unit. Longevity of the patients and free fluid in CT predicted significantly prolonged hospitalization. Mortality was 1 % and older patients were significantly affected. The recurrence rate of acute diverticulitis was 24 % (43/177) in the whole group and 18 % (23/129) after uncomplicated diverticulitis. CONCLUSIONS: Low CRP values do not reliably predict uncomplicated disease in patients presented first time at the emergency unit with acute diverticulitis. We recommend that the need for abdominal CT is carefully evaluated according to the patient's clinical status, always even when the CRP value is under 150 mg/L.

The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit.

OBJECTIVE: Computed tomography (CT) is the most appropriate initial imaging modality for the assessment of acute diverticulitis. The aim here was to determine the usefulness of C-reactive protein (CRP) in predicting the severity of the diverticulitis process and the need for a CT examination. METHODS: The CRP values of 350 patients who presented first time with symptoms of acute diverticulitis and underwent CT imaging on admission to Oulu University Hospital were compared with the CT findings and clinical parameters by means of both univariate and multivariate analyses. RESULTS: The receiver operating characteristic curve showed that a CRP cut-off value of 149.5 mg/l significantly discriminated acute uncomplicated diverticulitis from complicated diverticulitis (specificity 65%, sensitivity 85%, area under the curve 0.811, p = 0.0001). In multivariate analysis, a CRP value over 150 mg/l and old age were independent risk factors for acute complicated diverticulitis. The mean CRP value was significantly higher in the patients who died, 207 (84 SD), than in those who survived, 139 (SD 83). In addition, a CRP value over 150 mg/l and free abdominal fluid in CT were independent variables predicting postoperative mortality. CONCLUSIONS: CRP is useful for the predicting the severity of acute diverticulitis on admission. Patients with a CRP value higher than 150 mg/l have an in increased risk of complicated diverticulitis and a CT examination should always be carried out.

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.

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.

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.

Intra-arterial chemotherapy with mitomycin C in gallbladder cancer: a follow-up study.

BACKGROUND AND OBJECTIVES: There is only limited and somewhat controversial information available on hepatic artery infusion of cytotoxic agents in gallbladder cancer. We report the results of 5-year follow-up of all gallbladder cancer patients treated with surgery and intra-arterial mitomycin C or mitomycin C alone in our hospital during 15 years. METHODS: Thirty-five patients with gallbladder cancer were treated with superselective intra-arterial chemotherapy (SIAC) with mitomycin C during 1981-1996. Survival was measured from diagnosis, and all patients were followed up until death or the end of January 2002. Cumulative survival rates and median survival times were calculated for all patients, according to response to treatment and staging. The data are presented as 5-year survival. RESULTS: Median survival times after SIAC for all patients, responders, and non-responders were 48, 60+, and 8.5 months, respectively. Overall response rate was 60%. Survival was significantly better for tumors limited to the gallbladder wall, as expected. Drug toxicity occurred in half of the patients, requiring cessation of chemotherapy in 25% of the cases. CONCLUSIONS: The median survival of gallbladder cancer patients treated with surgery and SIAC seems to be significantly better compared to the previously reported outcome of surgical treatment alone. Drug toxicity limits the use of i.a. chemotherapy and requires careful monitoring for early side-effects.

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.

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.

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.