The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference.

BACKGROUND: It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors. METHOD: There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction. RESULT: The oncological rationale for CME and various technical aspects of the surgical management will be explored. CONCLUSION: The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.

Short term results of complete (D3) vs. standard (D2) mesenteric excision in colon cancer shows improved outcome of complete mesenteric excision in patients with TNM stages I-II.

BACKGROUND: The aim of the present study was to investigate whether the new method of complete mesocolic excision (CME) with a high (apical) vascular tie (D3 resection) had an immediate effect compared with a conventional (standard) approach even in those patients without lymph node metastases. METHODS: A cohort of 189 consecutive patients with tumour-nodal-metastasis (TNM) stages I-II and a mean age of 73 years were operated on in the period from January 2007 to December 2008 in three community teaching hospitals. The CME approach (n = 89), used in hospital A, was compared to the standard technique used (n = 105) in two other hospitals, B and C. Lymph node yields from the specimens were used as a surrogate measure of radical resections. Outcome was analysed after a median follow-up of 50.2 months. RESULTS: In-hospital mortality rate was 2.8 % in the CME group and 8.6 % in the standard group. The 3-year overall survival (OS) in the CME group was 88.1 versus 79.0 % (p = 0.003) in the standard group, and the corresponding disease-free survival (DFS) was 82.1 versus 74.3 % (p = 0.026). Cancer-specific survival was 95.2 % in the CME group versus 90.5 % in the standard group (p = 0.067). Age, operative technique, and T category were significant in multiple Cox regressions of OS and DFS. CONCLUSIONS: Compared with the standard (D2) approach, introduction of CME surgical management of colon cancer resulted in a significant immediate improvement of 3-year survival for patients with TNM stage I-II tumours as assessed by OS and DFS.

The result of liver resection for colorectal metastases in a small volume hospital in western Norway.

AIM: Our aim was to compare liver resection for colorectal metastases in a non-referral, small volume unit with a dedicated staff, with results from larger units. METHODS: Thirty patients (15 men and 15 women) with a median age of 64years (range 29-78) underwent hepatic resection during a 5-year period from 1997 to 2003 in a teaching hospital in western Norway. RESULTS: Sixty-three percent (19/30) of the colorectal tumours were Dukes stage C (n=19) and CEA was increased in seven patients (23%), of which four (13%) had values above 50microg/l. The metastases were synchronous with the colorectal tumours in 11 patients (37%). Non-anatomical (wedge) resections were the dominant type of surgeries and the resection margins were clear in all patients. A 77-year-old man (3%) died of MOF after right hemihepatectomy. Morbidity was encountered in eight other patients (28%). In 22 patients (76%) with recurrent disease, metastases first appeared in the liver in 18 (82%) of these patients. Seven patients (23%) have had resections for recurrences. Mean time to recurrence was 20months (range 3-87). The actuarial 5-year survival rate was 42%. Six patients (20%) are currently disease free. CONCLUSION: Although our unit has treated a small number of patients compared with specialized units elsewhere, the survival rate, as well as morbidity and mortality, were comparable. However, 62% have had recurrent liver disease and this may suggest a role for neoadjuvant or adjuvant chemotherapy in selected cases.

Cholecystectomy improves long-term success after endoscopic treatment of CBD stones.

BACKGROUND/AIMS: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome. METHODOLOGY: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance. RESULTS: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones. CONCLUSIONS: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.

Ultrasound examination shows disturbed proximal gastric function in symptomatic gallstone patients with dyspepsia and improvement after cholecystectomy--gallstones and gastric emptying.

AIM: The aim of our study was to examine gastric function, gallbladder emptying, and dyspepsia in symptomatic gallbladder stone patients (SGBS) to see if a motility disorder, expressed by gastric function and gallbladder emptying, may cause dyspepsia in SBGS. MATERIALS AND METHODS: Gastric function and gallbladder emptying in 21 SGBS referred for surgical treatment were measured by ultrasound after ingestion of 500 ml of a meat soup (bouillon). Dyspeptic symptoms were simultaneously recorded on a Visual Analog Scale (VAS). The patients were re-examined 10 months after cholecystectomy. Hospital staff (n = 14) served as control subjects (C). RESULTS: In SGBS, the frontal diameter of the proximal stomach was wider than in C at both 10 minutes (55.7 vs. 48.3 mm; p = 0.053) and 20 minutes (49.3 vs. 39.5 mm; p = 0.002), and the sagittal area of the proximal stomach was larger at 10 minutes (25.0 vs. 20.9 cm (2); p = 0.03). The postprandial frontal diameter decreased significantly after cholecystectomy (immediately after the meal: 51.3 mm; p = 0.03, at 10 minutes: 47.6 mm; p = 0.05, and at 20 minutes: 39.1 mm; p = 0.004). Twenty minutes after meal ingestion, gallbladder emptying was significantly less in SGBS than in C with a mean (SD) emptying of 20 % (17) versus 33 % (18); p < 0.04. In the fasting state, SGBS felt more hunger than C (VAS 67 mm vs. 39 mm; p = 0.03). After cholecystectomy, the feeling of hunger decreased (VAS 27 mm; p = 0.01). CONCLUSION: SGBS had a wider proximal stomach and more hunger in the fasting state than C. After cholecystectomy the proximal stomach function and the hunger score improved. Our results suggest a physiological link between symptomatic gallstone disease and dyspepsia expressed by impaired proximal gastric function.

Quality of life and pain in patients with acute cholecystitis. Results of a randomized clinical trial.

BACKGROUND: Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy. METHODS: Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later. RESULTS: Patients were followed-up for a median of 67 months. Ten of 33 patients (30%, 95% CI 15%-46%) patients randomized to observation and 27 of 31 (87%, 95% CI 75 %- 99%) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36%, 95% CI 20%-53%) patients in the observation group had a gallstone related event compared to 6 of 31 (19%, 95% CI 5%-33%) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/- cholecystectomy), we did not find any significant differences in pain or quality of life measurements. CONCLUSION: Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.

Pain and quality of life in patients with symptomatic, non-complicated gallbladder stones: results of a randomized controlled trial.

BACKGROUND: Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience postcholecystectomy symptoms, including pain. There is limited information in the literature on gallstone-related pain and its influence on quality of life. The aim of this study was to examine how pain and quality of life in patients with symptomatic, uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder. METHODS: One-hundred and thirty-seven patients were randomized to observation (watchful waiting; n = 69) or cholecystectomy (n = 68) and answered questionnaires on pain, quality of life (PGWB index and NHP Part II) at randomization and fixed intervals (6, 12 and 60 months). All gallstone-related events (hospital admission for pain, complications of gallstone disease and cholecystectomy) and crossover between treatment groups were recorded. RESULTS: Of patients randomized to observation, 35 of 69 patients (51%) eventually underwent a cholecystectomy. Significant improvements in quality of life and pain scores were detected regardless of surgical treatment. Patients that subsequently experienced gallstone-related events had significantly higher pain scores at randomization than patients that did not experience any subsequent events, and this difference was maintained throughout follow-up. CONCLUSIONS: Unexpectedly, in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life. Patients that had high intensity and frequency of pain at randomization had a higher risk of experiencing subsequent events.

Acute cholecystitis: delayed surgery or observation. A randomized clinical trial.

BACKGROUND: The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients randomly allocated to delayed operation or conservative treatment. METHODS: One-hundred-and-eighty patients were considered for participation in the study; 71 were excluded according to predefined criteria and 45 did not join for other reasons. The remaining 64 patients were randomized to cholecystectomy (n = 31) or observation (n = 33). Randomized patients were contacted regularly and followed up for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group (19%; 95% CI 5%-33%) and in 12 patients (36%; 9% CI 20%-53%) in the observation group. Twenty-seven of 31 patients randomized to cholecystectomy had a cholecystectomy at a median of 3.6 months after randomization, and, of these, 3 (11%; 95% CI 0%-23%) suffered a major and 7 (26%; 95% CI 9%-42%) a minor complication. Ten patients randomized to observation later had their gallbladders removed, 1 (10%; 95% CI 0%-29%) patient had a major and 1 (10%; 95% CI 0%-29%) a minor complication. We found no mortality after cholecystectomy. CONCLUSIONS: We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis, but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis.

Symptomatic, non-complicated gallbladder stone disease. Operation or observation? A randomized clinical study.

BACKGROUND: Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy (n = 68) or non-operative, expectant treatment (n = 69). METHODS: Randomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Eight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor. CONCLUSIONS: We found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.

Severe ARDS may cause right heart failure with extreme hepatomegaly but without hepatic failure.

A young trauma patient developed severe adult respiratory distress syndrome (ARDS), right heart failure, hepatic congestion and an extreme hepatomegaly but no hepatic failure. The patient needed 100% oxygen during ventilatory support for 80 days and was weaned from the ventilator after more than 100 days. The hepatomegaly gradually disappeared. Four months after the injury, the anatomical shape of the lungs, heart and liver were normalized. This case illustrates that severe ARDS may cause right heart failure and extreme hepatomegaly due to venous congestion in the liver and spleen, but without hepatic failure.

Complications and late outcome following percutaneous drainage of the gallbladder in acute calculous cholecystitis.

BACKGROUND: Acute septic cholecystitis (AC) remains a difficult problem in patients with coexisting severe illness, and ultrasonographically guided percutaneous puncture and drainage of the gallbladder (PTBD) may be an alternative treatment in this context. SETTING: University Hospital, Norway. METHODS: Retrospective study of the safety and efficacy of this approach in 86 consecutive patients treated from 1992 to 1999. RESULTS: Five patients died. Drainage did not seem to influence the condition in these patients, who were drained for a mean of 8 days after admission compared to 4 days for the survivors (p = 0.01), and had a higher S-bilirubin on the day of the drainage, 46 and 29 micromol/l (p = 0.05), respectively. Seven patients had an intraperitoneal bile leak and 2 had worsening septicemia. One of these patients had both, and the gallbladder was removed. An open cystic duct demonstrated at catheter cholangiography was associated with a bile leak in 3 (4%) of 76 patients as opposed to 4 (40%) of 10 patients with obstruction (p = 0.001). Only 60 patients survived another 6 months because of general debility and other diseases. Twenty-seven (45%) of these were asymptomatic during follow-up. Twenty-eight (47%) of the remaining patients had at least one recurrent episode of AC. One patient who was readmitted due to AC had urgent cholecystectomy and 8 others had elective cholecystectomy during follow-up for a total cholecystectomy rate of 12%. A common bile duct stone was demonstrated in 4 patients after ERCP and indicative signs were found in another 5 (10%). CONCLUSIONS: PTBD remains a good option in patients with septic AC who have severe coexisting disease and may be too ill to undergo an operation. It may not be necessary to remove the gallbladder in 45% or more of the patients as many remain asymptomatic after PTBD.

Perforated and non-perforated acute appendicitis--one disease or two entities?

OBJECTIVE: To analyse the pattern of clinical presentation of perforated and non-perforated acute appendicitis in 544 unselected patients treated surgically for suspected acute appendicitis; to find out if their presentation differed. DESIGN: Open prospective population-based study. SETTING: Teaching hospital, western Norway. PATIENTS: All 434 patients operated on for suspected acute appendicitis from the catchment area of a single hospital in whom the diagnosis was confirmed. INTERVENTIONS: Appendicectomy; history, clinical findings, and inflammatory markers were recorded in all patients. MAIN OUTCOME MEASURES: Odds Ratio (OR) and 95% confidence interval (CI) obtained by logistic regression analysis of symptoms and signs of acute appendicitis with regard to independent predictors of perforation of the appendix. Receiver operating characteristic (ROC) curve analysis of inflammatory markers. RESULTS: The perforation rate was 20% (n = 88). Perforation was unlikely when abdominal pain was limited to the right iliac fossa, (OR 0.13, 95% CI 0.05 to 0.33). Increased C-reactive protein (CRP) concentration >50 U/L (OR 4.6, 95% Cl 2.44 to 8.75) and greater age (by decade; OR 1.18, 95% CI 1.02 to 1.36) were independent predictors of perforation of the appendix. CONCLUSIONS: Clinical differences between perforated and non-perforated acute appendicitis could be explained by the presence of advanced inflammation in patients with perforated appendicitis. Our data do not support the hypothesis that they are two clinically different diseases.

Endoscopic sphincterotomy in acute gallstone pancreatitis: a prospective study of the late outcome.

OBJECTIVE: To describe the outcome after acute biliary pancreatitis in patients treated during the acute attack by endoscopic sphincterotomy without cholecystectomy. DESIGN: Prospective observational study. SETTING: University hospital, Norway. SUBJECTS: 130 patients with gallstones and acute pancreatitis. In 62 patients with common bile duct stones the bile duct was cleared by sphincterotomy and stone extraction. The remaining 68 patients had prophylactic sphincterotomy. Cholecystectomy was not planned later. MAIN OUTCOME MEASURES: Incidence of recurrent acute pancreatitis and need for cholecystectomy. RESULTS: 21 patients were dead or not available for the follow-up. Consequently 109 patients were followed-up for a median of 39 months (range 23-62). One patient had recurrent pancreatitis. 20 patients had a cholecystectomy later for symptoms related to gallstone disease. Of the rest, 25 patients had moderate or mild gallstone-related symptoms. There was no difference in gallstone-related symptoms between those who had had stones in the bile duct and those who had not. 63 patients had no symptoms related to gallstones. CONCLUSION: Endoscopic sphincterotomy during or immediately after acute gallstone pancreatitis resulted in half the patients being free of symptoms during the next three years.

Long-term follow-up of 1059 consecutive primary and recurrent inguinal hernias in a teaching hospital.

OBJECTIVE: To study the early and late outcome of various methods of inguinal hernia repair. DESIGN: Retrospective study. SETTING: Teaching hospital, Norway. SUBJECTS: 1059 repairs of inguinal hernias in men and women by 43 surgeons. INTERVENTIONS: Analysis of patients charts, results of questionnaires concerning 712 hernias (67%) and follow-up consultations when needed. MAIN OUTCOME MEASURES: Freedom from recurrence and postoperative groin symptoms after repairs of primary and recurrent hernias. RESULTS: After a median follow-up of 5.5 years, range 3-8, the recurrence rate was 8% for primary repairs and 29% after recurrent hernias. The incidence of permanent pain or discomfort was unexpectedly high, being 11% after primary repairs and 15% after recurrent hernia repairs. CONCLUSIONS: The number of recurrences at long-term follow-up after repairs of primary and recurrent inguinal hernias was unsatisfactory. The extent of postoperative pain was surprising as this was not given enough attention during the learning period. We have introduced a uniform treatment policy with a prospective surveillance programme with the aim of improving results in our teaching programme.

Stability in incidence of acute appendicitis. A population-based longitudinal study.

UNLABELLED: BACKGROUND/AIM OF THE STUDY: During the past 50 years, a decrease in incidence of appendicitis has been reported. The various studies were retrospective and based on different data sources. In the present study, we analyze prospectively the incidence of acute appendicitis during a 10-year period in a well defined population of 265,000. METHODS: Prospective registration of all operations performed in patients with suspected acute appendicitis in the catchment area of a single institution. The diagnosis of acute appendicitis was based on histology in all cases. The annual incidence of acute appendicitis was calculated with regard to nonperforated and perforated acute appendicitis. MAIN RESULTS: Between 1989 and 1998, 2,861 patients underwent surgery for suspected acute appendicitis. In 2,232 (78%) patients, acute appendicitis was confirmed histologically. Mean annual incidence was 84/100,000 (95% confidence interval 80 to 88/100,000). Crude incidence remained stable during the study period, with the exception of a significant increase in 1991 followed by a significant decrease the next year. Nonperforated acute appendicitis showed a different incidence pattern as compared to perforated acute appendicitis. CONCLUSION: In our prospective study, the incidence of acute appendicitis remained stable in our well-defined study population during the study period of 10 years. This is in contrast to the majority of studies during the last decades.

The history is important in patients with suspected acute appendicitis.

BACKGROUND/AIMS: The clinical diagnosis of acute appendicitis is incorrect in 20-30% of patients undergoing surgery. We analysed the clinical importance of nine commonly used symptoms and signs in 544 consecutive patients with regard to the correct diagnosis of acute appendicitis. METHODS: Open population-based prospective study. The degree of the surgeon's certainty of the preoperative diagnosis was assessed. The final diagnosis was based on histology. Logistic regression was used to analyze the independent value of nine symptoms and signs to predict acute appendicitis by calculating odds ratio (OR) with 95% confidence intervals (CI). RESULTS: In 434 of 544 patients (80%) acute appendicitis was confirmed. A history of nausea or vomiting (OR = 2.3; CI = 1.11 to 4.76) and pain migration to right iliac fossa (OR = 1.9; CI = 1.12 to 3.22) were significant predictors of acute appendicitis. Pain migration was found to be an independent predictor in females and nausea or vomiting in males. In the group of patients (29%) with an uncertain preoperative diagnosis, pain migration predicted a correct diagnosis in females (OR = 4.7; CI = 1.2 to 18), while tenderness over McBurney's point was a significant predictor in males (OR = 8.3; CI = 1.1 to 63). CONCLUSIONS: A history of pain migration and nausea or vomiting were independent predictors for the correct diagnosis of acute appendicitis in patients undergoing surgery. Thus, patient history is important in this patient group.

The significance of personality in pain from gallbladder stones.

BACKGROUND: The aim of the study was to investigate the association between personality factors related to coping styles and reported pain due to gallstones. METHODS: Personality trait measures were completed by 28 consecutive gallstone patients to provide estimates of positive coping resources (Life Regard Index, Sense of Coherence Scale, Sense of Humor Questionnaire) and negative coping resources (Eysenck Personality Questionnaire on Neuroticism, Tension, and Effort Stress Inventory). An overall index of gallstone-related complaints (pain) over the past 7 days/6 months was also obtained. Ultrasonography confirmed the gallstone condition. Multiple regression analyses tested the hypothesis that pain would be moderated by positive coping resources and mediated by negative coping resources. RESULTS: Reported pain was less severe with positive coping resources (39% of pain variance explained) and more severe with negative coping resources (45% of pain variance explained). CONCLUSION: The results confirm that mental coping resources have a significant role in pain differences among gallstone patients.