[Show abstract][Hide abstract] ABSTRACT: Laparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published.
BMC Surgery 10/2014; 14(1):77. · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: New biomarkers are needed to better predict the severity of acute pancreatitis. CD73/ecto-5'-nucleotidase is an enzyme that generates adenosine, which dampens inflammation and improves vascular barrier function in several disease models. CD73 also circulates in a soluble form in the blood. We studied whether levels of soluble form of CD73 predict the development of organ failure in acute pancreatitis.
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to construct a new scoring system for more accurate diagnostics of acute appendicitis. Applying the new score into clinical practice could reduce the need of potentially harmful diagnostic imaging.
[Show abstract][Hide abstract] ABSTRACT: Severe acute pancreatitis (AP) is associated with high morbidity and mortality. Early prediction of severe AP is needed to improve patient outcomes. The aim of the study was to find novel cytokines or combinations of cytokines for early identification of patients with AP at risk for severe disease.
Critical care (London, England) 05/2014; 18(3):R104. · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.
World Journal of Emergency Surgery 02/2014; 9(1):15. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications.
[Show abstract][Hide abstract] ABSTRACT: Current guidelines recommend computed tomography (CT) for diagnosing diverticulitis and for routine follow-up colonoscopy to rule out cancer. Scientific data to support routine colonoscopy after acute diverticulitis are scarce and conflicting. This study aimed to evaluate the risk of colon cancer mimicking diverticulitis, and hence the need for routine colonoscopy after CT-diagnosed acute diverticulitis.
This study was a retrospective analysis of patients treated for acute diverticulitis in a single academic institution during 2006-2010. Data regarding age, sex, laboratory parameters, prior diverticulitis, surgical operations, pathology reports, and CT characteristics were collected. Risk factors for finding colon cancer after CT-diagnosed acute diverticulitis were identified by multivariate analysis.
The study enrolled 633 patients with CT-diagnosed acute diverticulitis. Of these patients, 97 underwent emergency resection, whereas 536 were treated conservatively, 394 of whom underwent colonoscopy. The findings showed 17 cancers (2.7 %) in patients with an initial diagnosis of acute diverticulitis. As shown by CT, 16 cancer patients (94 %) had abscess, whereas one patient had pericolic extraluminal air but no abscess. Of the patients with abscess, 11.4 % had cancer mimicking acute diverticulitis. No cancer was found in the patients with uncomplicated diverticulitis. Besides abscess, other independent risk factors for cancer included suspicion of cancer by a radiologist, thickness of the bowel wall exceeding 15 mm, no diverticula observed, and previously undiagnosed metastases.
Routine colonoscopy after CT-proven uncomplicated diverticulitis seems to be unnecessary, but colonoscopy should be performed for patients with a diagnosis of diverticular abscess.
[Show abstract][Hide abstract] ABSTRACT: The study aimed to determine the effect of the activated protein C on the course of systemic inflammation in the APCAP (activated protein C in acute pancreatitis) trial where we randomized 32 patients with severe acute pancreatitis to receive either recombinant activated protein C (drotrecogin alfa activated) (n = 16) or placebo (n = 16) for 96 hours. In the present study, we present the time course of the patients' plasma or serum levels of soluble markers (IL-8, IL-6, IL-10, IL-1ra, sE-selectin, PCT) and monocyte and neutrophil cell surface (CD11b, CD14, CD62L, HLA-DR) markers of systemic inflammatory response during the first 14 days after the randomization. The results of the intervention and placebo groups were comparable showing that recombinant APC treatment did not alter the course of systemic inflammation in severe acute pancreatitis. Our finding is in accordance with the clinical findings in the APCAP trial indicating that the intervention did not affect evolution of multiple organ dysfunctions.
International journal of inflammation. 01/2012; 2012:712739.
[Show abstract][Hide abstract] ABSTRACT: Being a central link between inflammation and coagulation, tissue factor (TF) and its inhibitor (TFPI) might be associated with the severity of acute pancreatitis (AP) and the development of organ failure (OF).
The study comprises 9 severe AP patients with OF and 24 reference patients (11 mild AP and 13 severe AP without OF). Plasma samples were collected on admission. TF-induced thrombin generation in plasma samples was studied using the thrombogram method. In vivo thrombin generation was estimated by prothrombin fragment F1+2. Free and total TFPI levels were measured. To evaluate coagulation status the activated partial thromboplastin time, prothrombin time, platelet count, D-dimer, fibrinogen, antithrombin (AT) 3 and protein C (PC) were determined.
There was no significant difference in F1+2 levels between the patient groups. Patients with severe AP tended to show low platelet counts, PC and AT3 levels, and high D-dimer levels. In 11 patients the standard TF stimulation did not trigger thrombin generation in the thrombogram. All deaths occurred in these patients. Free TFPI levels and free/total TFPI ratios were significantly higher in these patients and in non-survivors.
Failure of TF-initiated thrombin generation in the thrombogram assay explained by high levels of circulating free TFPI may be associated with OF and mortality in AP. and IAP.
[Show abstract][Hide abstract] ABSTRACT: Management of severe liver injuries has evolved to include the options for nonoperative management and damage control surgery. The present study analyzes the criteria for choosing between nonoperative management and early surgery, and definitive repair versus damage control strategy during early surgery.
In a retrospective analysis of 144 patients with severe (AAST grade III-V) liver injuries (94% blunt trauma), early laparotomy was performed in 50 patients. Initial management was nonoperative in 94 blunt trauma patients with 8 failures. Uni- and multivariate analyses were used to calculate predictor odds ratios (OR) with 95% confidence intervals (CI).
Factors associated with early laparotomy in blunt trauma included shock on admission, associated grade IV-V splenic injury, grade IV-V head injury, and grade V liver injury. Only shock was an independent predictor (OR, 26.1; 95% CI, 8.9-77.1; P < 0.001). The presence of a grade IV-V splenic injury predicted damage control strategy (OR infinite; P = 0.021). Failed nonoperative management was associated with grade IV-V splenic injury (OR, 14.00; 95% CI, 1.67-117.55), and shock (OR, 6.82; 95% CI, 1.49-31.29). The hospital mortality rate was 15%; 8 of 21 deaths were liver-related. Shock (OR, 9.3; 95% CI, 2.4-35.8; P = 0.001) and severe head injury (OR, 9.25; 95% CI, 3.0-28.9; P = 0.000) were independent predictors for mortality.
In patients with severe liver injury, associated severe splenic injury favors early laparotomy and damage control strategy. Patients who arrive in shock or have an associated severe splenic injury should not be managed nonoperatively. In addition to severe head injury, uncontrollable bleeding from the liver injury is still a major cause of early death.
World Journal of Surgery 12/2011; 35(12):2643-9. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The open abdomen is increasingly used for the treatment and prevention of abdominal compartment syndrome. The leading non-traumatic conditions that may cause abdominal compartment syndrome requiring surgical decompression include secondary peritonitis, ruptured abdominal aortic aneurysm and severe acute pancreatitis. Patients may also end up with the open abdomen when the laparotomy wound cannot be closed without tension because of excessive visceral swelling. Also, surgical complications such as laparotomy wound dehiscence, may require temporary abdominal closure techniques. In critically ill surgical patients and in situations when second-look laparotomy is mandatory the open abdomen can be utilized in a preventive manner like in damage control trauma surgery. Underlying disease and the indication for the open abdomen significantly contributes to outcome of patient with open abdomen. Non-traumatic aetiology of the open abdomen is associated with lower likelihood of primary fascial closure and higher rate of open abdomen related complications compared with traumatic aetiology. A number of temporal abdominal closure techniques have been described. Ideally, temporal abdominal closure technique should prevent the development of recurrent abdominal compartment syndrome and facilitate later primary fascia closure with low complication rate. Although fascial closure rate varies between techniques, there are few evidence-based data to support one technique over another. However, recent evolution of temporary abdominal closure techniques have decreased the number of patients with frozen abdomen and reduced the need for planned hernia management. Highest fascial closure rates have been achieved with vacuum-assisted closure systems and systems that provide continuous fascial traction.
[Show abstract][Hide abstract] ABSTRACT: Subcutaneous linea alba fasciotomy (SLAF) is a minimally invasive treatment method for abdominal compartment syndrome initially used in severe acute pancreatitis (SAP). A retrospective analysis of the first 10 patients with SAP undergoing SLAF was performed to analyze the effect and outcome of this decompressive procedure. The mean age of the patients was 46 (range 33-61) years. SLAF was performed 1 to 17 days postadmission, in six cases within 48 hours. The mean (range) preoperative intra-abdominal pressure was 31 (23-45) mm Hg and immediate postoperative intra-abdominal pressure was 20 (10-33) mm Hg. The mean decrease was 10 (2-17) mm Hg and the decompressive effect was considered sufficient in six cases. A completion laparostomy within 24 hours was required in four cases. The mean preoperative Sequential Organ Failure Assessment score was 12 (4-17) and 11 (1-20) 1 to 5 days postoperatively. The decrease was five or more score points in three patients with successful SLAF. The overall mortality and morbidity rates were 4/10 and 2/10; no complications were attributed to the SLAF itself. It is concluded that SLAF is a safe decompressive technique in SAP-related abdominal compartment syndrome. The initial effect is sufficient in about half of the patients. A completion midline laparostomy is required in the nonresponders.
The American surgeon 01/2011; 77(1):99-102. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In patients with severe acute pancreatitis and abdominal compartment syndrome, establishment of the indications and optimal time for surgical decompression may avoid exacerbation of multiple-organ dysfunction syndrome.
Tertiary care university teaching hospital.
Twenty-six consecutive patients with severe acute pancreatitis and abdominal compartment syndrome treated by surgical decompression between January 1, 2002, and December 31, 2007.
Surgical decompression of the abdomen.
Morbidity, mortality, and organ dysfunction before and after surgical decompression.
At the time of surgical decompression, the median sequential organ failure assessment score among patients was 12 (interquartile range, 10-15), and the median intra-abdominal pressure was 31.5 (interquartile range, 27-35) mm Hg. After surgical decompression, renal or respiratory function was improved in 14 patients (54%). The overall hospital mortality was 46%, but mortality was 18% among 17 patients in whom surgical decompression was performed within the first 4 days after disease onset.
Patients with severe acute pancreatitis and abdominal compartment syndrome managed by surgical decompression had severe multiple-organ dysfunction syndrome and high mortality. Surgical decompression may improve renal or respiratory function. Early surgical decompression is associated with reduced mortality in patients with severe acute pancreatitis, early multiple-organ dysfunction syndrome, and abdominal compartment syndrome.
Archives of surgery (Chicago, Ill.: 1960) 08/2010; 145(8):764-9. · 4.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Postoperative intra-abdominal hypertension (IAH) is a frequent occurrence in critically ill patients operated on for severe abdominal trauma, secondary peritonitis or ruptured abdominal aortic aneurysm. IAH may progress to abdominal compartment syndrome (ACS) with new-onset organ dysfunction. Early recognition of IAH and interventions that prevent the development of ACS may preserve vital organ functions and increase the probability of survival. The best method to prevent postoperative ACS is to leave the abdomen open during the operation. The decision to leave the abdomen open is usually based on the surgeon's judgment without intra-abdominal pressure (IAP) measurements during the operation. Because significant morbidity and mortality are associated with the open abdomen, the measurement of IAP immediately after the fascial closure, when feasible, could offer an objective method for determining the optimal IAP threshold for leaving the abdomen open. The management of the open abdomen requires a temporary abdominal closure (TAC) system that would ideally prevent the development of ACS and facilitate later primary fascia closure. Among several TAC systems, the most promising are those that provide negative pressure to the wound or continuous fascial traction or both.
Critical care (London, England) 02/2010; 14(1):111. · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study in patients with acute pancreatitis (AP) the plasma soluble form of the receptor for advanced glycation end products (sRAGE) and high-mobility group box chromosomal protein 1 (HMGB1) levels, followed-up for 12 days after hospitalization, in relation to the occurrence of organ failure and mortality.
Thirty-eight patients with severe AP and organ failure (grade 2). A control group (127 patients) consisted of 38 patients with severe AP without organ failure (grade 1) and 89 patients with mild AP (grade 0). Plasma samples for determination of HMGB1 and sRAGE levels were collected on admission and on days 1 and 2, days 3 and 4, and days 7 and 12 after admission.
The median of the highest sRAGE levels was higher in grade 2 patients (472 pg/mL; interquartile range [IQR], 259-912) than in grade 0 plus grade 1 patients (349 pg/mL; IQR, 209-544; P = 0.024). Among the patients with detectable HMGB1, the median of the highest HMGB1 levels was 117 ng/mL (IQR, 56-212; n = 24) in grade 2 patients and 87 ng/mL (IQR, 54-161; n = 62) in grade 0 plus grade 1 patients (P = 0.310).
We demonstrate that sRAGE level, but not HMGB1 level, is significantly higher in AP patients who develop organ failure than in AP patients without organ failure who recover.
[Show abstract][Hide abstract] ABSTRACT: We have here elucidated whether ulcerogenic agents affect the production of NO and reactive oxygen species (ROS). The ulcerogenic agents dose dependently induced NO and ROS production in mouse gastric epithelial cells. Taurocholate (TC, 5 mM) exposure did not affect cell viability, but it increased inducible nitric oxide synthase (iNOS) expression, NO production, ROS production, and epithelial permeability. Epithelial permeability was inhibited with NOS inhibitors or antioxidants. Oxidative stress induced by acetylsalicylic acid (ASA) and ethanol was not inhibited with NOS inhibitors. ASA induced ROS production even at low concentrations (1 mM), which did not affect cell viability. Ethanol-induced ROS production was linked to cell viability, suggesting direct oxidative stress caused by ethanol. Taurocholate-induced NO signaling and the ensuing production of ROS might contribute to initiation of defensive or adaptive cellular mechanisms. ASA-induced ROS signaling might have similar effects, whereas ethanol induced direct oxidative stress, having an influence on cell viability.
Digestive Diseases and Sciences 06/2008; 53(12):3119-27. · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Complement activation occurs in patients with acute pancreatitis (AP) and may contribute to the development of organ failure. Because a number of enzymes are released during AP that could influence the complement inhibitor CD59, the purpose of this study was to examine serum levels of CD59 in relation to severity of AP.
Twelve patients with severe AP had organ failure (referred to as the grade 2 group). For each of them, we found 2-3 age-matched AP patients who served as controls (n=27). Of these, a total of 13 had mild AP (grade 0 group) and 14 severe AP without organ failure (grade 1 group). Blood samples were collected at admission and on days 1 and 3-7 post-admission. Grade 2 patients were compared with grade 0 and grade 1 patients. CD59 levels were measured by a sandwich enzyme immunoassay.
At admission, median CD59 levels were significantly higher (p = 0.002) in grade 2 patients (median 104.2 ng/ml, range 26.1-186.3) than in grade 0 patients (37.3, range 30.3-75.9) and grade 1 patients (38.6, range 19.9 96.1). CD59 levels remained higher in grade 2 patients than in grade 0 and 1 patients on day 1 (p = 0.001) and days 3-7 (p = 0.002). The CD59 levels correlated significantly (p < 0.05) with C-reactive protein (CRP) levels (R = 0.40) and APACHE II scores (R = 0.32) on admission.
Organ failure and severity of AP are associated with elevated serum levels of CD59.
Scandinavian Journal of Gastroenterology 03/2008; 43(3):350-5. · 2.33 Impact Factor