Trends in Diagnosis and Surgical Management of Patients with Perforated Peptic Ulcer

Introduction While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. Material and Methods The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. Results Included were 114 patients with a median age of 67 years (range, 20–100). Women comprised 59% and were older (p<0.001), had more comorbidities (p=0.002), and had a higher Boey risk score (p=0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p<0.001). Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p=0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p=0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. Conclusion This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes

Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study

Background The clinical effect of stent treatment has been evaluated by mainly physicians; only a limited number of prospective studies have used patient-reported outcomes for this purpose. The aim of this work was to study the clinical effect of self-expanding metal stents in treatment of malignant gastrointestinal obstructions, as evaluated by patient-reported outcomes, and compare the rating of the treatment effect by patients and physicians. Methods Between November 2006 and April 2008, 273 patients treated with SEMS for malignant GI and biliary obstructions were recruited from nine Norwegian hospitals. Patients and physicians assessed symptoms independently at the time of treatment and after 2 weeks using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire supplemented with specific questions related to obstruction. Results A total of 162 patients (99 males; median age = 72 years) completed both assessments and were included in the study. A significant improvement in the mean global health score was observed after 2 weeks (from 9 to 18 on a 0–100 scale, P\0.03) for all stent locations. Both patients and physicians reported a significant reduction in all obstruction-related symptoms ([20 on the 0–100 scale, P\0.006) after SEMS treatment. The physicians reported a larger mean improvement in symptoms than did the patients, mainly because they reported more severe symptoms before treatment. Conclusion SEMS treatment is effective in relieving symptoms of malignant GI and biliary obstruction, as reported by patients and physicians. The physicians, however, reported a larger reduction in obstructive symptoms than did the patients. A prospective assessment of patientreported outcomes is important in evaluating SEMS treatment

Endoscopic retrograde cholangiopancreatography (ERCP) in Norway: Patterns of activity and undesired events

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of common bile duct stones (CBDS) and palliative decompression of malignant strictures. However, concerns remain regarding procedure-related complications and patient discomfort and pain. National data on ERCP are lacking, and international data on risk factors for complications and patient experiences are sparse and ambiguous. Objectives: In this project, we wanted to (1) collect national figures on ERCP activity and local routines in Norway over a period of 11 years, between 1998 and 2008; (2) describe and evaluate routine clinical ERCP practices in Norway over three years (2007 –2009); (3) evaluate the incidence of complications and (30-day) mortality, and identify possible risk factors for undesired outcomes after ERCP; and (4) evaluate patient pain and satisfaction after ERCP, and investigate potential predictors of pain and dissatisfaction.Methods: Based on surveys conducted in all Norwegian hospitals, data were collected on ERCP activity at four time points. As a part of a voluntary, national, Quality Assurance (QA) program in Gastronet, ERCP procedures were registered prospectively at 14 different hospitals in Norway, and these data were collected for the present study. Based on consecutive, registration and reporting, including a 30- day follow up from 11 hospitals, a descriptive evaluation of the ERCP activity per se, and specifically of complications was performed. Statistical analyses were performed to identify independent risk factors for complications, procedure-related pain, and patient dissatisfaction. Results: In the first paper, a total of 42,260 procedures were reported over 11 years (average 3842 procedures per year, range 3492-4632). During that time, the number of hospitals that offered ERCP decreased from 41 to 35, and the annual number of procedures decreased by 13% (from 4632 to 4036). However, the number of ERCPtrained endoscopists in Norway remained stable (≈100). The proportion of surgical procedures decreased from 40% to 32% (p150 procedures/center, and pre-cut ESTs were independent predictive factors for severe complications. Overall, the 30-day mortality was 2.2% (63 patients), with a possible procedure-related mortality rate of 1.4% (39 patients). The patient questionnaire was returned for 52.6% of procedures. Moderate or severe pain, respectively, was experienced in 15.5% and 14.0% of procedures during the ERCP and in 10.8% and 7.7% of procedures after the ERCP. In addition, female gender, EST, and longer procedure times were independent predictors of increased pain during the ERCP. The performing hospital was an independent predictor (p<0.001) of procedural pain experience. In 90.9% of procedures, the patients were satisfied with the information provided; overall, 98.3% of patients were satisfied with the treatment. However, the occurrences of specific complications after ERCP, and pain during or after the procedure were independent predictors for dissatisfaction with the treatment. Conclusions: Regional variation in the number of ERCPs performed appeared to have diminished. Patient selection, indications, and procedures employed in Norway were consistent with international guidelines and recommendations. Disease patterns partly differed from patterns reported both in middle Europe and in the US. ERCP-related morbidity and mortality and differences between units in reported outcome remain a concern. A mandatory, electronic, national registry with more resources is needed to continue a QA program for ERCP

Patient-Reported Outcome Measures after Endoscopic Retrograde Cholangiopancreatography: A Prospective, Multicenter Study

Objective: While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences. Methods From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded. Results: Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure. Conclusions: Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience

Construct validity of eoSim - a low-cost and portable laparoscopic simulator

Purpose: To examine the construct validity of the low-cost, portable laparoscopic simulator eoSim using motion analysis. Material and methods: Novice and experienced surgeons (≤ 100 and >100 laparoscopic procedures performed, respectively) completed four tasks on the eoSim using the SurgTrac software: intracorporeal suture and tie, tube ligation, peg capping and precision cutting. The following metrics were recorded: Time to complete task, distance traveled, handedness (left- versus right hand use), time off-screen, distance between instrument tips, speed, acceleration and motion smoothness. Results: Compared to novices (n = 22), experienced surgeons (n = 14) completed tasks in less time (p ≤ .025), except when performing peg capping (p = .052). On all tasks, they also scored lower on the distance metric (p ≤ .001). Differences in handedness (left hand compared between groups, right hand compared between groups) were found to be significant for three tasks (p ≤ .025). In general, the experienced group made greater use of their left hand than the novice group. Conclusion: The eoSim can differentiate between experienced and novice surgeons on the tasks intracorporeal suture and tie, tube ligation and precision cutting, thus providing a convenient method for surgical departments to implement testing of their surgeons’ basic laparoscopic skills

Gastric diverticulum and halitosis - A case for surgery?

INTRODUCTION Gastric diverticulum is a rare and frequently asymptomatic condition. Symptoms include vague pain, fullness, dyspepsia, vomiting, hemorrhage and perforation. Occasionally, the patient can present with belching and oral fetor. PRESENTATION OF CASE We report a 58-year-old woman with a gastric diverticulum who was suffering from a socially disabling oral fetor. After a thorough evaluation, a laparoscopic resection of the diverticulum was offered and completed successfully. At follow-up, the oral fetor had disappeared. The patient had no complaints and regarded herself as cured. DISCUSSION Although indications for the treatment of asymptomatic patients remain to be defined, pharmacological therapies including protein pump inhibitors and histamine receptor blockers have been employed, with limited effects in patients with miscellaneous symptoms. Surgery is required when serious complications such as hemorrhage or perforation of the diverticulum occur. CONCLUSION Surgery is required when serious complications such as hemorrhage or perforation of the diverticulum occur. Therapy resistent social disabling oral fetor may add to the indications for surgery

Gastronet survey on the use of one- or two-person technique for colonoscopy insertion

Background Usually, colonoscopy insertion is performed by the colonoscopist (one-person technique). Quite common in the early days of endoscopy, the assisting nurse is now only rarely doing the insertion (two-person technique). Using the Norwegian national endoscopy quality assurance (QA) programme, Gastronet, we wanted to explore the extent of two-person technique practice and look into possible differences in performance and QA output measures. Methods 100 colonoscopists in 18 colonoscopy centres having reported their colonoscopies to Gastronet between January and December 2009 were asked if they practiced one- or two-person technique during insertion of the colonoscope. They were categorized accordingly for comparative analyses of QA indicators. Results 75 endoscopists responded to the survey (representing 9368 colonoscopies) - 62 of them (83%) applied one-person technique and 13 (17%) two-person technique. Patients age and sex distributions and indications for colonoscopy were also similar in the two groups. Caecal intubation was 96% in the two-person group compared to 92% in the one-person group (p < 0.001). Pain reports were similar in the groups, but time to the caecum was shorter and the use of sedation less in the two-person group. Conclusion Two-person technique for colonoscope insertion was practiced by a considerable minority of endoscopists (17%). QA indicators were either similar to or better than one-person technique. This suggests that there may be some beneficial elements to this technique worth exploring and try to import into the much preferred one-person insertion technique

Gastronet survey on the use of one- or two-person technique for colonoscopy insertion

Abstract Background Usually, colonoscopy insertion is performed by the colonoscopist (one-person technique). Quite common in the early days of endoscopy, the assisting nurse is now only rarely doing the insertion (two-person technique). Using the Norwegian national endoscopy quality assurance (QA) programme, Gastronet, we wanted to explore the extent of two-person technique practice and look into possible differences in performance and QA output measures. Methods 100 colonoscopists in 18 colonoscopy centres having reported their colonoscopies to Gastronet between January and December 2009 were asked if they practiced one- or two-person technique during insertion of the colonoscope. They were categorized accordingly for comparative analyses of QA indicators. Results 75 endoscopists responded to the survey (representing 9368 colonoscopies) - 62 of them (83%) applied one-person technique and 13 (17%) two-person technique. Patients age and sex distributions and indications for colonoscopy were also similar in the two groups. Caecal intubation was 96% in the two-person group compared to 92% in the one-person group (p Conclusion Two-person technique for colonoscope insertion was practiced by a considerable minority of endoscopists (17%). QA indicators were either similar to or better than one-person technique. This suggests that there may be some beneficial elements to this technique worth exploring and try to import into the much preferred one-person insertion technique.</p