The C-BRAHMS Project

Bononia University Press; 88-7395-155-4;Peer reviewe

Kuvantamislöydöksenä koliitti

Vertaisarvioitu.Koliittiin viittaava paksusuolen seinämän turpeus tai poikkeava ulkonäkö vatsan tietokonetomografiassa (TT) on yleinen mutta epäspesifinen löydös. Sen taustalla voi olla useita eri syitä, esimerkiksi tulehduksellinen suolistosairaus, iskemia, infektiotauti, yleissairaus tai jokin suolistosyöpä. Löydös voi olla myös kliinisesti merkityksetön ja liittyä suolen normaaliin toimintaan. Jatkotutkimukset suhteutetaan kliiniseen tilanteeseen. Epäiltäessä infektiotautia otetaan ulosteen mikrobinäytteet. Usein syyn selvittäminen edellyttää kolonoskopiaa

Kuvantamislöydöksenä koliitti

Koliittiin viittaava paksusuolen seinämän turpeus tai poikkeava ulkonäkö vatsan tietokonetomografiassa (TT) on yleinen mutta epäspesifinen löydös. Sen taustalla voi olla useita eri syitä, esimerkiksi tulehduksellinen suolistosairaus, iskemia, infektiotauti, yleissairaus tai jokin suolistosyöpä. Löydös voi olla myös kliinisesti merkityksetön ja liittyä suolen normaaliin toimintaan. Jatkotutkimukset suhteutetaan kliiniseen tilanteeseen. Epäiltäessä infektiotautia otetaan ulosteen mikrobinäytteet. Usein syyn selvittäminen edellyttää kolonoskopiaa.publishedVersio

Routine use of laparoscopic techniques in daily practice improves outcomes after appendectomy

Background: Appendectomy is the most common emergency operation and is often performed during on-call hours, when surgeons with different sub-specialties and levels of experience in emergency surgery operate on patients. However, little is known about the safety of the procedure when operations are performed by surgeons not regularly using standard laparoscopic techniques. Here we aim to assess variation in outcomes in patients operated on by surgeons with different levels of experience in laparoscopic surgery. Materials and methods: Consecutive patients undergoing appendectomy at Tampere University Hospital between September 1, 2014 and April 30, 2017 for acute appendicitis were included. The data were analyzed by level of experience among surgeons regularly performing laparoscopic surgery and by volume among surgeons performing over 30 appendectomies per year or fewer. Results: A total of 1560 patients underwent appendectomy, with 61% operated on by laparoscopic surgeons, and the rest by surgeons not habitually using laparoscopic techniques. Demographic characteristics, as well as share of patients with perforated appendicitis were similar in both groups. Morbidity was higher among those operated on by non-laparoscopic surgeons (6.1% and 3.0% p = 0.004), especially if appendicitis was complicated (18% and 5.6%, p < 0.001). Infectious complications were the most common. The risk of postoperative organ/space surgical site infections was higher among patients operated on by non-laparoscopic surgeons (3.5% vs. 1.4%, p = 0.006; Clavien–Dindo III–IV 2.0% vs. 0.7%, p = 0.030). Morbidity was 2.7% among those operated on by surgeons performing ≥ 30 appendectomies per year compared to 5.2% among those performing < 30 appendectomies per year. In multivariate analysis surgeon’s experience (p = 0.002; HR 2.32, 95% CI 1.38–3.90) and complicated disease (p < 0.001; HR 4.71; 95% CI 2.79–7.93) predicted higher morbidity. Discussion: According to our study, routine use of laparoscopic techniques in daily practice improves outcomes after appendectomy. In addition, a higher surgical volume correlates with improved outcomes.publishedVersionPeer reviewe

Short learning curve in transition from laparoscopic to robotic-assisted rectal cancer surgery : a prospective study from a Finnish Tertiary Referral Centre

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien–Dindo III–IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.Peer reviewe

Computer-generated structured electronic medical records are preferable to conventional medical records for patients with acute abdominal pain : a prospective, double-blinded study

Objectives: Structured medical records improve readability and ensure the inclusion of information necessary for correct diagnosis and treatment. This is the first study to assess the quality of computer-generated structured medical records by comparing them to conventional medical records on patients with acute abdominal pain. Materials and methods: A prospective double-blinded study was conducted in a tertiary referral center emergency department between January 2018 and June 2018. Patients were examined by emergency department physicians and by experience and inexperienced researcher. The researchers used a new electronical medical records system, which gathered data during the examination and the system generate structured medical records containing natural language. Conventional medical records dictated by physician and computer-generated medical records were compared by a group of independent clinicians. Results: Ninety-nine patients were included. The overall quality of the computer-generated medical records was better than the quality of conventional human-generated medical records – the structure was similar or better in 99% of cases and the readability was similar or better in 86% of cases, p < 0.001. The quality of medical history, current illness, and findings of physical examinations were likewise better with the computer-generated recording. The results were similar when patients were examined by experienced or inexperienced researcher using the computer-generated recording. Discussion: The quality of computer-generated structured medical records was superior to that of conventional medical records. The quality remained similar regardless of the researcher’s level of experience. The system allows automatic risk scoring and easy access for quality control of patient care. We therefore consider that it would be useful in wider practice.publishedVersionPeer reviewe

Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Nilkan lateraalimalleolin murtumat - operatiivisesti hoidettujen potilaiden pitkäaikaisennuste Weberin luokituksen mukaan

Nilkkamurtumien välittömät ja lyhyellä viiveellä ilmaantuvat komplikaatiot ovat pitkäaikaisia paremmin tunnettuja. Tämä tutkimus selvitti operatiivisesti hoidettujen potilaiden pitkäaikaisennusteen ja murtuman anatomisen sijainnin välistä yhteyttä. Hypoteesina oli, että korkeissa nilkkamurtumissa komplikaatiot ovat yleisempiä ja näin ollen myös ennuste on huonompi. Tutkimus toteutettiin vuosien 1997 ja 1998 aikana Tampereen yliopistollisessa sairaalassa leikatuille potilaille. Mukaan valittiin vain lateraalisen malleolin operatiivista hoitoa saaneet henkilöt (n = 182). Murtumat jaettiin Danis-Weber -luokituksen mukaan A-, B- ja C-tyyppisiksi. Tietoa kerättiin kyselylomakkeella ja potilaskertomuksista. Niiden perusteella selvitettiin kipuja sekä liikunta- ja työkyvylle aiheutunutta haittaa. Lisäksi selvitettiin apuvälineiden ja uusintahoitojen tarvetta. Vastauksissa haitta-astetta arvioitiin asteikolla 1–5, kun taas apuvälineiden ja uusintahoitojen tarvetta kyllä – ei -kysymyksellä. Keskimäärin kivuista aiheutuvaksi haitta-asteeksi (ja keskihajonnaksi) vastattiin 1,85 ± 1,13. Liikuntakyvyn haitaksi arvioitiin 1,61 ± 0,77 ja työkyvyn haitaksi 1,56 ± 0,96. Jatkohoitoa oli saanut 31,1 % ja apuvälineitä tarvitsi 9,0 % vastanneista. Tuloksia verrattiin murtuman luokitteluun. Paitsi yhteispisteiden perusteella, tuloksia analysoitiin myös kysymyskohtaisesti. Weber A -tyyppisiä murtumia oli kyselylomakkeen palauttaneista vain kahdella, joten nämä jätettiin pois analyysista. Murtuman anatomisen luokittelun ja ennusteen välillä ei havaittu yhteyttä (p > 0,05). Tutkimuksen merkittävin löytö oli kipujen ja liikunta- sekä työskentelyrajoitusten ennakoitua suurempi esiintyvyys. Asiasanat:Nilkkamurtuma, Danis-Weber -luokittelu, pitkäaikaisennuste, lateraalinen malleoli, leikkaushoito, komplikaatio

Gastrokirurgisten päivystystoimenpiteiden tulokset iäkkäillä

Väestön ikääntymisen johdosta vanhusten osuus väestössä kasvaa ja samalla päivystysresurssien tarve lisääntyy. Vatsaelinkirurgisiin päivystystilanteisiin liittyy merkittävä kuolleisuus- ja komplikaatioriski sekä kustannukset, jotka ovat suurempia iäkkäillä potilailla. Tutkimusnäyttö uusien hoitomenetelmien soveltuvuudesta tälle potilasryhmälle on osin puutteellista. Selvitimme tässä väitöskirjatutkimuksessa vatsaelinkirurgisten päivystysleikkausten yleisyyttä ja tuloksia, tehohoitoa vaatineen vaikean sepsiksen ennustetta, endoskoopppisen retrograadisen kolangiopankreatografian (ERCP) tuloksia sekä sappileikkausten jälkeistä toipumista vanhusväestössä. Osoitimme, että akuutti sappirakon tulehdus on yleisin syy päivystysleikkauksiin yli 65-vuotiailla potilailla. Huolimatta viime vuosien teknisestä kehityksestä (mm. akuutin hoidon resursointi, laadukkaammat ja paremmin saatavissa olevat kuvantamispalvelut sekä entistä parempi tehohoidon laatu) olivat kirurgisen hoidon tulokset vastaavanlaiset kuin on raportoitu 1980–1990 -luvuilla. Vanhusten leikkaushoitoon liittyy siis edelleen merkittävä komplikaatioriski ja kuolleisuus, jota lisää ikääntymisen lisäksi vielä merkittävämmin potilaan vaikeat perussairaudet ja aliravitsemus. Infektiot olivat yleisin syy leikkauksien jälkeisiin kuolemiin. Seuraavana tutkimme tehohoitoa vaatineita vaikeita leikkauksen jälkeisiä systeemisiä infektioita vanhuspotilailla. Osoitimme vatsaelinkirurgiaan liittyvän sepsiksen olevan yhteydessä merkittävään kuolleisuuteen, joka oli korkea paitsi sairaalahoitoajan, niin se myös pysyi toipuneilla ja kotiutuneilla potilailla korkeana koko vuoden seuranta-ajan. Akuutti sappirakon tulehdus oli yleisin syy leikkaukseen myös tässä aineistossa. Korkea ikä ja aiemmat perussairaudet lisäsivät kuolleisuutta. Tehohoidossa käytettävät riskipisteytykset korreloivat iäkkäiden potilaiden ennusteeseen. Koska komplisoitunut sappikivitauti oli yleinen syy päivystystoimenpiteisiin iäkkäillä, halusimme tutkia myös sen endoskooppisia hoitoja. Selvitimme päivystyksellisesti tehdyn ERCP:n tuloksia iäkkäillä. Sappikivitaudin aiheuttama sappitietukos oli yleisin syy toimenpiteeseen. ERCP osoittautui tehokkaaksi sappitietukoksen sekä myös leikkausten jälkeisten sappitievaurioiden hoidossa. Toimenpide oli vähintäänkin yhtä turvallinen vanhuksilla kuin mitä aiemmin on raportoitu nuorilla potilailla. Komplikaatioriskiä lisäsivät vaikea kanulaatio ja keuhkoahtaumatauti. Viimeisenä kartoitimme akuutin sappirakon tulehduksen leikkaushoidon tuloksia iäkkäillä potilailla. Yllättäen korkealla iällä tai valitulla leikkaustekniikalla ei ollut tilastollisesti merkittävää vaikutusta tuloksiin. Vaikkei eroa saavutettu, oli erityisesti entuudestaan huonokuntoisimpien tähystysleikkauksen läpikäyneiden potilaiden ennuste parempi kuin avoleikkauksella hoidettujen potilaiden. Potilaan aiemmat vaikeat perussairaudet tai hankala tulehdustilanne olivat ennusteellisia sekä korkeammalle komplikaatioriskille että kuolleisuudelle. Yhteenvetona voidaan todeta, että komplisoitunut sappikivitauti on yleisin syy päivystysleikkauksiin iäkkäillä potilailla. Leikkauksiin liittyy merkittävä komplikaatioriski ja kuolleisuus, joka ei ole huomattavasti laskenut viime vuosina. Postoperatiivinen sepsis on varsin harvinainen tila, johon liittyy erittäin huono sekä lyhyen että pitkän aikavälin ennuste. Sappitiekivitauti on yleisin syy vanhusten päivystykselliseen ERCP:n ja se on tehokas ja turvallinen toimenpide myös iäkkäille potilaille. Potilaan aiemmat vaikeat perussairaudet tai vaikea akuutti sairaustilanne vaikuttivat ennusteeseen akuutin sappirakon tulehduksen jälkeisessä toipumisessa. Vaikka leikkaustekniikan valinnalla ei saavutettu tilastollisesti merkittävää eroa, oli erityisesti tähystysleikkauksen läpikäyneillä entuudestaan vaikeasti sairailla potilailla ennuste parempi.The elderly are more likely than younger adults to experience gastrointestinal emergencies. As the normal aging-related physiological changes and comorbidities reduce older people's tolerance of acute illness and associated treatments, they are more susceptible to postoperative adverse events. In this thesis the focus is on gastrointestinal emergencies and associated outcomes in elderly patients. First we investigated indications and safety of emergency alimentary tract related surgery in the elderly. The most common reason for surgery was acute cholecystitis. Emergency gastrointestinal operations were still associated with significant morbidity and mortality. Regardless of novel diagnostic and therapeutic techniques, the outcome has not improved at a similar pace. Older age, concomitant conditions and low body-mass index were among the risk factors for poor outcomes. Infections, including postoperative pneumonia and sepsis, accounted for the majority of postoperative deaths. Sepsis in gastrointestinal surgery in the elderly was also examined. Acute cholecystitis was the most common reason for the surgery in this patient population. While sepsis was a rare event in surgical patients, it was found to be associated with excessive mortality. The mortality remained high through one-year follow up after successful treatment of the infection. The intensive care unit used scoring systems predicted higher mortality. Because elderly patients are more prone to gallstone disease and its complications, we also focused on emergency endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Biliary obstruction caused by bile duct stones was the most common indication for the procedure. There were no procedure-related deaths, and complications occurred less often than has been previously reported in adult population in general. Chronic obstructive pulmonary disease and difficult cannulation were independently associated with increased risk of complications. Finally we studied surgical outcomes in elderly patients undergoing surgery for acute cholecystitis. The occurrence of postoperative complications or death after surgery was more often reflecting the severity of pre-existing diseases than surgical technique, older age or hospital type. However, there was a trend towards lower morbidity and mortality in patients undergoing laparoscopic surgery. We conclude that 1) acute cholecystitis is the most common indication for emergency gastrointestinal surgery in the elderly and emergency surgery is still associated with significant morbidity and mortality, 2) both short and long-term outcomes are very poor in older patients with severe sepsis related to alimentary tract surgery, 3) biliary obstruction caused by bile duct stones is the most common indication for acutely performed ERCP in the elderly, and the procedure can be performed safely and efficaciously on older patients and 4) older age, hospital type and surgical technique were not independently associated with poorer outcomes after emergency cholecystectomy, whereas severity of concomitant conditions and acute condition itself predicted morbidity and mortality