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The incidence of occult inguinal or Spigelian hernias found in other laparoscopies is seldom studied and their development to symptomatic hernias is unknown.The orifices of all inguinal and Spigelian hernias at linea semilunaris were carefully recorded prospectively in the laparoscopic surgery during the years 2003-2004 (104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous). The patients were followed up over 15 years to find out how often the detected occult hernias at index laparoscopy become later symptomatic and were repaired.The index laparoscopic operation was performed to 201 patients with a mean age of 53±14 years. The overall frequency of unexpected hernias was 21% including 36 (18%) inguinal hernias, 5 (2.5%) Spigelian hernias, and 2 (1.0%) ventral hernias. At the index laparoscopy, only 5/201 inguinal and 2 Spigelian hernioplasties were concomitantly undertaken. After 15 years, data of 169 patients were available and new hernia repairs were performed only in 8 (4.7%) patients (2 inguinal, 4 umbilical, and 2 ventral hernias).Asymptomatic occult hernias detected during laparoscopic surgery of other reason evolve very seldom (5%) to symptomatic and need to be repaired.

Background This was a prospective, multicentre, non-blinded, randomized clinical trial involving two parallel groups of patients. Methods Adult patients with symptomatic unilateral primary inguinal hernia were included in this study. Patients were enrolled and treated in five Finnish hospitals. Eligible patients were randomized by use of a computer-based program to receiving either open anterior repair (modified Lichtenstein) with glue mesh fixation or totally extraperitoneal (TEP) repair. The primary aims were to compare 30-day patient-reported pain scores and return to work after surgery between the two groups. Results A total of 202 patients were randomized: 98 patients to TEP repair and 104 patients to open repair. All randomized patients received their allocated treatment. A total of 86 patients (88 per cent) in the TEP group and 94 patients (90 per cent) in the Lichtenstein group completed the 30-day follow-up. Patients experienced less early pain (P Conclusion TEP inguinal hernia repair is associated with less early postoperative pain compared to the open glue mesh fixation technique. Trial registration NCT03566433 (http://www.clinicaltrials.gov).

The two most common abdominal infections in emergency departments (ED) are acute appendicitis (AA) and sigmoid diverticulitis (AD). The frequency of ED visits for diverticulitis has increased strongly in many countries during recent decades. The aim of this study was to analyze the nationwide changes in AD rate requiring hospital admission compared to AA during a 10-year study period.Register data of AD and AA in the whole of Finland were obtained between the years 2009 and 2018. Changes in the incidence and surgical treatment of AD in the whole country were compared to those of AA. Patient demographics and treatment of AD were analyzed in greater detail from a smaller cohort (The incidence of AD increased from 262 to 413 cases (58%) per 100,000 inhabitants during 10 years and emergency surgery for AD decreased from 27 to 24 cases per 100,000 (11%). The incidence of AA remained stable and varied from 118 to 124 annual cases per 100,000 inhabitants. In a patient cohort of AD (Our study indicates that the incidence of acute diverticulitis is still increasing and is now 2-3 times higher than that of appendicitis in emergency departments.

Purpose Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology. Methods This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor. Results The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98–32.49, p p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95–88.09, p p = 0.67). Conclusion More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid).Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0-10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire.At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR.5200658.

Gastrointestinal bleeding is a common clinical problem in patients using low-dose acetylsalicylic acid (ASA). It is uncertain whether aspirin should continue to be used in patients who develop acute gastrointestinal bleeding during low-dose ASA therapy.To assess whether ASA should be continued in patients who develop GI bleeding during low-dose ASA.All patients admitted to an academic hospital for acute gastrointestinal bleeding between 2009 and 2011 were reviewed retrospectively. Clinical characteristics, comorbidities, medications and treatments were recorded from the patient records. Patients were divided into two groups based on continuing or discontinuing ASA after discharge.A total of 548 patients were included. ASA was continued in 282 (51.5%) (ASAc group) and discontinued in 266 (48.5%) patients (ASAd group). ASAc patients had more often coronary artery disease (57.8% vs. 42.5%,Continuing low-dose ASA after gastrointestinal bleeding was associated with lower all-cause mortality during the first year without increasing the risk of re-bleeding.

Importance Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known. Objective To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography–confirmed uncomplicated acute appendicitis. Design, Setting, and Participants The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019. Interventions Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days. Main Outcomes and Measures The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference. Results Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was −3.6% ([1-sided 95% CI, −9.7% to ∞];P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin. Conclusion and Relevance Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics. Trial Registration ClinicalTrials.gov Identifier:NCT03236961; EudraCT Identifier:2015-003633-10

Study Design. A prospective follow-up study. Objective. The aim of this study was to investigate whether early lumbar disc degeneration (DD) in young low back pain (LBP) patients predicts progression of degenerative changes, pain, or disability in a 30-year follow-up. Summary of Background Data. MRI is an accurate method for studying degenerative changes in intervertebral discs. Decreased signal intensity (SI) can be used as indication of decreased water content. Long-term prognosis of early DD remains unclear. Methods. In an earlier study, 75 conscripts aged 20 years with LBP had their lumbar spine examined by MRI. At a follow-up of 30 years, the subjects were contacted; 35 of 69 filled a pain and disability questionnaire, and 26 of 35 were also reexamined clinically and by MRI. The images were evaluated for decreased SI and other degenerative changes. Association between decreased SI of a disc at baseline and the presence of more severe degenerative changes in the same disc space at follow-up was analyzed using Fisher exact test. Association between decreased baseline SI and pain/disability scores from the questionnaire was analyzed with Kruskal-Wallis H test. Results. The total number of lumbar discs with decreased SI increased from 23 of 130 (18%) to 92 of 130 (71%)-from 0.9 to 3.5 per subject during the follow-up. Distribution of DD changed from being mostly in L4- L5 and L5-S1 discs to being almost even between the four lowermost discs. Discs that had even slightly decreased SI at baseline were more likely to have severely decreased SI at follow-up, compared to healthy discs (57% vs. 11%, P

Long-term results support antibiotics for uncomplicated acute appendicitis as an alternative to appendectomy. To our knowledge, treatment-related long-term patient satisfaction and quality of life (QOL) are not known.To determine patient satisfaction and QOL after antibiotic therapy and appendectomy for treating uncomplicated acute appendicitis.Open appendectomy vs antibiotics with intravenous ertapenem, 1 g once daily, for 3 days followed by 7 days of oral levofloxacin, 500 mg once daily, and metronidazole, 500 mg 3 times per day.This observational follow-up of the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotics included 530 patients age 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis who were randomized to undergo appendectomy (273 [52%]) or receive antibiotics (257 [49%]). The trial was conducted from November 2009 to June 2012; the last follow-up was May 9, 2018. The data were analyzed in February 2019.In this analysis, post hoc secondary end points of postintervention QOL (EQ-5D-5L) and patient satisfaction and treatment preference were evaluated.Of the 530 patients enrolled in the trial (appendectomy group: 273 [174 men (64%)] with a median age of 35 years; (antibiotic group: 257 [155 men (60%)] with a median age of 33 years), 423 patients (80%) were available for phone interview at a median follow-up of 7 years; 206 patients (80%) took antibiotics and 217 (79%) underwent appendectomy. Of the 206 patients taking antibiotics, 81 (39%) had undergone appendectomy. The QOL between appendectomy and antibiotic group patients was similar (median health index value, 1.0 in both groups; 95% CI, 0.86-1.0; P = .96). Patients who underwent appendectomy were more satisfied in the treatment than patients taking antibiotics (68% very satisfied, 21% satisfied, 6% indifferent, 4% unsatisfied, and 1% very unsatisfied in the appendectomy group and 53% very satisfied, 21% satisfied, 13% indifferent, 7% unsatisfied, and 6% very unsatisfied in the antibiotic group; P .001) and in a subgroup analysis this difference was based on the antibiotic group patients undergoing appendectomy. There was no difference in patient satisfaction after successful antibiotic treatment compared with appendectomy (cumulative odds ratio [COR], 7.8; 95% CI, 0.5-1.3; P .36). Patients with appendectomy or with successful antibiotic therapy were more satisfied than antibiotic group patients who later underwent appendectomy (COR, 7.7; 95% CI, 4.6-12.9; P .001; COR, 9.7; 95% CI, 5.4-15.3; P .001, respectively). Of the 81 patients taking antibiotics who underwent appendectomy, 27 (33%) would again choose antibiotics as their primary treatment.In this analysis, long-term QOL was similar after appendectomy and antibiotic therapy for the treatment of uncomplicated acute appendicitis. Patients taking antibiotics who later underwent appendectomy were less satisfied than patients with successful antibiotics or appendectomy.Clinicaltrials.gov Identifier: NCT01022567.

Different bariatric procedures have been associated with variable weight loss and decrease in serum levels of lipids and lipoproteins. This variation could be partly related to the length of the small intestinal bypass. We evaluated the association of the small intestinal length with the non-alcoholic fatty liver disease (NAFLD) at baseline and with lipid metabolism before and after laparoscopic Roux-en-Y gastric bypass (LRYGB). Seventy consecutive morbidly obese patients were recruited to this prospective study. A standard 60-cm biliopancreatic limb (BPL) and 120-cm alimentary limb (AL) was performed, and thereafter, the common channel (CC) length was measured during elective LRYGB. Histological analysis of liver biopsy to diagnose NAFLD was performed. The mRNA expression of genes participating in the cholesterol and fatty acid metabolism in the liver was analyzed. Female sex (p = 0.006), serum triglycerides (TG, p = 0.016), serum alanine aminotransferase (ALT, p = 0.007), and liver steatosis (p = 0.001) associated with the small intestinal length (BPL + AL + CC) at baseline. Association remained significant between levels of serum TG and CC length (p = 0.048) at 1-year follow-up. Liver mRNA expression of genes regulating cholesterol synthesis and bile metabolism did not associate with the baseline small intestinal length. Our findings support the suggestions that small intestinal length regulates TG metabolism before and after LRYGB. Therefore, modification of the length of bypassed small intestine based on measured total small intestinal length could optimize the outcomes of the elective LRYGB.

Background/goal Intra-abdominal adhesions are probably underdiagnosed cause for chronic abdominal pain. Our aim was to evaluate late (>10 y) effect of laparoscopic adhesiolysis on chronic abdominal pain. Study This was a nonrandomized follow-up study of 68 patients (9 males, 59 females) who suffered chronic abdominal pain. The index operation (laparoscopy and adhesiolysis; n=72 patients) was performed during 1997 to 2001. A quality-of-life questionnaire was asked after the mean follow-up time of 15 years. The hospital records of patients, reoperations for chronic abdominal pain, and full medical history were also reviewed. Results Patients reported that adhesion-related pain was abolished or diminished in 90% during 15-year follow-up, but still 28 (41%) complained about some abdominal symptom. One third of the patients used pain-relieving medication or proton-pump inhibitors to relieve their symptoms. Furthermore, 46 (68%) patients had contacted medical service for reexamination of abdominal discomfort and 16 (24%) were reoperated because of some abdominal disease. When the patients with dense adhesions versus no or minimal adhesions were compared in the long term, no difference in the response of pain was noticed after 15 years of adhesiolysis. Conclusions In carefully selected patients suffering from chronic abdominal pain, the positive effect of laparoscopic adhesiolysis stands beyond 15 years after the surgery. Although the patients reported relief of pain they still had various abdominal symptoms.

Background/Aims: The role of emergency surgery is decreasing in the treatment of patients with upper gastrointestinal bleeding (UGIB). We investigated the need of urgent surgery and outcome of elderly UGIB patients who often have cardiovascular comorbidities with antithrombotic medication. Methods: All consecutive adult patients who received emergency treatment for suspected gastrointestinal bleeding between January 2009 and December 2011 were registered in an electronic database (n = 1,643). A total of 569 patients with a first-time UGIB were identified, of whom 282 were ≥70 years old. Age-specific incidence rates, risk factors for bleeding and need of endoscopic or emergency surgery were studied. Long-term mortality was compared to age-adjusted control subjects (n = 569) without bleeding. Results: The age-specific incidence of UGIB increased from 156 to 401 cases per 100,000 inhabitants from age 60–69 to 80–89 years, respectively. Cardiovascular comorbidities and antithrombotic therapies (acetosalicylic acid 51 vs. 27%; warfarins 25 vs. 11%) related to UGIB were more common in patients over than under 70 years of age (p < 0.0001). Early endoscopic therapy was successful in over 95% of patients, whereas emergency surgery was needed only in 6 (2%) patients ≥70 years old. Hospital mortality (7.8%) was acceptable in these patients, but the 5-year mortality (40%) was significantly higher than in controls (20%, p < 0.001). Conclusion: Today, emergency surgery is seldom needed in the patients with UGIB. In comparison to the age-matched control population, long-term survival was significantly lower after UGIB in the elderly.

Purpose The aim of this study was to examine the association between angiotensin converting enzyme (ACE) inhibitor use and the risk of acute pancreatitis. Methods Information on all 4966 cases hospitalized in 2008–2010 for acute pancreatitis was retrieved from the Finnish national registers on hospital discharges and prescriptions. A total of 24 788 age and sex-matched population-based controls were randomly selected using density sampling. ACE inhibitor use between 1 January 2003 and the index date were determined by the date of hospitalization for acute pancreatitis among the cases. The incidence rate ratios of acute pancreatitis not diagnosed as biliary or alcohol-induced were modeled by conditional logistic regression and adjusted for comorbidities. Results A total of 1276 (26%) cases and 3946 (16%) controls had been exposed to ACE inhibitors. The use of ACE inhibitors was associated with an increased incidence rate of acute pancreatitis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.59–1.95). The increase was slightly higher among current new users (OR 1.86, 95%CI 1.65–2.09) and somewhat lower among current prevalent (OR 1.54, 95%CI 1.35–1.75) and former users (OR 1.51, 95%CI 1.31–1.74). Conclusions Angiotensin converting enzyme inhibitor use seems to be associated with a moderately increased risk of acute pancreatitis. Copyright © 2017 John Wiley & Sons, Ltd.

To evaluate the impact of patient age on hospital resource use and treatment costs of acute abdominal pain (AAP).A total of 300 adult patients with AAP were randomised to either computed tomography (CT, n=150) or selective imaging practice (SIP, n=150) groups. Final analysis included 254 patients, 143 (42 patients ≥65years) in the CT and 111 (32 patients ≥65years) in the SIP group. All CT group patients underwent abdominal CT whereas in the SIP group, imaging was based on the clinical assessment. For each patient, the hospital length of stay (LOS), the numbers and costs of diagnostic and treatment procedures arising from AAP were calculated and registered. The incremental cost-effectiveness ratio (ICER) and bootstrapped cost-effectiveness acceptability curve (CEAC) were estimated for routine CT.Treatment costs, imaging costs and LOS increased in conjunction with aging in both study groups, and were generally higher in the CT group compared to the SIP group. In the SIP group, CT was undertaken in 34% (27/79) of the65year olds but in 59% (19/32) of the older patients (≥65years) (p=0.02). The proportion of patients with non-specific abdominal pain was significantly lower in patients ≥65years than in their younger counterparts (p=0.04). In the routine CT group, the ICER of obtaining a specific diagnosis was 1682 € for patients65years and 1055 € for patients ≥65years. According to CEAC estimation, routine CT for every patient with AAP has a 95% probability of being cost-effective if society is willing to pay 14087 € for an additional specific diagnosis for patients65 years but only 4204 € in those ≥65years.Treatment costs of AAP increase in parallel with aging, and the costs are generally higher with routine CT compared to selective imaging. The probability of obtaining a specific diagnosis of AAP increases with aging. If obtaining a specific diagnosis is deemed crucial, then routine CT is more cost-effective in patients over 65 years compared to younger patients. Considering the diagnostic challenges of AAP in the elderly, liberal CT use can be advocated in this patient group.

Background An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. Methods The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. Results Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. Conclusion Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.

Lichtenstein hernioplasty has relatively low recurrence rate, but chronic inguinal pain may cause harm to the patient. The aim of our study was to compare long-term results of cyanoacrylate glue versus absorbable sutures for mesh fixation in Lichtenstein hernioplasty. Lichtenstein hernioplasty (n = 302) was performed under local anesthesia in three hospitals. The patients were randomized to receive either 1 ml of butyl-2-cyanoacrylate tissue glue (Glubran®; 151 hernias) or absorbable polyglycolic acid sutures (Dexon®; 151 hernias) for mesh fixation (Optilene® mesh). Short-term results were published previously. Chronic groin pain, foreign body sensation, use of analgesics, recurrence and re-operations were analyzed 7 years after surgery. We reached 236 patients (78%) to present study. In the glue group (n = 115), there were five (4.3%) and in the suture group (n = 121) three (2.5%) recurrent hernias (p = 0.491). The prevalence of chronic pain (NRS ≥ 3) in the patients without re-operations was similar in two groups: 15/118 (13%) and 13/111 (12%), respectively (p = 0.843). There were no significant differences in the foreign body sensation (8/14, p = 0.267) or in the need of analgesics (2/2, p = 1.00) between the two study groups. Both cyanoacrylate glue and mesh fixation with absorbable sutures were equal in terms of chronic pain and rate of recurrences in Lichtenstein hernioplasty after 7-year follow-up. NCT00659542.

Introduction: About half of the adult patients suffering from chronic abdominal pain may have no organ-related cause. Our purpose was to evaluate the additional information of magnetic resonance imaging (MRI) in diagnosing the underlying organic causes of such pain. Methods: We performed retrospective audit of 636 consecutive abdominal MRI in patients suffering from nonspecific abdominal pain (NSAP) during years 2014–2017. Medical history, clinical examination, endoscopy reports, and the results of MRI were compared in all patients. The hypothesis was that MRI increases markedly the diagnostic specificity of patients’ symptoms. Results: The mean age of patients was 66 ± 14 years and 60 percent were females. Duration of abdominal pain ranged from 1 month to 30 years (median 1.1 ± 4.0 years). Concurrently with abdominal MRI (n = 636), also ultrasound (n = 106, 17%), colonoscopy (n = 222, 35%), and gastroscopy (n = 217, 34%) were performed. Abdominal MRI revealed additional information in 161/636 (25%) of NSAP patients. Spinal and pelvic bone abnormalities (n = 107) and malignant tumors (n= 31) were the most significant organ-specific findings changing the treatment algorithm. Conclusions: When computerized tomography is not available in outpatient clinics, abdominal MRI increases markedly diagnostic specificity and alters the treatment in 1 of 4 patients suffering from NSAP. Abdominal MRI is therefore suggested for patients suffering from severe symptoms of NSAP.

ObjectivesWe aimed to prospectively evaluate the prevalence of long-standing groin pain and related MRI findings in contact sports.MethodsThis case–control study followed three male elite-level soccer, ice-hockey and bandy teams (102 players) for 2 years. All athletes with long-standing groin pain lasting >30 days and age-matched controls (1:3) from the same teams were examined clinically, using pelvic MRI and Hip and Groin Outcome Scores (HAGOS). Primary outcome measures were annual prevalence of groin pain and underlying MRI findings.ResultsThe annual prevalence of chronic groin pain was 7.5%. Training characteristics and pain scores of athletes were similar in all teams. On MRI, there was no significant difference in the percentage of pubic bone marrow oedema (p = 0.80) between symptomatic players (8/15; 53%) versus controls (20/43; 47%), but adductor tendinopathy and degenerative changes at the pubic symphysis were twice more common among players with pain. Rectus muscle or iliopsoas pathology were seldom observed. Lower HAGOS subscales (p < 0.01) were recorded in players who experienced groin pain compared with the controls.ConclusionLong-standing groin pain was observed annually in 1 of 14 athletes in contact sports. Abnormalities in the pubic symphysis were common MRI findings in both symptomatic and asymptomatic players.Trial registration numberNCT02560480

BackgroundSportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.MethodsA randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.ResultsA total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).ConclusionTotally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

BackgroundThe efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years.Methods and findingsThis multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (pConclusionsAt 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.

Based on epidemiological and clinical data acute appendicitis can present either as uncomplicated (70–80%) or complicated (20–30%) disease. Recent studies have shown that antibiotic therapy is both safe and cost-effective for a CT-scan confirmed uncomplicated acute appendicitis. However, based on the study protocols to ensure patient safety, these randomised studies used mainly broad-spectrum intravenous antibiotics requiring additional hospital resources and prolonged hospital stay. As we now know that antibiotic therapy for uncomplicated acute appendicitis is feasible and safe, further studies evaluating optimisation of the antibiotic treatment regarding both antibiotic spectrum and shorter hospital stay are needed to evaluate antibiotics as the first-line treatment for uncomplicated acute appendicitis. APPAC II trial is a multicentre, open-label, non-inferiority randomised controlled trial comparing per oral (p.o.) antibiotic monotherapy with intravenous (i.v.) antibiotic therapy followed by p.o. antibiotics in the treatment of CT-scan confirmed uncomplicated acute appendicitis. Adult patients with CT-scan diagnosed uncomplicated acute appendicitis will be enrolled in nine Finnish hospitals. The intended sample size is 552 patients. Primary endpoint is the success of the randomised treatment, defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during one-year follow-up. Secondary endpoints include post-intervention complications, late recurrence of acute appendicitis after one year, duration of hospital stay, pain, quality of life, sick leave and treatment costs. Primary endpoint will be evaluated in two stages: point estimates with 95% confidence interval (CI) will be calculated for both groups and proportion difference between groups with 95% CI will be calculated and evaluated based on 6 percentage point non-inferiority margin. To our knowledge, APPAC II trial is the first randomised controlled trial comparing per oral antibiotic monotherapy with intravenous antibiotic therapy continued by per oral antibiotics in the treatment of uncomplicated acute appendicitis. The APPAC II trial aims to add clinical evidence on the debated role of antibiotics as the first-line treatment for a CT-confirmed uncomplicated acute appendicitis as well as to optimise the non-operative treatment for uncomplicated acute appendicitis. Clinicaltrials.gov , NCT03236961, retrospectively registered on the 2nd of August 2017.

We aimed to evaluate the outcome of elderly patients with severe sepsis after alimentary tract surgery. A prospective study was conducted in 24 intensive care units (ICU) in Finland. Four thousand five hundred consecutive patients were admitted to ICUs and 470 patients fulfilled the criteria for severe sepsis. All patients who had undergone gastrointestinal surgery were included. The outcomes of elderly (≥65 years) and younger patients were compared. The key factor under analysis was death from any cause during the hospitalization or within 1 year after the surgery. A total of 73 elderly patients (and 81 younger patients) were found to have severe alimentary tract surgery-related sepsis. The mean age of the elderly patients was 76.4 years, and 56.2 % were female. The most common indication for surgery was acute cholecystitis (21.9 %), followed by acute diverticulitis (13.7 %), and gastroduodenal ulcer (13.7 %). The anatomic site of the infection was intra-abdominal in 86.3 % of cases, the second most common being pulmonary (13.7 %). In-hospital mortality was 47.9 % and 1-year mortality 64.4 %. Of the discharged patients, 31.6 % died within 1 year. Patients who died were older and more frequently had concomitant conditions. The ICU scoring systems (APACHE, SAPS, and SOFA) and elevated lactate levels were predictive of increased mortality. Severe sepsis among the elderly is a rare but often-fatal infectious event. In addition to high in-hospital mortality, it is also associated with significant 1-year mortality.

Background One of the main aims of appendicitis research is the differential diagnostics between complicated and uncomplicated acute appendicitis that enable provision of the optimal treatment for each patient. Methods Data in the present study were collected prospectively in our randomized antibiotic treatment for uncomplicated acute appendicitis trial (APPAC) comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (NCT01022567). We evaluated 705 patients who had acute appendicitis on computed tomography. Patients with uncomplicated acute appendicitis (n = 368) were compared with all complicated acute appendicitis patients (n = 337), and subgroup analyses were performed between uncomplicated acute appendicitis and an appendicolith appendicitis (CA1; n = 256) and uncomplicated acute appendicitis and perforation and/or abscess (CA2; n = 78). Age, sex, body temperature (°C), duration of symptoms, white blood cell count (E9/L), and C-reactive protein (mg/L) were recorded on admission. Receiver operating characteristic curves were calculated for white blood cell count, C-reactive protein, and temperature. Results CA2 patients had significantly greater C-reactive protein levels (mean 122 and 47, respectively, P 24 hours before admission (P 0.7), but no optimum cutoff points could be identified. Conclusion In clinical decision making, neither clinical findings nor laboratory markers are reliable enough to estimate the severity of the acute appendicitis accurately or to determine the presence of an appendicolith. The current results emphasize the role of computed tomography in the differential diagnosis of complicated and uncomplicated acute appendicitis.

Objectives (1) To evaluate the ability of emergency room radiologists to detect acute mesenteric ischemia (AMI) from computed tomography (CT) images in patients with acute abdominal pain. (2) To identify factors affecting radiologists’ performance in the CT interpretation and patient outcome. Materials and methods A retrospective study of 95 consecutive patients treated for 97 AMI events between 2009 and 2013 was carried out. The etiology of AMI was embolism in 24 (25%), atherosclerotic vascular disease (ASVD) in 39 (40%), non-obstructive mesenteric ischemia (NOMI) in 25 (26%), and mesenteric venous thrombosis (MVT) in nine (9%) cases. The protocols, referrals and initial radiology reports of the abdominal CTs were analyzed. The CT studies were further scrutinized for vascular and intestinal findings. Results The referring clinician had suspected AMI in 30 (31%) cases prior to imaging. The crucial findings of AMI had been stated in 97% of the radiology reports if the clinician had mentioned AMI suspicion in the referral; if not, the corresponding rate was 81% (p = 0.04). Patients without suspicion of AMI prior to CT were more prone to undergo bowel resection. CT protocol was optimal for AMI (with contrast enhancement in arterial and venous phases) in only 34 (35%) cases. Intestinal findings were more difficult to detect than vascular findings. Vascular findings were retrospectively detectable in 92% of cases with embolism and 100% in ASVD and MVT. Some evidence of intestinal abnormality was retrospectively found in the CT findings in 92%, 100%, 100% and 67% of cases with embolism, ASVD, NOMI and MVT, respectively. Conclusions AMI is underdiagnosed in the CT of the acute abdomen if there is no clinical suspicion.

Correction: Volume: 22 Issue: 5 Pages: 819-819 DOI: 10.1007/s10029-018-1788-y WOS:000446065400016 Chronic pain after inguinal hernioplasty is the foremost side-effect up to 10-30% of patients. Mesh fixation may influence on the incidence of chronic pain after open anterior mesh repairs. Some 625 patients who underwent open anterior mesh repairs were randomized to receive one of the three meshes and fixations: cyanoacrylate glue with low-weight polypropylene mesh (n = 216), non-absorbable sutures with partially absorbable mesh (n = 207) or self-gripping polyesther mesh (n = 202). Factors related to chronic pain (visual analogue scores; VAS ae 30, range 0-100) at 1 year postoperatively were analyzed using logistic regression method. A second analysis using telephone interview and patient records was performed 2 years after the index surgery. At index operation, all patient characteristics were similar in the three study groups. After 1 year, chronic inguinal pain was found in 52 patients and after 2 years in only 16 patients with no difference between the study groups. During 2 years' follow-up, three (0.48%) patients with recurrences and five (0.8%) patients with chronic pain were re-operated. Multivariate regression analysis indicated that only new recurrent hernias and high pain scores at day 7 were predictive factors for longstanding groin pain (p = 0.001). Type of mesh or fixation, gender, pre-operative VAS, age, body mass index or duration of operation did not predict chronic pain. Only the presence of recurrent hernia and early severe pain after index operation seemed to predict longstanding inguinal pain.

Appendiceal tumors are rare, but high neoplasm rates have been reported at interval appendectomy after periappendicular abscess. Non-operative management of uncomplicated acute appendicitis has shown promising results. The data on appendiceal tumor incidence and presentation among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. Objective was to assess appendiceal tumor incidence and tumor association to appendicitis in patients with uncomplicated and complicated acute appendicitis. This nationwide population-based registry study was conducted from 2007 to 2013. The Finnish Cancer Registry and the National Institute for Health Registry were used to combine data on all appendiceal tumors and acute appendicitis diagnosis with medical reports evaluated at eight study hospitals. Altogether, 840 appendiceal tumors were identified, and out of these, 504 patient reports were reviewed, including 472 patients in this study. Tumor was diagnosed at appendectomy for suspected acute appendicitis in 276 patients (58%). In the whole study, histologically acute appendicitis and tumor were both present in 53% (n = 250), and out of these, 41% (n = 102) were complicated and 59% (n = 148) uncomplicated acute appendicitis. The associated tumor risk was significantly higher in complicated acute appendicitis compared with uncomplicated cases (3.24% vs. 0.87%, p

Acute mesenteric ischemia resulting from mesenteric arterial thrombosis is a life-threatening cardiovascular complication with symptoms ranging from sudden-onset abdominal pain to vague symptoms of several days' duration. Although contrast-enhanced computed tomography is an excellent diagnostic tool, detection of the disease before the development of permanent intestinal injury is still difficult. Endovascular treatment is usually successful in restoring intestinal blood flow acutely. Chronic mesenteric ischemia requires urgent detection and therapy in order to prevent irreversible intestinal ischemia.

Purpose The aim of this research was to examine the association between statin use and the risk of acute pancreatitis. Methods This register-based case–control study with incidence density sampling was based on 4376 patients hospitalized in 2008–2010 for acute pancreatitis and 19 859 randomly selected age and sex-matched controls from the adult population of Finland. The relationship between statin use from 1 January 2004 to the index date and the relative incidence rate of acute pancreatitis was modelled by conditional logistic regression. The rate ratios were adjusted for comorbidities. Results A total of 826 (19%) cases and 2589 (13%) controls had been exposed to statins. Statin use was associated with an increased incidence rate of acute pancreatitis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.13–1.39). This increase was seen especially during the first year of use both among current (OR 1.37, 95% CI 0.94–2.00 for at most 3 months of use and OR 1.32, 95% CI 1.07–1.63 for 4–12 months of use) and former users (OR 1.64, 95% CI 1.33–2.03). The overall association remained when restricting analyses to participants with current use only, or with no history of gallstone or alcohol-related diseases, or with no comorbidities or medicines other than statins. Conclusions Statin use seems to be associated with an increased risk of acute pancreatitis. The association is more apparent during the first year of statin use and among former users. Copyright © 2015 John Wiley & Sons, Ltd.

The incidence of acute mesenteric ischemia (AMI) increases exponentially with age. The significance of AMI as a differential diagnosis in elderly patients with acute abdomen may be underestimated. Consecutive patients hospitalized for AMI between 2009 and 2013 were retrospectively identified in a well-defined population. Acute appendicitis, ruptured abdominal aortic aneurysm, acute pancreatitis, and acute cholecystitis were used as reference diagnoses, and the age-specific incidence rates were calculated. In addition, long-term mortality risk was assessed for AMI survivors. The in-hospital incidence rates of AMI, acute obstructive mesenteric ischemia, and non-obstructive mesenteric ischemia were 7.3, 4.5, and 2.0/100,000/year, respectively. AMI was more common than ruptured abdominal aortic aneurysm, and the age-specific incidence of AMI was higher than the incidence of acute appendicitis in patients over age 75 years with acute abdomen. During the follow-up, the age-adjusted risk of death was 1.8 times higher in AMI survivors than in survivors of acute cholecystitis. AMI may be a more common cause of acute abdomen in elderly patients than is generally thought, emphasizing the importance of performing urgent computed tomography with contrast enhancement preferably in arterial and venous phases in these patients.

Clinical tools for predicting postoperative pain should be developed to provide better care for patients. The aims of this study were to evaluate preoperative magnetic resonance imaging (MRI) findings to reveal reasons for overwhelming pain in patients with inguinal hernia and to detect changes in quality-of-life (QoL) and pain scores preoperatively and following laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia.Twenty-two patients aged 18-50 years presenting with extremely painful inguinal hernias (highest pain scores50, scale 0-100) were examined with MRI prior to operative treatment with TEP repair. Postoperative follow-up lasted 6 months and consisted of questionnaires regarding functional status, pain, QoL and possible complications. Postoperative MRI scans were performed only in cases of preoperative findings on the MRI or prolonged inguinal pain persisting over 6 months.Prolonged postoperative pain could not be predicted from preoperative MRI scans, because no signs of the pain's origin such as pubic periostal irritation, bone marrow edema, pelvic bone or hip joint abnormalities, or lower abdominal muscle hemorrhage were detected in MRI. TEP repair of inguinal hernia significantly improved the patients' quality of life and relieved pain symptoms. High preoperative pain scores were major predictors of prolonged postoperative pain.Carefully evaluated preoperative pelvic MRI was usually normal in patients with high pain scores prior to operation. Preoperative pain scores may serve as indicators of development of prolonged inguinal pain.

Inguinal hernia repair is the most common elective procedure in general surgery. Therefore, the number of patients having complications related to inguinal hernia surgery is relatively large. The aim of this study was to compare complication profiles of inguinal open mesh (OM) hernioplasties with open non-mesh (OS) repairs and laparoscopic (LAP) repairs using retrospective nationwide registry data. The database of the Finnish Patient Insurance Centre (FPIC) was searched for complications of inguinal and femoral hernia repairs during 2002–2010. Complications of OM repairs were compared to complications of OS repairs and LAP repairs. Over 75 % of all inguinal hernia procedures during the study period in Finland were OM hernioplasties. FPIC received 245 complication reports after OM repairs, 40 after OS repairs, and 50 after LAP repairs. Reported complications were significantly more severe after LAP and OS repairs than OM surgery (p

To evaluate endovascular therapy (EVT) as the primary revascularization method for acute mesenteric ischemia (AMI).A retrospective review was performed on all consecutive patients treated for AMI during a 5-year period (January 2009 to December 2013). EVT was attempted in all patients referred for emergent revascularization. Surgical revascularization was performed selectively after failure of EVT. Patient characteristics, clinical presentation, and outcomes were studied. Failures and complications of EVT were recorded.Fifty patients, aged 79 ± 9 years (mean ± SD), out of 66 consecutive patients with AMI secondary to embolic or thrombotic obstruction of the superior mesenteric artery were referred for revascularization. The etiology of AMI was embolism in 18 (36 %) and thrombosis in 32 (64 %) patients. EVT was technically successful in 44 (88 %) patients. Mortality after successful or failed EVT was 32 %. The rates of emergency laparotomy, bowel resection, and EVT-related complication were 40, 34, and 10 %, respectively. Three out of six patients with failure of EVT were treated with surgical bypass. EVT failure did not significantly affect survival.EVT is feasible in most cases of AMI, with favorable patient outcome and acceptable complication rate.

Background and Aims: To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience. Material and Methods: Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups. Results: Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1–97.8) and 95.9% (95% confidence interval, 93.2–97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. Conclusion: The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.

Background:Athletic pubalgia is typically associated with male athletes participating in contact sports and less frequently with females. Endoscopic surgery may fully treat the patient with athletic pubalgia.Purpose:To perform an outcomes analysis of magnetic resonance imaging (MRI) and endoscopic surgery in female patients with athletic pubalgia.Study Design:Cohort study; Level of evidence, 3.Methods:Fifteen physically active female patients (mean age, 37 years) with athletic pubalgia were treated surgically via placement of total extraperitoneal endoscopic polypropylene mesh behind the injured groin area. The presence of preoperative bone marrow edema (BME) at the pubic symphysis seen on MRI was graded from 0 to 3 and correlated with pain scores after surgery. The outcome measures were pre- and postoperative pain scores and recovery to daily activity between 1 and 12 months after surgery. Results were compared with previously published scores from male athletes (n = 30).Results:With the exception of lower body mass index, the females with (n = 8) and without (n = 7) pubic BME had similar patient characteristics to the corresponding males. Mean inguinal pain scores (0-10) before surgical treatment were greater in females than males (during exercise, 7.8 ± 1.1 vs 6.9 ± 1.1; P = .0131). One month after surgery, mean pain scores for females were still greater compared with males (2.9 ± 1.7 vs 1.3 ± 1.6; P = .0034). Compared with female athletes with normal MRI, pubic BME was related to increased mean preoperative pain scores (8.13 ± 0.99 vs 6.43 ± 1.2; P = .0122). After 1 year, surgical outcomes were excellent or good in 47% of women.Conclusion:Endoscopic surgery was helpful in half of the females with athletic pubalgia in this study. The presence of pubic BME may predict slightly prolonged recovery from surgery.

Distribution of diagnoses causing acute abdominal pain (AAP) may change because of population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Our aim was to evaluate the diagnoses causing AAP during a 26-year period.This was a retrospective cross-sectional cohort study in one emergency department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and 2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, obesity and alcohol consumption during 1980-2012 were obtained from national registers.The AAP patients represented 10-20% of our total ED census. The most common causes of AAP were nonspecific abdominal pain (NSAP, 31-37%), acute appendicitis (11-23%), biliary disease (9-11%), bowel obstruction (5-7%), acute pancreatitis (4-8%) and acute diverticulitis (1-7%). The percentage of NSAP remained highest throughout the study period. Decrease in the number of acute appendicitis (from 23 to 11%; p .0001), increase in acute diverticulitis (from 1 to 5%; p ≤ .0001) and acute pancreatitis (from 4 to 7%; p = .0273) was observed over time. The utilization of diagnostic imaging increased significantly (CT from 2 to 37% and US from 4 to 38%, p .0001). Hospital mortality was very low (1-2%).NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis, distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Upper gastrointestinal bleeding (UGIB) is a common emergency, with in-hospital mortality between 3 and 14%. However, the long-term mortality and causes of death are unknown. We investigated the long-term mortality and causes of death in UGIB patients in a retrospective single-centre case-control study design.A total of 569 consecutive patients, aged ≥18 years, admitted to Kuopio University Hospital for their first endoscopically verified UGIB during the years 2009-2011 were identified from hospital records. For each UGIB patient, an age, sex and hospital district matched control patient was identified from the Statistics Finland database. Data on endoscopy procedures, laboratory values, comorbidities and medication were obtained from patient records. Data on deaths and causes of death were obtained from Statistics Finland.In-hospital mortality of UGIB patients was low at 3.3%. The long-term (mean follow-up 32 months) mortality of UGIB patients was significantly higher than controls (34.1 versus 12.1%, p .001). During the 6 months following UGIB, the risk of death compared to controls was highest (HR 19.2, 95% CI 7.0-52.4, p .001) and remained higher up to 3 years after the bleeding. Beyond 3 years' follow-up, there was no difference in mortality between the groups (HR 0.7, 95% CI 0.4-1.6, p = .436). During the first 3 months after the UGIB episode, mortality was related to gastrointestinal diseases; after 3 months, the causes of death were related to comorbidities and did not differ from causes of death in controls.UGIB patients have three times higher long-term mortality than population controls.

BACKGROUND: Non-specific abdominal pain (NSAP) and acute appendicitis (AA) are the two most frequent diagnoses of acute abdomen in the emergency wards. The long-term morbidity, mortality and quality of life of the patients with NSAP compared to AA are unknown. METHODS: The study group consisted of 186 patients with acute NSAP compared to 147 patients with AA initially treated during 1985-1986. Medical history, social background, quality of life and abdominal symptoms were assessed with standardized questionnaires in both groups during 2006-2009. The patients who continued to have abdominal symptoms were invited to a check-up visit. RESULTS: During 1985-6, the NSAP group had more previous abdominal symptoms and operations than the AA group. Some 29% of patients with NSAP and 11% of patients with AA had still abdominal symptoms at long-term check-up (p < 0.0001). Chronic abdominal pain (38 vs 17) and peptic ulcer disease (18 vs 2) occurred more often in the NSAP group than in the controls, respectively (p = 0.001). After five years of follow-up, 11 patients in the NSAP group and 6 patients in the AA group had died (ns). During the twenty years of follow-up, mortality was higher (46/22, 25/15%) in the patients with NSAP than in controls (p = 0.013). Ischaemic heart disease was the leading cause of death in both groups (18 NSAP vs 5 AA, p = 0.017). The quality of life scores were comparable in both study groups. CONCLUSION: Over 70% of NSAP- and almost 90% of AA-patients were free of symptoms after 20 years of follow-up. Mortality was higher and various alimentary track diseases were more frequent in patients with NSAP than in AA.

Gallstone disease (GD) has been associated with low serum levels of plant sterols. We evaluated the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and non-alcoholic fatty liver disease (NAFLD) on the association of GD with low levels of serum plant sterols. Two hundred forty-two consecutive morbidly obese patients were recruited to this prospective study. Histological analysis of liver biopsy to diagnose NAFLD was performed. Bile sample was taken during the LRYGB. Associations of GD with serum non-cholesterol sterol to cholesterol ratios, measured using gas liquid chromatography and with mRNA expression of genes participating in the cholesterol, bile, and fatty acid metabolism in the liver, were analyzed. Out of the 242 participants, 95 had GD. Lower weight (p = 0.002) and female sex (p = 0.0006) were associated with GD. Serum plant sterols, campesterol (p = 0.003), sitosterol (p = 0.002), and avenasterol (p = 0.015), were lower in patients with GD compared to those without GD. This association remained significant after adjustment for NAFLD, use of statin medication, and previous laparoscopic cholecystectomy (LCC). Levels of sitosterol (p = 0.001) and campesterol (p = 0.001) remained lower in obese individuals with GD also after obesity surgery. Liver mRNA expression of genes regulating cholesterol synthesis and bile metabolism was increased in individuals with GD. Serum plant sterols were lower in patients with GD independent of NAFLD, history of LCC, use of statin medication, and weight loss after LRYGB. Low serum plant sterols in patients with GD suggest potentially inherited alterations in sterol absorption and biliary transport in subjects susceptible for GD.

The long-term outcome between laparoscopic cholecystectomy (LC) and minilaparotomy (MC) has not been compared in randomised trials as day-surgery procedures. We therefore investigated the outcome after day-case LC and MC in 48 patients. Initially 60 patients with noncomplicated symptomatic gallstone disease were randomly allocated to a day-case MC (n = 29) or LC (n = 31) over a period of 2 years (2006–2008), and 48 of them (80 %) were reached for a follow-up interview 5.8 (4.8–6.9) years after the surgery. Baseline parameters were similar in the two groups: 1 of 21 MCs and 2 of 27 LCs were converted to open laparotomy. The prevalence of chronic postsurgical pain (CPSP) 5 years after the procedure was quite similar in the two groups: 3 of 21 (14 %) in the MC group and 1 of 27 (4 %; p = 0.2). Residual abdominal symptoms were common, but the proportion was similar in both groups (43 % in MC and 30 % in LC group, p = 0.26). In the MC group 100 % and in the LC group 89 % (18/21) were satisfied with the cosmetic outcome (p = 0.11). Quality of life (QoL) improved for 16 of 21 (76 %) in the MC group and 26 of 27 (96 %) in the LC group (p = 0.38), and patients in both groups were satisfied with the operation overall. Day-case MC and LC patients have a quite similar long-term outcome with no significant difference regarding residual abdominal symptoms, cosmetic satisfaction, QoL, or CPSP.

Background and Aims: Aging with comorbidities, obesity, and rapid recovery from operation may increase the need for laparoscopic cholecystectomy, but long-term use of statins may be associated with a decreased risk of gallstones. This population-based cohort study presents the changing rate and causative factors of laparoscopic cholecystectomy in Finland during the era of statin use. Materials and Methods: Age structure of the population, changes in body mass index and diabetes, and the number of all cholecystectomies in 1995–2009 were retrieved from the registers of National Institute for Health and Welfare. Additionally, these results were supplemented by a population-based retrospective cohort (1581 laparoscopic cholecystectomy) in one community-based hospital area. The risk factors for laparoscopic cholecystectomy, use of statins, and surgical outcome were analyzed. Results: During the 15 years, 123,794 cholecystectomies were performed in Finland, of which 94,740 (76.5%) were performed using laparoscopic technique. The median rate of laparoscopic cholecystectomy varied between 110 and 140 operations per 100,000 inhabitants. In 1995–2009, the annual number of cholecystectomies decreased from 8600 to 7500, the number of laparoscopic cholecystectomies increased by 10%, and the number of open cholecystectomies declined by 60%. In a cohort of 1581 laparoscopic cholecystectomies, the proportion of elderly (>65 years of age), obese (body mass index > 30 kg/m2), and diabetic patients increased from 17% to 28%, 9% to 34%, and 4% to 8%, respectively. Use of statins increased more than fourfold during the 15 years. Conclusions: The rates of all cholecystectomies decreased despite marked increase in laparoscopic cholecystectomies performed. The increase in risk factors for gallstones in Finland implied more marked increase in laparoscopic cholecystectomies. The possible role of statins on gallstone disease is discussed.

Testicular ischemia and necrosis are uncommon complications after inguinal hernioplasty. Our aim was to evaluate the incidence of severe urological complications related to adult inguinal hernia surgery in Finland with special reference to orchiectomy in relieving intractable chronic testicular pain.All urological complications related to inguinal hernia surgery during 2003-2010 were analysed from the Finnish Patient Insurance Centre. The patients with intractable chronic scrotal or testicular pain that resulted in orchiectomy were re-evaluated after a median follow-up of 7 years (range 2-15 years). The operative factors related to chronic testicular pain and atrophy were analysed using multiple regression analysis.Altogether 62 urological complications (from 335 litigations) were recorded from 92,000 inguinal hernia operations. The distribution of claimed urological complications consisted of 34 testicular injuries, ten bladder perforations, seven massive scrotal haemorrhage or 11 miscellaneous injuries. Seventeen atrophic testes were left in situ and 17 (six early7 days, 11 late8 days) orchiectomies were performed due to necrosis or chronic testicular pain syndrome. In the conservative group of moderate scrotal or testicular pain (n = 17), all patients had late pain symptoms (8 days), but pain was not so severe that orchiectomy was attempted. Using a multivariate analysis, postoperative infections were associated with chronic testicular or scrotal pain and atrophy, but hospital status, surgeon's training level, laparoscopic or open operation, type of hernia or use of mesh did not correlate with testicular injuries. During follow-up, 11/17 (65%) patients with orchiectomy were free of testicular pain.Urological injuries form one-fifth of the major complications after inguinal hernioplasty. Orchiectomy appears to help the majority of patients with severe testicular pain syndrome.

The incidence of acute appendicitis (AA) has decreased in Finland. We hypothesized that changing trends in outpatient antibiotic use might explain at least part of this declining incidence of AA.The number of all patients with AA in Finland was extracted from the national data base from 1990 to 2008. For comparison, the incidence of acute diverticulitis of the colon (AD) was also recorded. All outpatient prescriptions of antibiotics belonging to the major groups of these drugs were also recorded. We used unit root and co-integration analyses for statistical analysis of the data in the study.The incidence of AA in Finland declined from 14.5 to 9.8 per 10,000 inhabitants (32%) and the incidence of AD increased by 47% between 1993 and 2007. The total outpatient use of antibiotics did not increase during this same period, but the use of antibiotics effective widely against colonic pathogens (macrolides, fluoroquinolones, and cephalosporins) increased significantly. No correlation was found between the incidence of AA, that of AD, and the use of different groups of antibiotics.Our nationwide registry study indicated that changes in outpatient antibiotic use do not explain the decreasing trend in AA in Finland. Other factors, such as improved diagnosis of AA, may have some role in the decreasing incidence of AA.

To evaluate the costs of treatment and use of hospital resources when comparing routine abdominal CT and selective imaging practice based on clinical assessment in patients with acute abdomen. Altogether 300 patients with acute abdominal pain were randomised to computed tomography (CT, n = 150) or selective imaging practice (SIP, n = 150) groups. Final analysis included 254 patients, 143 in the CT and 111 in the SIP group. All CT group patients underwent contrast-enhanced abdominal CT within 24 h of admission. In the SIP group, imaging was individually tailored based on clinical assessment. The numbers of various examinations and procedures as well as costs of treatment arising from acute abdomen were calculated for each patient. Length of hospital stay was registered. Total treatment cost per patient was 1,202 euros (€) higher in the CT group compared to the SIP group (P = 0.002). The length of hospital stay was 1.2 days longer in the CT group (3.7 vs. 2.5 days, P = 0.010). Routine CT had no impact on ED discharge times. Imaging costs accounted for approximately 10 % of total costs. Routine abdominal CT results in higher treatment costs compared to selective use of imaging in patients with acute abdomen. • CT is widely used almost routinely in the diagnostics of acute abdomen. • Patients with acute abdomen were randomised to routine CT or selective imaging. • The treatment costs were significantly higher in the routine CT group. • Length of hospital stay was longer in the CT group. • Selective use of imaging may help control continuous increases of treatment costs.

Endoscopic transanal resection (ETAR) is a scarcely used technique to treat large or sessile rectal adenomas not amenable to polypectomy. The purpose of this study was to evaluate safety and long-term results of ETAR in treating rectal adenomas in three hospitals over 15 years. Patients who underwent ETAR during 1996–2010 were retrospectively analyzed with respect to patient, adenoma, and operative characteristics, earlier operations, complications, follow-up time, recurrence rates, recurrence treatment, and cancer incidence. Ninety-two patients underwent a total 111 ETARs to treat rectal adenoma. The mean age of patients was 71 years, and the median ASA class 3. Twenty-eight patients previously had received other treatments for rectal adenoma. Incidental carcinoma was found in eight patients. Sixty-seven adenomas were treated with only one ETAR and 17 with two or three ETARs. Sixty-seven patients did not have a recurrence, whereas 14 patients had an adenoma recurrence and 3 patients developed invasive carcinoma during a mean follow-up of 30 months. Complications occurred in 14 patients; all were minor, except for one explorative laparotomy without findings. No mortalities or conversions to open surgery occurred. ETAR is a minimally invasive and safe technique with inexpensive instrumentation to treat rectal adenomas that are not amenable to polypectomy. Adenoma recurrence rate was 15 % and cancer incidence 3 % in follow-up.

Obesity is a risk factor for operative treatment. This study examined the impact of obesity and associated comorbidities on complications after laparoscopic cholecystectomy (LC). Altogether, 1581 consecutive patients with symptomatic gallstones underwent LC between the years 1995 and 2008. Preoperative data and operative outcome of the 437 obese patients [302 with body mass index (BMI) 30 to 35 kg/m² and 135 with BMI ≥ 35.1 kg/m²] and 1144 nonobese controls (BMI ≤ 29.9 kg/m²) undergoing LC were compared. The impact of obesity, diabetes, cholecystitis, coronary heart disease, pulmonary disease, hypertension, and renal insufficiency on the postoperative outcome was analyzed by using multiple logistic regression analysis. The percentage of obese patients undergoing LC did not change during the study period. Over half of obese patients (63%) had 1 or multiple comorbidities, but only 15% of the patients had an acute surgery because of cholecystitis. Conversion to open surgery was required in 11.7% of the obese patients compared with 6.1% in the nonobese controls (P=0.0003). Acute cholecystitis increased the conversions in class II and III obese patients (50%) compared with elective surgery (8.7%, P

The aim of this study was to examine the association between angiotensin converting enzyme (ACE) inhibitor use and the risk of acute pancreatitis.Information on all 4966 cases hospitalized in 2008-2010 for acute pancreatitis was retrieved from the Finnish national registers on hospital discharges and prescriptions. A total of 24 788 age and sex-matched population-based controls were randomly selected using density sampling. ACE inhibitor use between 1 January 2003 and the index date were determined by the date of hospitalization for acute pancreatitis among the cases. The incidence rate ratios of acute pancreatitis not diagnosed as biliary or alcohol-induced were modeled by conditional logistic regression and adjusted for comorbidities.A total of 1276 (26%) cases and 3946 (16%) controls had been exposed to ACE inhibitors. The use of ACE inhibitors was associated with an increased incidence rate of acute pancreatitis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.59-1.95). The increase was slightly higher among current new users (OR 1.86, 95%CI 1.65-2.09) and somewhat lower among current prevalent (OR 1.54, 95%CI 1.35-1.75) and former users (OR 1.51, 95%CI 1.31-1.74).Angiotensin converting enzyme inhibitor use seems to be associated with a moderately increased risk of acute pancreatitis. Copyright © 2017 John WileySons, Ltd.