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Selective laparoscopy for possible acute appendicitis
A32
Abstracts/Netherlands
Journal of Medicine 48 (1996) AI-A42
graphy and endoanal MRI. The study included 10 volunteers and 30 consecutive patients with clinically evident fistula-inano. A Briiel & Kjaer scanner was used to perform endoanal sonography. For MRI COST,Philips Medical Systems) a newly developed endoanal coil was used. In all subjects, a turbo spin echo and a fast field echo were performed. There are three types of perianal fistulae: cryptoglandular, Crohn’s and anovaginal. According to Parks, cryptoglandular fistulae can be divided into intersphincteric, transsphincteric, suprasphincteric, extrasphincteric and horse-shoe fistulae. The preoperative Parks’classification is crucial for proper surgical management. The imaging findings were correlated with surgery. With endoanal MRI, all layers of the anal canal wall (i.e., the internal sphincter, longitudinal muscle and the external sphincter1 were well visible. With endoanal sonography only the internal anal sphincter was well displayed. Exact classification of fistulae was possible in 60% (18/30) with endoanal sonography but in 90% (27/30) with endoanal MRI. The intersphincteric fistulae were diagnosed equally with both imaging modalities. The more complex fistulae, such as transsphincteric and horse-shoe fistulae, were particularly easier to identify with endoanal MRI. Non-classification occurred in 40% (12/30) with endoanal sonography but in only 10% (3/30) with endoanal MRI. Conclusion: The imaging of the normal anatomy and the classification of fistula-in-ano are improved by endoanal MRI as compared to endoanal sonography.
Selective laparoscopy for possible acute appendicitis. P.V. van Eerten, A.B. Bijnen, P. de Ruiter. Department of Surgery, Medical Centre, Alkmaar, Netherlands.
Since the correct diagnosis of acute appendicitis is difficult, a normal appendectomy rate of 15% in men and 30% in women is generally accepted. Deutch showed in a restrospective study a morbidity rate of 17% in patients with a normal appendectomy by direct laparotomy. Diagnostic laparoscopy can increase the number of other diagnoses and lower the normal appendectomy rate. Routine laparoscopy is unnecessary when the clinical diagnosis is “certain” and the surgeon will not perform a laparoscopic appendectomy. To reduce the negative appendectomy rate all patients in 1994 presenting to the emergency ward with a possible diagnosis of acute appendicitis were treated in a prospective study protocol. The essential part of this protocol was that only direct laparotomy was allowed when the clinical diagnosis was “certain” based on the clinician’s subjective judgment and laboratory tests written down in the protocol in advance. In all other cases diagnostic laparoscopy or observation (clinical or out-doors) was justified. Appendectomy after diagnostic laparoscopy was only performed when the appendix was (doubtful) inflamed. Therefore a normal appendix diagnosed by laparoscopy was left in situ. After appendectomy histology was the golden standard. Statistical analysis was made using the chi-square test or Fisher’s exact test when appropriate. In 1994 all 349 patients with a possible diagnosis or acute appendicitis were included in the protocol. 30% were stratified for direct la-
parotomy, 30% for diagnostic laparoscopy: the other 40%, were observed. Of the patients in observation 30 were operated later on, with a 7% normal appendectomy rate. 28 patients were stratified for direct laparotomy without the clinical diagnosis of “certain”, so the protocol was violated in these patients. The patients treated according to the protocol by direct laparotomy showed a significantly better result with a 4% normal appendectomy rate than the 21% normal appendectomy rate in the group of the protocol violation. Diagnostic laparoscopy was followed by appendectomy in 70% of the patients. Despite the diagnostic laparoscopy the normal appendectomy rate was 6%. Overall 249 patients were operated for the possible diagnosis of acute appendicitis, 88% according to protocol, with a 7% normal appendectomy rate. Compared to previous years, the total number of operative procedures decreased 17% and the normal appendectomy rate was significantly halved from 14 to 7% (p < 0.05). Con&ion: After the introduction of a prospective protocol for the possible diagnosis of acute appendicitis, with the selective use of diagnostic laparoscopy on subjective criteria, the normal appendectomy rate was significantly reduced to 7% and total number of operative procedures decreased. To reduce the extra costs of the added diagnostic laparoscopy, objective criteria will be formulated that allow optimal stratification.
Tumour DNA content and cell proWration (W-67) in distal bile duct carcinomas assessed in 33 subtotal pancreatoduodenectomy specimens. T.M. van Gulik, A. Umezawa, A. Bosma ‘, K. Koyama, G.J.A. Offerhaus i, H. Obertop, D.J. Gouma. Departments of Surgery and I Pathology, Academic Medical Centre, Amsterdam, NetherIan&
The prognostic value of tumour DNA content and the cell-cycle-associated antigen Ki-67 were studied in 33 patients who had undergone subtotal pancreatoduodenectomy for distal bile duct carcinoma (DBDC). The results of Ki-67 expression and DNA content were related to survival time. The surgical specimens of 33 patients with DBDC were examined after pancreatoduodenectomy. Of each case, 1-5 samples were selected from the tumour area in the tissue blocks. As controls, 8 samples of non-tumour areas from 16 of the DBDC cases were analyzed. For assessmentof nuclear DNA content, 50 pm sections of the tumour were processed into a nuclear suspension stained with propidium iodide. DNA content was measured with a flowcytometry FACScan and the data of 20000 nuclei of each sample were analyzed. According to the DNA histograms, tumour ploidy was classified as diploid or aneuploid. Ki-67 was detected by immunohistochemical staining of 4 pm tumour sections with MIB-1 (avidin-biotin-peroxidase technique). MIB-1 expression was recorded as the ratio of positive nuclei (%) in 1000 tumour cells (MIB-1 index). The mean MIB-1 index was determined for each patient. Of 33 patients (age 31-73 yr mean 60 yrl, a total of 120 samples were examined after resection of DBDC. 19 patients had a radical resection; 14 resections were micro-
Abstracts/Netherlands
Journal of Medicine 48 (1996) AI-A42
graphy and endoanal MRI. The study included 10 volunteers and 30 consecutive patients with clinically evident fistula-inano. A Briiel & Kjaer scanner was used to perform endoanal sonography. For MRI COST,Philips Medical Systems) a newly developed endoanal coil was used. In all subjects, a turbo spin echo and a fast field echo were performed. There are three types of perianal fistulae: cryptoglandular, Crohn’s and anovaginal. According to Parks, cryptoglandular fistulae can be divided into intersphincteric, transsphincteric, suprasphincteric, extrasphincteric and horse-shoe fistulae. The preoperative Parks’classification is crucial for proper surgical management. The imaging findings were correlated with surgery. With endoanal MRI, all layers of the anal canal wall (i.e., the internal sphincter, longitudinal muscle and the external sphincter1 were well visible. With endoanal sonography only the internal anal sphincter was well displayed. Exact classification of fistulae was possible in 60% (18/30) with endoanal sonography but in 90% (27/30) with endoanal MRI. The intersphincteric fistulae were diagnosed equally with both imaging modalities. The more complex fistulae, such as transsphincteric and horse-shoe fistulae, were particularly easier to identify with endoanal MRI. Non-classification occurred in 40% (12/30) with endoanal sonography but in only 10% (3/30) with endoanal MRI. Conclusion: The imaging of the normal anatomy and the classification of fistula-in-ano are improved by endoanal MRI as compared to endoanal sonography.
Selective laparoscopy for possible acute appendicitis. P.V. van Eerten, A.B. Bijnen, P. de Ruiter. Department of Surgery, Medical Centre, Alkmaar, Netherlands.
Since the correct diagnosis of acute appendicitis is difficult, a normal appendectomy rate of 15% in men and 30% in women is generally accepted. Deutch showed in a restrospective study a morbidity rate of 17% in patients with a normal appendectomy by direct laparotomy. Diagnostic laparoscopy can increase the number of other diagnoses and lower the normal appendectomy rate. Routine laparoscopy is unnecessary when the clinical diagnosis is “certain” and the surgeon will not perform a laparoscopic appendectomy. To reduce the negative appendectomy rate all patients in 1994 presenting to the emergency ward with a possible diagnosis of acute appendicitis were treated in a prospective study protocol. The essential part of this protocol was that only direct laparotomy was allowed when the clinical diagnosis was “certain” based on the clinician’s subjective judgment and laboratory tests written down in the protocol in advance. In all other cases diagnostic laparoscopy or observation (clinical or out-doors) was justified. Appendectomy after diagnostic laparoscopy was only performed when the appendix was (doubtful) inflamed. Therefore a normal appendix diagnosed by laparoscopy was left in situ. After appendectomy histology was the golden standard. Statistical analysis was made using the chi-square test or Fisher’s exact test when appropriate. In 1994 all 349 patients with a possible diagnosis or acute appendicitis were included in the protocol. 30% were stratified for direct la-
parotomy, 30% for diagnostic laparoscopy: the other 40%, were observed. Of the patients in observation 30 were operated later on, with a 7% normal appendectomy rate. 28 patients were stratified for direct laparotomy without the clinical diagnosis of “certain”, so the protocol was violated in these patients. The patients treated according to the protocol by direct laparotomy showed a significantly better result with a 4% normal appendectomy rate than the 21% normal appendectomy rate in the group of the protocol violation. Diagnostic laparoscopy was followed by appendectomy in 70% of the patients. Despite the diagnostic laparoscopy the normal appendectomy rate was 6%. Overall 249 patients were operated for the possible diagnosis of acute appendicitis, 88% according to protocol, with a 7% normal appendectomy rate. Compared to previous years, the total number of operative procedures decreased 17% and the normal appendectomy rate was significantly halved from 14 to 7% (p < 0.05). Con&ion: After the introduction of a prospective protocol for the possible diagnosis of acute appendicitis, with the selective use of diagnostic laparoscopy on subjective criteria, the normal appendectomy rate was significantly reduced to 7% and total number of operative procedures decreased. To reduce the extra costs of the added diagnostic laparoscopy, objective criteria will be formulated that allow optimal stratification.
Tumour DNA content and cell proWration (W-67) in distal bile duct carcinomas assessed in 33 subtotal pancreatoduodenectomy specimens. T.M. van Gulik, A. Umezawa, A. Bosma ‘, K. Koyama, G.J.A. Offerhaus i, H. Obertop, D.J. Gouma. Departments of Surgery and I Pathology, Academic Medical Centre, Amsterdam, NetherIan&
The prognostic value of tumour DNA content and the cell-cycle-associated antigen Ki-67 were studied in 33 patients who had undergone subtotal pancreatoduodenectomy for distal bile duct carcinoma (DBDC). The results of Ki-67 expression and DNA content were related to survival time. The surgical specimens of 33 patients with DBDC were examined after pancreatoduodenectomy. Of each case, 1-5 samples were selected from the tumour area in the tissue blocks. As controls, 8 samples of non-tumour areas from 16 of the DBDC cases were analyzed. For assessmentof nuclear DNA content, 50 pm sections of the tumour were processed into a nuclear suspension stained with propidium iodide. DNA content was measured with a flowcytometry FACScan and the data of 20000 nuclei of each sample were analyzed. According to the DNA histograms, tumour ploidy was classified as diploid or aneuploid. Ki-67 was detected by immunohistochemical staining of 4 pm tumour sections with MIB-1 (avidin-biotin-peroxidase technique). MIB-1 expression was recorded as the ratio of positive nuclei (%) in 1000 tumour cells (MIB-1 index). The mean MIB-1 index was determined for each patient. Of 33 patients (age 31-73 yr mean 60 yrl, a total of 120 samples were examined after resection of DBDC. 19 patients had a radical resection; 14 resections were micro-