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Purpose: Trauma mechanisms and patterns of severe injuries during the Estonian independence have not been evaluated. The aim of the study was to compare the incidence and outcomes of severe injuries between time periods of early independence from the Soviet Union and the present time. Methods: After the ethics review board approval, all adult trauma admissions to major trauma facilities in 1993-1994 and 2013-2014 with Injury Severity Score >15 were identified. Data collection included demographics, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes included incidence of penetrating trauma, hospital length of stay (HLOS), and in-hospital complications. Primary outcome difference comparing the two time segments was determined using logistic regression analysis. Results: A total of 1064 patients were included, 593 and 471 from 1993-1994 to 2013-2014, respectively. Incidence of penetrating trauma during 1993-1994 was 11.1 % and in 2013-2014 at 6.4 % ( p = 0.007). Gunshot injuries constituted 62.1 and 23.3 % of all penetrating trauma in 1993-1994 and 2013-2014, respectively ( p < 0.001). The overall mean HLOS was 15.5 ± 19.8 days and did not differ between the periods. The rate of adjusted complications showed a trend for a decreased incidence (adj. p = 0.064). Adjusted mortality rate was 50.3 and 16.4 % during 1993-1994 and 2013-2014, respectively (adj. OR 7.01; 95 % CI 4.69-10.47; p < 0.001). Conclusions: Effective law enforcement, gun control, evolution of trauma system, and reduction of interpersonal violence have all contributed to a significant decrease in penetrating trauma incidence and all-cause adjusted mortality during the 20 years of Estonian independence. [ABSTRACT FROM AUTHOR]

Purpose: Emergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group., Methods: This retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression., Results: Of the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89-8.20), 5 (5.86, 95% CI 2.87-11.97), and 6-7 (14.17, 95% CI 7.33-27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS., Conclusion: Our results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Conflict of interest: None., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: The purpose of this study is to investigate noninferiority of postoperative oral administration of antibiotics in complicated appendicitis., Background: Recent investigations have used exclusively intravenous administration of antibiotics when comparing outcomes of postoperative antibacterial therapy in complicated appendicitis. We hypothesized that oral antibacterial treatment results in noninferior outcomes in terms of postoperative infectious complications as intravenous treatment., Methods: In this pilot, open-label, prospective randomized trial, all consecutive adult patients with complicated appendicitis, including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between November 2020 and January 2023, were randomly allocated to 24-hour intravenous administration of antibiotics versus 24-hour oral administration of antibiotics after appendectomy. Primary outcomes included 30-day postoperative complications per Comprehensive Complication Index. The secondary outcome was hospital length of stay. Follow-up analysis at 30 days was conducted per intention to treat and per protocol. The study was registered at ClinicalTrials.gov (NCT04947748)., Results: A total of 104 patients were enrolled, with 51 and 53 cases allocated to the 24-hour intravenous and the 24-hour oral treatment group, respectively. Demographic profile and disease severity score for acute appendicitis were similar between the study groups. There were no significant differences between the study groups in terms of 30-day postoperative complications. Median Comprehensive Complication Index did not differ between the study groups. Hospital length of stay was similar in both groups., Conclusions: In the current pilot randomized controlled trial, the 24-hour oral antibiotic administration resulted in noninferior outcomes when compared with the 24-hour intravenous administration of antibiotics after laparoscopic appendectomy in complicated appendicitis., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account., Methods: In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model., Results: The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65 years. However, in younger patients, this effect was less marked than in the elderly., Conclusion: Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Objectives: The aim of the study was to evaluate voice and swallowing function before thyroid surgery and to explore the possible role of thyroid enlargement and laryngopharyngeal reflux (LPR)., Methods: We conducted a prospective study of patients who underwent hemi- or total thyroidectomy ( n  = 118) and compared the results with patients of laparoscopic cholecystectomy ( n  = 110). All subjects underwent videolaryngostroboscopy, filled in subjective evaluations of voice, swallowing and reflux complaints. Acoustic voice analysis (AVA), maximum phonation time (MPT) and perceptual voice evaluation were conducted., Results: We found no difference in voice quality between study and control group, neither in subjective complaints nor in AVA or perceptual evaluation. We did find indicative signs of minor laryngeal changes in thyroid group. Swallowing Impairment Score (SIS) revealed worse swallowing function in thyroid patients ( p  = 0.0006). Comparison of Reflux Symptom Index (RSI) scores revealed that thyroid group patients have higher values compared to control group ( p  = 0.006). Nevertheless, Reflux Finding Score (RFS) showed identical scores in both groups ( p  = 0.220). In thyroid group there was a strong positive correlation between RSI and SIS (ρ = 0.641), but no correlation between RFS and SIS (ρ = -0.002). In addition, we found a weak positive correlation between thyroid weight and RFS (ρ = 0.379)., Conclusions: Changes in laryngeal area caused by thyroid disorders do not lead to subjective but indicate slight objective disturbances in voice quality. We detected a decline in swallowing quality within thyroid patients. Higher RSI scores and a positive correlation between RFS and thyroid weight, indicate a possible role of thyroid gland in LPR.

Purpose: Iatrogenic bile duct injuries (BDI) following laparoscopic cholecystectomy (LC) result in major morbidity and incidental mortality. There is a lack of unselected population-based cross-sectional studies on the incidence, management, and outcomes of BDI. We hypothesised that due to improved imaging capabilities and collective laparoscopic experience, BDI incidence will decrease over the study period and compare favourably with contemporary literature., Methods: After IRB approval, all cholecystectomies performed at national public healthcare facilities between 2008 and 2018 were retrospectively reviewed. BDIs were classified according to the Strasberg classification. The follow-up period ranged from 36 to 156 months., Results: A total of 241 BDIs of 29,739 laparoscopic cholecystectomies (LC) resulted in overall, minor, and major BDI incidence rates of 0.81%, 0.68%, and 0.13%, respectively. No significant decline in the BDIs was noted during the study period. Drainage in 66 (42.6%) and cases ERCP stent placement in 65 (41.9%) cases were equally used in Strasberg A lesions. Suture over T-tube in 20 (42.6%) and ERCP stenting in 19 (40.4%) cases were used in Strasberg D lesions. Roux-en-Y hepatojejunostomy (RYHJ) was performed in 30 (88.9%) of Strasberg E lesions. There were 27 (11.2%) patients with long-term bile duct strictures after BDI management. The overall mortality rate of BDIs and subsequent complications was 4.6%., Conclusions: The annual incidence of iatrogenic bile duct injury over an 11-years' time after laparoscopic cholecystectomy did not decline significantly. We noted an overall BDI incidence of 0.81% comprising of 0.68% minor and 0.13% of major lesions. The management of injuries met contemporary guidelines with comparable outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Laparoscopic appendectomy (LA) is the standard treatment for acute appendicitis (AA) in general population. However, the safety of LA during pregnancy has remained a matter of debate. The purpose of this study was to compare surgical and obstetrical outcomes in pregnant women who underwent LA vs. open appendectomy (OA) for AA. We hypothesized that LA results in improved surgical and obstetric outcomes during pregnancy., Methods: Using a nationwide claim-based database in Estonia, a retrospective review of all cases of pregnant women undergoing OA or LA for AA from 2010 to 2020 was performed. Patient characteristics, surgical and obstetrical outcomes were analyzed. Primary outcomes were preterm delivery, fetal loss and perinatal mortality. Secondary outcomes included operative time, hospital length of stay (HLOS) and 30-day postoperative complications., Results: Overall, 102 patients were included of whom 68 (67%) underwent OA and 34 patients (33%) LA, respectively. Patients in LA cohort had a significantly shorter length of pregnancy in terms of gestational weeks when compared to OA cohort (12 weeks versus 17 weeks, p = 0.002). Most of the patients in their 3 rd trimester pregnancy were subjected to OA. Operative time in LA cohort was shorter than in OA cohort (34 min. versus 44 min., p = 0.038). HLOS in LA cohort was shorter than in OA cohort (2.1 days versus 2.9 days, p = 0.016). There were no differences between OA and LA cohorts in terms of surgical complications or obstetrical outcomes., Conclusions: Laparoscopic appendectomy for acute appendicitis was associated with a significantly shorter operative time and a shorter hospital length of stay while open and laparoscopic appendectomy cohorts experienced comparable obstetrical outcomes. Our findings support the laparoscopic approach for acute appendicitis in pregnancy., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification., Aim: The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up., Methods: After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP., Results: We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency., Conclusion: The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient's needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: The Partington-Rochelle pancreaticojejunostomy (PJ) is an essential management option for patients with chronic pancreatitis (CP) associated with intractable pain and a dilated pancreatic duct (PD). Wide ductotomy and long PJ (L-PJ) have been advocated as the standard of care to ensure full PD decompression. However, the role of short PJ (S-PJ) in a uniformly dilated PD has not yet been evaluated., Aim: To evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP., Methods: A retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ. The length of the PJ was adapted to anatomical alterations in PD. A comparison was made of S-PJ (< 50 mm) for uniformly dilated PD and L-PJ (50-100 mm) in the setting of multiple PD strictures, calcifications and dilatations. We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes. The primary outcomes were pain relief and quality of life (QOL); the secondary outcomes were perioperative characteristics, body weight, patients' satisfaction with treatment, and readmission rate due to CP., Results: Overall, 91 patients underwent side-to-side PJ for CP, including S-PJ in 46 patients and L-PJ in 45 patients. S-PJ resulted in better perioperative outcomes: Significantly shorter operative time (107.5 min vs 134 min), lower need for intraoperative (0% vs 15.6%) and total (2.2% vs 31.1%) blood transfusions, and lower rate of perioperative complications (6.5% vs 17.8%). We noted no significant difference in pain relief, improvement in QOL, body weight gain, patients' satisfaction with surgical treatment, or readmission rate due to CP., Conclusion: Based on our data, in the setting of a uniformly dilated PD, S-PJ provides adequate decompression of the PD. As the clinical outcomes following S-PJ are not inferior to those of L-PJ, S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD., Competing Interests: Conflict-of-interest statement: The authors declare no conflicts of interest., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Vascular surgery patients have reduced tissues` blood supply, which may lead to mitochondrial dysfunction and accumulation of acylcarnitines (ACs). It has been suggested that remote ischaemic preconditioning (RIPC) has its organ protective effect via promoting mitochondrial function. The aim of this study was to evaluate the effect of RIPC on the profile of ACs in the vascular surgery patients., Methods: This is a randomised, sham-controlled, double-blinded, single-centre study. Patients undergoing open surgical repair of abdominal aortic aneurysm, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited non-consecutively. The RIPC protocol consisting of 4 cycles of 5 min of ischaemia, followed by 5 min of reperfusion, was applied. A blood pressure cuff was used for RIPC or a sham procedure. Blood was collected preoperatively and approximately 24 h postoperatively. The profile of ACs was analysed using the AbsoluteIDQp180 kit (Biocrates Life Sciences AG, Innsbruck, Austria)., Results: Ninety-eight patients were recruited and randomised into the study groups and 45 patients from the RIPC group and 47 patients from the sham group were included in final analysis. There was a statistically significant difference between the groups regarding the changes in C3-OH ( p  = 0.023)-there was a decrease (- 0.007 µmol/L, ± 0.020 µmol/L, p  = 0.0233) in the RIPC group and increase (0.002 µmol/L, ± 0.015 µmol/L, p  = 0.481) in the sham group. Additionally, a decrease from baseline to 24 h after surgery ( p  < 0.05) was detected both in the sham and the RIPC group in the levels of following ACs: C2, C8, C10, C10:1, C12, C12:1, C14:1, C14:2, C16, C16:1, C18, C18:1, C18:2. In the sham group, there was an increase ( p  < 0.05) in the levels of C0 (carnitine) and a decrease in the level of C18:1-OH. In the RIPC group, a decrease ( p  < 0.05) was noted in the levels of C3-OH, C3-DC (C4-OH), C6:1, C9, C10:2., Conclusions: It can be concluded that RIPC may have an effect on the levels of ACs and might therefore have protective effects on mitochondria in the vascular surgery patients. Further larger studies conducted on homogenous populations are needed to make more definite conclusions about the effect of RIPC on the metabolism of ACs., Trial Registration: ClinicalTrials.gov database, NCT02689414. Registered 24 February 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02689414., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Objective: The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on preventing the leakage of cardiac damage biomarkers in patients undergoing vascular surgery., Methods: This is a randomised, sham-controlled, double-blinded, single-centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited non-consecutively. The RIPC protocol consisting of 4 cycles of 5 minutes of ischaemia, followed by 5 minutes of reperfusion, was applied. A RIPC or a sham procedure was performed noninvasively along with preparation for anaesthesia. High sensitivity troponin T level was measured preoperatively and 2, 8 and 24 hours after surgery and pro b-type natriuretic peptide was measured preoperatively and 24 hours after surgery., Results: There was significantly higher leakage of high sensitivity troponin T (peak change median 2 ng/L, IQR 0.9-6.2 ng/L vs 0.6 ng/L, IQR 0.7-2.1 ng/L, p = .0002) and pro b-type natriuretic peptide (change median 144 pg/mL, IQR 17-318 pg/mL vs 51 pg/mL, IQR 12-196 pg/mL, p = .02) in the sham group compared to the RIPC group., Conclusion: RIPC reduces the leakage of high sensitivity troponin T and pro b-type natriuretic peptide. Therefore, it may offer cardioprotection in patients undergoing non-cardiac vascular surgery. The clinical significance of RIPC has to be evaluated in larger studies excluding the factors known to influence its effect., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Perioperative kidney injury affects 12.7% of patients undergoing lower limb revascularisation surgery. Remote ischaemic preconditioning (RIPC) is a potentially protective procedure against organ damage and consists of short nonlethal episodes of ischaemia. The main objective of this substudy was to evaluate the effect of RIPC on kidney function, inflammation, and oxidative stress in patients undergoing open surgical lower limb revascularisation. Materials and Methods . This is a subgroup analysis of a randomised, sham-controlled, double-blinded, single-centre study. A RIPC or a sham procedure was performed noninvasively along with preparation for anaesthesia in patients undergoing open surgical lower limb revascularisation. The RIPC protocol consisted of 4 cycles of 5 minutes of ischaemia, with 5 minutes of reperfusion between every episode. Blood was collected for analysis preoperatively, 2, 8, and 24 hours after surgery, and urine was collected preoperatively and 24 hours after surgery., Results: Data of 56 patients were included in the analysis. Serum creatinine, cystatin C, and beta-2 microglobulin increased, and eGFR decreased across all time points significantly more in the sham group than in the RIPC group ( p = 0.021, p = 0.021, p = 0.021, p = 0.021, p = 0.021., Conclusions: Our finding of reduced release of kidney injury biomarkers may indicate the renoprotective effect of RIPC in patients undergoing open surgical lower limb revascularisation. The trial is registered with ClinicalTrials.gov NCT02689414., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Teele Kasepalu et al.)

Objectives: The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on arterial stiffness in patients undergoing vascular surgery., Methods: This was a randomised, sham controlled, double blind, single centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited. A RIPC or a sham procedure was performed, using a blood pressure cuff, along with preparation for anaesthesia. The RIPC protocol consisting of four cycles of 5 min of ischaemia, followed by 5 min of reperfusion was applied. Arterial stiffness and haemodynamic parameters were measured pre-operatively and 20-28 h after surgery. Two primary outcomes were selected: augmentation index and pulse wave velocity., Results: Ninety-eight patients were randomised. After dropouts 44 and 46 patients were included in the RIPC and sham groups, respectively. Both groups were comparable. There were no statistically significant differences in augmentation index (p = .8), augmentation index corrected for heart rate of 75 beats per minute (p = .8), pulse wave velocity (p = .7), large artery elasticity indices (p = .8), small artery elasticity indices (p = .6), or mean arterial pressure (p = .7) changes between the RIPC and sham groups. There occurred statistically significant (p ≤ .01) improvement in augmentation index (-5.8% vs. -5.5%), augmentation index corrected for a heart rate of 75 beats per minute (-2.5% vs. -2%), small artery elasticity indices (0.7 mL/mmHg × 100 vs. 0.9 mL/mmHg × 100), and mean arterial pressure post-operatively in both the RIPC and the sham groups (change median values in RIPC and sham groups, respectively)., Conclusions: RIPC had no significant effect on arterial stiffness, but there was significant improvement in arterial stiffness after surgery in both groups. Arterial stiffness and haemodynamics may be influenced by surgery or anaesthesia or oxidative stress or all factors combined. Further studies are needed to clarify these findings. CLINICALTRIALS.GOV: NCT02689414., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial., Methods: After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol., Results: A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005)., Conclusion: In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective., Level of Evidence: Therapeutic Level IV.

Background: The primary aim of the present study was to evaluate whether usage of self-gripping mesh in open inguinal hernia repair, compared with standard Lichtenstein repair with sutured mesh, could result in a decreased rate of chronic pain. The secondary aim was to evaluate the rate of foreign body feeling, hernia recurrence, and risk factors for chronic pain development., Methods: The patients were randomized into two study groups: the OLP group received Optilene LP mesh and the PPG group received self-gripping Parietex ProGrip mesh. Pain scores were measured on a visual analog scale. Foreign body feeling was registered as a yes-no question., Results: A total of 75 patients in the OLP group and 70 patients in the PPG group were analyzed at 3-y follow-up. According to the primary endpoint, of the patients, 41.3% in the OLP group and 28.6% in the PPG group experienced pain during different activities at 3-y follow-up (P = 0.108). The risk ratio for the primary endpoint was 1.45, 95% confidence interval (CI): 0.91, 2.29 (P = 0.114). Analysis demonstrated an increased rate of chronic pain in patients with severe preoperative pain (odds ratio: 2.47; 95% CI: 1.08, 5.65; P = 0.032) and severe early postoperative pain (odds ratio: 4.29; 95% CI: 1.82, 10.10; P = 0.001). Overall, of the patients, 28% in the OLP group and 21.4% in the PPG group reported foreign body feeling at the operation site at 3-y follow-up (P = 0.360). There were two hernia recurrences in the OLP group and none in the PPG group (P = 0.168)., Conclusions: We failed to demonstrate the advantages of self-gripping mesh in terms of chronic pain and foreign body feeling. However, usage of self-gripping mesh does not increase hernia recurrence rate. Considering the higher price of self-gripping mesh, analysis of cost-effectiveness is needed to prove its advantage and to justify its usage. As severe early postoperative pain is a risk factor for chronic pain development, a very effective postoperative pain control strategy is important after inguinal hernioplasty to reduce the rate of chronic pain., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Despite significant progress in surgery, controversy persists about timing of appendectomy. Objective of this prospective observational study was to determine associations between time interval from onset of symptoms in appendicitis to appendectomy and postoperative complications., Methods: After institutional review board approval, all adult consecutive patients subjected to emergency appendectomy between 1/9/2013 and 1/12/2014 were prospectively enrolled. Data collection included demographics, open vs. laparoscopic appendectomy, comprehensive complication index (CCI), and 30-day follow-up. To determine time-dependent associations between delay of surgery and complications all patients were stratified into subgroups based on 12-h time intervals from onset of abdominal pain to surgery. Primary outcome was complications per CCI in correlation to delay from symptoms to appendectomy. Secondary outcomes included duration of surgery, hospital length of stay (HLOS), and incidence of complication within 30-day follow-up., Results: A total of 266 patients with a mean age of 35.4 ± 14.8 years met inclusion criteria. Overall, 83.1 % of patients were subjected to laparoscopic appendectomy. Delay to surgery in 12-h increments showed stepwise-adjusted increase in complications per CCI (adj. P = 0.037). Also, delay to appendectomy increased significantly duration of surgery and HLOS, respectively (adj. P < 0.001 and adj. P < 0.001). Overall, 5.7 % of patients developed a surgical site infection after hospital discharge., Conclusion: Extended time interval from the onset of initial symptoms to appendectomy is associated with increased complications per CCI, duration of surgery, and HLOS in acute appendicitis. Prompt appendectomy in acute appendicitis is warranted.

Following the widespread use of mesh repairs, recurrence rates after inguinal hernia surgery have become acceptable and focus has shifted from recurrence to chronic pain. Although pain can be controlled with analgesics, chronic postsurgical pain is a major clinical problem, which can significantly influence the patient's quality of life. The rate of chronic pain after inguinal hernia mesh repair can reach 51.6%. The reasons for posthernioplasty chronic pain are often unclear. It has been linked to nerve injury and nerve entrapment, but there is also association between the rate of chronic pain and the type of mesh used for hernia repair. As there are >160 meshes available in the market, it is difficult to choose a mesh whose usage would result in the best outcome. Different mesh characteristics have been studied, among them weight of mesh has probably gained the most attention. The choice of adequate therapy for chronic groin pain after inguinal hernia repair is controversial. The European Hernia Society recommends that a multidisciplinary approach at a pain clinic should be considered for the treatment of chronic postoperative pain. Although surgical treatment of chronic posthernioplasty pain is limited because of the lack of relevant research data, resection of entrapped nerves, mesh removal in the case of mesh related pain or removal of fixation sutures can be beneficial for the patient with severe pain after inguinal hernia surgery. One drawback of published studies is the lack of consensus over definition of chronic pain, which makes it complicated to compare the results of different studies and to conduct meta-analyses and systematic reviews. Therefore, a uniform definition of chronic pain and its best assessment methods should be developed in order to conduct top quality multicenter randomized trials. Further research to develop meshes with optimal parameters is of vital importance and should be encouraged.

Background: The primary aim of the present study was to evaluate whether usage of self-gripping mesh in open inguinal hernia repair, compared with standard Lichtenstein repair with sutured mesh, could result in a decreased rate of chronic pain at 6-mo follow-up. The secondary outcome was to evaluate foreign body feeling and the quality of life after inguinal hernia repair., Methods: The patients were randomized into two study groups as follows: the OLP group received Optilene LP mesh and the PPG group received self-gripping Parietex ProGrip mesh. Pain scores were measured on a visual analog scale. Foreign body feeling was registered as a yes or no question. Quality of life was evaluated using the Medical Outcome Study Short-Form 36 questionnaire., Results: A total of 75 patients in the OLP group and 70 patients in the PPG group were included in the analysis. According to the primary end point, 45.3% and 31.4% of the patients in the OLP group and PPG group experienced pain during different activities at 6-mo follow-up, respectively (P = 0.092). Per secondary end point, 22.7% in the OLP group and 40% in the PPG group reported foreign body feeling at the operation site at 6-mo follow-up (P = 0.031, risk ratio 0.57, 95% confidence interval 0.29-1.07). There were no significant differences in any domain of quality of life according to the Short-Form 36 questionnaire between the two study groups at 6-mo follow-up, except for the social functioning domain (P = 0.035). In the OLP group, the quality of life scores improved significantly after operation in all domains except for general health and mental health. In the PPG group, the quality of life scores improved significantly after operation in the domains of bodily pain, physical functioning, and physical role., Conclusions: Self-gripping mesh compared with standard Lichtenstein operation has no advantages in reducing chronic pain 6-mo after surgery. The rate of foreign body feeling was higher in the self-gripping mesh group. Scores of bodily pain, physical functioning, and physical role improved significantly in both study groups after hernia surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The primary aim of this study was to determine whether mesh pore size influences the rate of chronic pain at 6-mo follow-up. Another aim was to evaluate the rate of foreign body feeling and quality of life after inguinal hernia repair., Methods: The patients were randomized into two study groups: the UM group received Ultrapro mesh (pore size 3-4 mm) and the OM group received Optilene LP mesh (pore size 1 mm). Pain scores were measured on a visual analog scale. The feeling of a foreign body was a yes-or-no question. Quality of life was evaluated using the Medical Outcome Study Short-Form-36 questionnaire., Results: A total of 67 patients in the UM group and 67 patients in the OM group were investigated 6 mo after operation. There were no significant differences in the results of the pain questionnaire between the study groups. Of the patients, 46.3% in the UM group reported pain during different activities at 6-mo follow-up versus 34.3% in the OM group (P = 0.165). The feeling of a foreign body in the inguinal region was experienced by 47.8% of the patients in the UM group and by 31.3% of the patients in the OM group at 6-mo follow-up (P = 0.052; risk ratio 1.52, 95% confidence interval: 1.00-2.37). There were no significant differences in the quality of life according to the Short-Form 36 questionnaire between the two study groups at 6-mo follow-up. In both study groups, the quality of life scores improved after operation by most dimensions., Conclusions: Differences in mesh pore size did not influence the rate of chronic pain. Although there was a trend for higher rate of foreign body feeling in the study group where a mesh with larger pores was used, we failed to find an explanation for this. The pore size of meshes investigated in this study did not affect the quality of life after inguinal hernia repair. Considering the fact that the quality of life improved significantly after operation, elective repair of symptomatic inguinal hernias should be undertaken as promptly as possible., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The aim of this prospective study was to report our results after thyroidectomy for Graves' disease. In addition, the relationship between the thyroid remnant and postoperative thyroid function was studied., Material and Methods: Forty-nine consecutive patients were operated on for Graves' disease. The indications for surgery were persistent or recurrent hyperthyroidism after medical treatment in 34 patients (69.4%), mechanical symptoms due to a large goiter in 7 (14.3%), increased ophthalmopathy in 7 (14.3%), and allergy to antithyroid medications in 1 patient (2.0%). Total thyroidectomy (TT) was performed in 28 and subtotal thyroidectomy (STT) in 21 patients. Follow-up lasted 24 to 70 months., Results: There was no statistically significant difference in the rate of postoperative complications comparing TT and STT. The patients who underwent TT had no recurrence during a mean follow-up of 47 months. After STT, with the mean weight of the thyroid remnant 3.0+/-1.0 g, there was no relapse of Graves' disease during a mean follow-up of 52 months. After STT, postoperative hypothyroidism developed in 14 patients (66.7%); 7 patients (33.3%) remained euthyroid during follow-up. Comparison of the euthyroid patients and the hypothyroid patients revealed no difference in the weight of the remnant (3.3 g vs. 2.8 g), but a statistically significant difference occurred in the weight of the resected gland (61.0 g vs. 94.4 g, P=0.026) and in the proportion of the remnant (5.6% vs. 3.3%, P=0.030)., Conclusions: Both TT and STT are safe procedures regarding postoperative complication rate. STT with the thyroid remnant of about 3 g allows to permanently cure hyperthyroidism ensuring the euthyroid state in a significant proportion of patients. Postoperative thyroid function after STT is best predicted by the proportion of the remnant.

Background and Aims: The clinical value of infiltration of wounds with local anaesthetics (LA) and their intraperitoneal application for treating pain after laparoscopic cholecystectomy (LC) still remain controversial. In this study the use of intraincisional and intraperitoneal LA was evaluated., Material and Methods: Eighty patients were prospectively randomised into four groups. In the control group (G1) LA was not used. In G2 all wounds were infiltrated with 80 ml of 0.125 % Bupivacaine containing 5 mg of Phenylephrine. In G3 the wounds were infiltrated with 80 ml of 0.9 % NaCl. In G4, in addition to wound infiltration with Bupivacaine/Phenylephrine, 200 ml of normal saline, containing 0.15 % of Lidocaine, was left intraperitoneally under the right diaphragm. Postoperative abdominal and shoulder pain scores were recorded on a visual analogue scale (VAS) during 24 hours after LC. Narcotic analgesic consumption was also recorded., Results: The mean abdominal pain scores were significantly lower in G2, compared with G3, 3 to 24 hours after operation, compared with G4, 3 to 6 hours and compared with G1, 3 to 24 hours (except at hour 12) after surgery. The incidence of shoulder pain was 30 %. There were no significant differences in the mean shoulder pain scores between the groups. The mean dosage and the total amount of Pethidine at 24 hours were significantly lower in G2 compared with G1., Conclusions: Intraincisional infiltration with a Bupivacaine/Phenylephrine mixture reduces significantly abdominal postoperative pain (for up to 24 h) and narcotic analgesic consumption after LC. An intraperitoneal subdiaphragmatic dilute solution of Lidocaine was not effective in reducing overall pain and shoulder pain after LC.

Aim of the Study: The aim of this study was to report our results and to make an attempt to define the possible role of Sugiura procedure in the treatment of variceal bleeding., Material and Methods: From January 1979 to December 1997, 39 patients with portal hypertension and acute variceal bleeding (17 patients) or previous variceal bleeding (22 patients) underwent Sugiura procedure. Operations were performed in two stages. When performed in an emergency situation (17 patients) thoracic operation was performed first. In elective cases abdominal operation was usually preferred. Complete two-stage operation was performed in 16 patients. Twenty-three patients did not undergo the second stage because of early postoperative death, deterioration of condition or refusal. There were 17 men and 22 women, aged 41.7 +/- 18.3 years (range 8-71 years). According to the Child--Turcotte classification of hepatic function there were 23 Child class A, 13 Child class B and 3 Child class C patients., Summary of Results: Overall operative mortality was 10.3% (4 deaths per 39 patients with 54 operations), mortality in an emergency situation was 17.6% (3 deaths per 17 patients) and in elective cases 4.3% (1 death per 22 patients with 37 operations). Variceal rebleeding occurred in 4 survivors (11.4%) at an average follow-up of 6.1 +/- 4.3 years. Survival rate was 84.6% at 1 year, 71.8% at 5 years and 64.1% at 10 years., Conclusions: Sugiura operation carries low operative risk in an elective situation and results in an effective prevention of recurrent variceal bleeding.

Objective: To evaluate the type, timing and number of vascular reconstructions that preceded amputation; to compare the characteristics of amputees who had had reconstructions with those of amputees who had not, and to compare the results of amputation., Design: Retrospective study of case notes., Setting: University hospital, Sweden., Subjects: All 219 patients who underwent amputation between 1987 and 1992., Main Outcome Measures: Incidence of amputations; presenting features, and type and results of vascular reconstructions., Results: The number of amputations decreased after 1988, and that of vascular reconstructions increased. 56 of the 99 who had amputations after reconstruction (57%) had had their last procedure within a month. This group had had a mean of three operations, had worse run-off as assessed by angiography, and 2 of them (5%) had amputations after failed suprainguinal reconstruction for claudication alone. 68 of the total (31%) had amputations without first being assessed by a vascular surgeon. 52 (24%) required reamputation., Conclusion: Better objective methods are needed for the assessment of patients before primary as well as secondary vascular reconstructions. All patients should be seen by a vascular surgeon before amputation is recommended.

The authors have performed Sugiura's operation since 1979 in 17 patients in bleeding from varicose veins of the esophagus. The patient's ages ranged from 14 to 69 years. Portal hypertension was caused by hepatic cirrhosis in 14 and extrahepatic blockade in 3 patients. Emergency operations were carried out in 12 and planned interventions on 5 patients. The 3 patients with extrahepatic blockade and 7 patients with Groups A and B hepatic cirrhosis (according to Child's classification) recovered. Among 7 patients with group C 4 died (total mortality, 24%). Recurrent bleeding was not encountered in long-term postoperative follow-up periods of up to 10 years.