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  • 1. Acosta, S.
    et al.
    Bjarnason, T.
    Petersson, U.
    Pålsson, B.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Svensson, M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Djavani, Khatereh
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 5, p. 735-743Article in journal (Refereed)
    Abstract [en]

    Background: Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. Methods: This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. Results: Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76.6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8.55, 95 per cent confidence interval 1.47 to 49.72; P = 0.017). The in-hospital mortality rate was 29.7 per cent. Age (OR 1.21, 1.02 to 1.43; P = 0.027) and failure of fascial closure (OR 44.50, 1.13 to 1748.52; P = 0.043) were independently associated with in-hospital mortality. Conclusion: The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia.

  • 2. Acosta, S.
    et al.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Modern treatment of acute mesenteric ischaemia2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 1, p. E100-E108Article, review/survey (Refereed)
    Abstract [en]

    Background: Diagnosis of acute mesenteric ischaemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischaemia may be treated with urgent intestinal revascularization.

    Methods: This was a review of modern treatment strategies for acute mesenteric ischaemia.

    Results: Endovascular therapy has become an important alternative, especially in patients with acute thrombotic superior mesenteric artery (SMA) occlusion, where the occlusive lesion can be recanalized either antegradely from the femoral or brachial artery, or retrogradely from an exposed SMA after laparotomy, and stented. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. Laparotomy is needed to evaluate the extent and severity of visceral organ ischaemia, which is treated according to the principles of damage control surgery.

    Conclusion: Modern treatment of acute mesenteric ischaemia involves a specialized approach that considers surgical and, increasingly, endovascular options for best outcomes. Endovascular increasingly important

  • 3.
    Acosta, S.
    et al.
    Lund Univ, Dept Clin Sci, Vasc Ctr, Malmo, Sweden..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 2, p. E75-E84Article, review/survey (Refereed)
    Abstract [en]

    BackgroundIndications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds. MethodsA PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms wound infection', abdominal aortic aneurysm (AAA)', fasciotomy', vascular surgery' and NPWT' or VAC'. ResultsNPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0-10 and 83-100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96-100 per cent) and low risk of graft infection (0-7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT. ConclusionNPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.

  • 4.
    Acosta, Stefan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Nilsson, Torbjörn
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    D-dimer testing in patients with suspected acute thromboembolic occlusion of the superior mesenteric artery2004In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 91, no 8, p. 991-994Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    There is no accurate non-invasive method available for the diagnosis of acute thromboembolic occlusion of the superior mesenteric artery (SMA). The aim of this study was to assess the diagnostic properties of the fibrinolytic marker D-dimer.

    METHODS:

    From September 2000 to April 2003 consecutive patients aged over 50 years admitted to hospital with acute abdominal pain were studied. Patients with possible acute SMA occlusion at presentation had blood samples taken within 24 h of the onset of the pain for analysis of D-dimer, plasma fibrinogen, activated partial thromboplastin time, prothrombin time and antithrombin. The value of D-dimer testing to diagnose SMA occlusion was assessed by means of likelihood ratios.

    RESULTS:

    Nine of 101 patients included had acute SMA occlusion. The median D-dimer concentration was 1.6 (range 0.4-5.6) mg/l, which was higher than that in 25 patients with inflammatory disease (P = 0.007) or in 14 patients with intestinal obstruction (P = 0.005). The combination of a D-dimer level greater than 1.5 mg/l, atrial fibrillation and female sex resulted in a likelihood ratio for acute SMA occlusion of 17.5, whereas no patient with a D-dimer concentration of 0.3 mg/l or less had acute SMA occlusion.

    CONCLUSION:

    D-dimer testing may be useful for the exclusion of patients with suspected acute SMA occlusion.

  • 5.
    Anandavadivelan, P.
    et al.
    Karolinska Inst, Karolinska Univ Hosp, Dept Mol Med & Surg, Surg Care Sci, 2nd Floor,Norra Stationsgatan 67, S-17176 Stockholm, Sweden..
    Wikman, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Reproductive Health.
    Johar, A.
    Karolinska Inst, Karolinska Univ Hosp, Dept Mol Med & Surg, Surg Care Sci, 2nd Floor,Norra Stationsgatan 67, S-17176 Stockholm, Sweden..
    Lagergren, P.
    Karolinska Inst, Karolinska Univ Hosp, Dept Mol Med & Surg, Surg Care Sci, 2nd Floor,Norra Stationsgatan 67, S-17176 Stockholm, Sweden..
    Impact of weight loss and eating difficulties on health-related quality of life up to 10 years after oesophagectomy for cancer2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 4, p. 410-418Article in journal (Refereed)
    Abstract [en]

    Background: Severe weight loss is experienced by patients with eating difficulties after surgery for oesophageal cancer. The aim of this prospective cohort study was to asssess the influence of eating difficulties and severe weight loss on health-related quality of life (HRQoL) up to 10years after oesophagectomy.

    Methods: Data on bodyweight and HRQoL were collected at 6months, 3, 5 and 10years in patients who underwent surgery for oesophageal cancer in Sweden between 2001 and 2005. Exposures were percentage weight loss, and eating difficulties defined by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-OES18 questionnaire. Outcomes were HRQoL scores from the EORTC QLQ-C30 questionnaire. Repeated-measures ANOVA, adjusting for potential confounders, was used to assess the association between eating difficulties and weight loss (4 exposure groups) and HRQoL scores at each time point. Mean score differences (MDs) between time points or exposure groups were defined as clinically relevant in accordance with evidence-based interpretation guidelines.

    Results: In total, 92 of 104 10-year survivors (885 per cent) responded to the questionnaires. Weight loss was greatest within 6months of surgery. Patients with eating difficulties with or without weight loss reported clinically and statistically significantly worsened HRQoL in almost all aspects. The largest MD was seen between 5 and 10years after surgery for global quality of life, physical, role and social function (MD -22 to -30), as well for fatigue, nausea, dyspnoea, insomnia, appetite loss and diarrhoea (MD 24-36).

    Conclusion: Eating difficulties are associated with deterioration in several aspects of HRQoL up to 10years after surgery for oesophageal cancer.

  • 6. Andersson, Y.
    et al.
    Frisell, J.
    Sylvan, M.
    de Boniface, J.
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Causes of false-negative sentinel node biopsy in patients with breast cancer2013In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 100, no 6, p. 775-783Article in journal (Refereed)
    Abstract [en]

    Background: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection as the routine staging procedure in clinically node-negative breast cancer. False-negative SLN biopsy results in misclassification and may cause undertreatment of the disease. The aim of this study was to investigate whether serial sectioning of SLNs reveals metastases more frequently in patients with false-negative SLNs than in patients with true-negative SLNs. Methods: This was a case-control study. Tissue blocks from patients with false-negative SLNs, defined as tumour-positive lymph nodes excised at completion axillary dissection or a subsequent axillary tumour recurrence, were reassessed by serial sectioning and immunohistochemical staining. For each false-negative node, two true-negative SLN biopsies were analysed. Tumour and node characteristics in patients with false-negative SLNs were compared with those in patients with a positive SLN by univariable and multivariable regression analysis. Results: Undiagnosed SLN metastases were discovered in nine (18 per cent) of 50 patients in the false-negative group and in 12 (11.2 per cent) of 107 patients in the true-negative group (P = 0.245). The metastases were represented by isolated tumour cells in 14 of these 21 patients. The risk of a false-negative SLN was higher in patients with hormone receptor-negative (odds ratio (OR) 2.50, 95 per cent confidence interval 1.17 to 5.33) or multifocal tumours (OR 3.39, 1.71 to 6.71), or if only one SLN was identified (OR 3.57, 1.98 to 6.45). Conclusion: SLN serial sectioning contributes to a higher rate of detection of SLN metastasis. The rate of upstaging of the tumour is similar in false-and true-negative groups of patients.

  • 7. Andersson, Yvette
    et al.
    de Boniface, J
    Jönsson, P-E
    Ingvar, C
    Liljegren, G
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Frisell, J
    Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer2012In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 2, p. 226-231Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the standard axillary staging procedure in breast cancer. Follow-up studies in SLN-negative women treated without ALND report low rates of axillary recurrence, but most studies have short follow-up, and few are multicentre studies.

    METHODS: Between September 2000 and January 2004, patients who were SLN-negative and did not have ALND were included in a prospective cohort. Kaplan-Meier estimates were used to analyse the rates of axillary recurrence and survival. The risk of axillary recurrence was also compared in centres with high and low experience with the SLN biopsy (SLNB) technique.

    RESULTS: A total of 2195 patients with 2216 breast tumours were followed for a median of 65 months. Isolated axillary recurrence was diagnosed in 1·0 per cent of patients. The event-free 5-year survival rate was 88·8 per cent and the overall 5-year survival rate 93·1 per cent. There was no difference in recurrence rates between centres contributing fewer than 150 SLNB procedures to the cohort and centres contributing 150 or more procedures.

    CONCLUSION: This study confirmed the low risk of axillary recurrence 5 years after SLNB for breast cancer without ALND.

  • 8.
    Bergkvist, L
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Frisell, J
    Uppsala University.
    Liljegren, G
    Uppsala University.
    Celebioglu, F
    Uppsala University.
    Damm, S
    Uppsala University.
    Thörn, M
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Multicentre study of detection and false-negative rates in sentinel nodebiopsy for breast cancer2001In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 88, no 12, p. 1644-1648Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sentinel node biopsy has recently evolved as a means of staging the axilla in breast cancer with minimal surgical trauma. The aim of this prospective multicentre study was to identify factors that influenced the detection and false-negative rates during the learning phase.

    METHODS: Data on all 498 sentinel node biopsies performed between August 1997 and December 1999 in Sweden were collected.

    RESULTS: A sentinel node was found in 450 patients (90 per cent). Preoperative scintigraphy visualized 83 per cent of all sentinel nodes. The detection rate was higher with same-day injection of tracer than with injection the day before (96 versus 86 per cent; P < 0.01). Dye injected less than 5 min or more than 30 min before the start of the operation lowered the detection rate (less than 60 per cent versus more than 65 per cent; P = 0.02). The detection rate varied from 61 to 100 per cent between surgeons. The false-negative rate was 11 per cent. The presence of multiple tumour foci and a high S-phase fraction increased the risk of a false-negative sentinel node, whereas the number of operations performed by each surgeon was less important.

    CONCLUSION: Training of the individual surgeon influenced the detection rate, as did timing of tracer and dye injection. The false-negative rate seemed to be related to biological factors.

  • 9.
    Birgisson, H
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Påhlman, L
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Gunnarsson, U
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Glimelius, B
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology.
    Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 2, p. 206-13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of the study was to analyse late gastrointestinal disorders necessitating hospital admission following rectal cancer surgery and to determine their relationship to preoperative radiation therapy. METHODS: Curatively treated patients participating in the Swedish Rectal Cancer Trial during 1987-1990, randomized to preoperative irradiation (454 patients) or surgery alone (454), were matched against the Swedish Hospital Discharge Registry. Hospital records for patients admitted with gastrointestinal diagnoses were reviewed. RESULTS: Irradiated patients had an increased relative risk (RR) of late small bowel obstruction (RR 2.49 (95 per cent confidence interval (c.i.) 1.48 to 4.19)) and abdominal pain (RR 2.09 (95 per cent c.i. 1.03 to 4.24)) compared with patients treated by surgery alone. The risk of late small bowel obstruction requiring surgery was greatly increased (RR 7.42 (95 per cent c.i. 2.23 to 24.66)). Irradiated patients with postoperative anastomotic leakage were at increased risk for late small bowel obstruction (RR 2.99 (95 per cent c.i. 1.07 to 8.31)). The risk of small bowel obstruction was also related to the radiation technique and energy used. CONCLUSION: Small bowel obstruction is more common in patients with rectal cancer treated with preoperative radiation therapy.

  • 10.
    Birgisson, Helgi
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Gunnarsson, U.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Glimelius, B.
    Authors' reply: Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy (Br J Surg 2008; 95 : 206-213)2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 6, p. 803-803Article in journal (Refereed)
  • 11.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Regional variation in the incidence of abdominal aortic aneurysm in Sweden ( Br J Surg 2012; 99: 647–653)2012In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 5, p. 654-654Article in journal (Refereed)
  • 12.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Vacuum and mesh-mediated fascial traction for primary closure of open abdomen in critically ill surgical patients (Br J Surg 2012; 99: 1725-1732)2012In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 12, p. 1732-1733Article in journal (Refereed)
  • 13.
    Björck, Martin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Djavani, Khatereh
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Valtysson, Johann
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm (Br J Surg 2009; 96:621-627) Reply2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 8, p. 959-960Article in journal (Refereed)
  • 14.
    Björck, Martin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Ravn, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Authors' reply: Nationwide study of the outcome of popliteal-artery aneurysms treated surgically2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 11, p. 1437-1438Article in journal (Refereed)
  • 15.
    Björck, Martin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Ravn, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Authors' reply: Risk of new aneurysms after surgery for popliteal artery aneurysm2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 9, p. 1185-1185Article in journal (Refereed)
  • 16. Blomgren, L.
    et al.
    Johansson, G.
    Emanuelsson, L.
    Dahlberg-Akerman, A.
    Thermaenius, P.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 8, p. 1112-1116Article in journal (Refereed)
    Abstract [en]

    Background: Routine preoperative duplex examination led to an improvement in results 2 years after surgery for primary varicose veins. The aim of the present study was to evaluate the impact of preoperative duplex imaging after 7 years, in relation to other risk factors for varicose vein recurrence. Methods: Patients with primary varicose veins were randomized to operation with (group 1), or without (group 2) preoperative duplex imaging. The same patients were invited to attend follow-up with interview, clinical examination and duplex imaging. Quality of life (QoL) was measured with the Short Form 36 questionnaire. Results: Some 293 patients (343 legs) were included initially; after 7 years 227 were interviewed, or their records reviewed: 114 in group 1 and 113 in group 2. One hundred and ninety-four legs (95 in group 1 and 99 in group 2) were examined clinically and with duplex imaging. Incompetence was seen at the saphenofemoral junction and/or saphenopopliteal junction in 14 per cent of legs in group 1 and 46 per cent in group 2 (P < 0.001). QoL was similar in both groups. After a mean follow-up of 7 years (and including patients who underwent surgery after the review), 15 legs in group 1 needed reoperation and 38 in group 2 (P = 0.001). Conclusion: Routine preoperative duplex imaging improved the results of surgery for primary varicose veins for at least 7 years.

  • 17.
    Blomgren, Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Johansson, Gunnar
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Randomized clinical trial of routine preoperative duplex imaging before varicose vein surgery2005In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 92, no 6, p. 688-694Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Duplex imaging is used increasingly for preoperative evaluation of varicose veins, but its value in terms of the long-term results of surgery is not clear.

    METHODS:

    Patients with primary varicose veins were randomized to operation with or without preoperative duplex imaging. Reoperation rates, clinical and duplex findings were compared at 2 months and 2 years after surgery.

    RESULTS:

    Two hundred and ninety-three patients (343 legs) had varicose vein surgery after duplex imaging (group 1; 166 legs) or no imaging (group 2; 177 legs). In 44 legs (26.5 per cent), duplex examination suggested a different surgical procedure than had been considered on clinical grounds; the procedure was changed accordingly for 29 legs. At 2 months, incompetence was detected at the saphenofemoral or saphenopopliteal junction (or both) in 14 legs (8.8 per cent) in group 1 and in 44 legs (26.5 per cent) in group 2 (P < 0.001). At 2 years, two legs (1.4 per cent) had undergone or were awaiting reoperation in group 1, and 14 legs (9.5 per cent) in group 2 (P = 0.002). In the remainder, major incompetence was found in 19 legs (15.0 per cent) in group 1 and in 53 (41.1 per cent) in group 2 (P < 0.001).

    CONCLUSION:

    Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins.

  • 18.
    Bondi, J.
    et al.
    Akershus Univ Hosp, Dept Gastrointestinal Surg, Lorenskog, Norway.;Drammen Hosp, Dept Surg, Vestre Viken, Norway..
    Avdagic, J.
    Akershus Univ Hosp, Dept Gastrointestinal Surg, Lorenskog, Norway.;Innlandet Hosp, Dept Surg, Hamar, Norway..
    Karlbom, Urban
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Hallböök, O.
    Linkoping Univ, Dept Surg, Linkoping, Sweden.;Linkoping Univ, Dept Clin & Expt Med, Linkoping, Sweden..
    Kalman, D.
    Linkoping Univ, Dept Surg, Linkoping, Sweden.;Linkoping Univ, Dept Clin & Expt Med, Linkoping, Sweden..
    Benth, J. Saltyte
    Akershus Univ Hosp, Hlth Serv Res Ctr, Lorenskog, Norway.;Univ Oslo, Inst Clin Med, Oslo, Norway..
    Naimy, N.
    Akershus Univ Hosp, Dept Gastrointestinal Surg, Lorenskog, Norway..
    Öresland, T.
    Akershus Univ Hosp, Dept Gastrointestinal Surg, Lorenskog, Norway.;Univ Oslo, Inst Clin Med, Oslo, Norway..
    Randomized clinical trial comparing collagen plug and advancement flap for trans-sphincteric anal fistula2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 9, p. 1160-1166Article in journal (Refereed)
    Abstract [en]

    Background: The role of a collagen plug for treating anal fistula is not well established. A randomized prospective multicentre non-inferiority study of surgical treatment of trans-sphincteric cryptogenic fistulas was undertaken, comparing the anal fistula plug with the mucosal advancement flap with regard to fistula recurrence rate and functional outcome.

    Methods: Patients with an anal fistula were evaluated for eligibility in three centres, and randomized to either mucosal advancement flap surgery or collagen plug, with clinical follow-up at 3 and 12 months. The primary outcome was the fistula recurrence rate. Anal pain (visual analogue scale), anal incontinence (St Mark's score) and quality of life (Short Form 36 questionnaire) were also reported.

    Results: Ninety-four patients were included; 48 were allocated to the plug procedure and 46 to advancement flap surgery. The median follow-up was 12 (range 9-24) months. The recurrence rate at 12 months was 66 per cent (27 of 41 patients) in the plug group and 38 per cent (15 of 40) in the flap group (P = 0.006). Anal pain was reduced after operation in both groups. Anal incontinence did not change in the follow-up period. Patients reported an increased quality of life after 3 months. There were no differences between the groups with regard to pain, incontinence or quality of life.

    Conclusion: There was a considerably higher recurrence rate after the anal fistula plug procedure than following advancement flap repair.

  • 19. Bringman, S.
    et al.
    Wollert, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Österberg, J.
    Smedberg, S.
    Granlund, H.
    Heikkinen, T. -J
    Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 9, p. 1056-1059Article in journal (Refereed)
    Abstract [en]

    Background: This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair. Methods: Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery. Results: Of the 590 men who had surgery, 243 (82.7 percent) of 294 in the standard mesh group and 251 (84.8 per cent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3.7 per cent with standard mesh and 3.6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh. Conclusion: Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.

  • 20.
    Chabok, Abbas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Hjern, F.
    Haapaniemi, S.
    Smedh, Kennet
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis2012In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 4, p. 532-539Article in journal (Refereed)
    Abstract [en]

    Background: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.

    Methods: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.

    Results: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1.9 per cent) who received no antibiotics and in three (1.0 per cent) who were treated with antibiotics (P = 0.302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0.881).

    Conclusion: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

  • 21.
    Chen, L.
    et al.
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Glimelius, Ingrid
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology. Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Neovius, M.
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Eloranta, S.
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Ekberg, S.
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden.;Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden..
    Martling, A.
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden..
    Smedby, K. E.
    Karolinska Inst, Dept Med Solna, Clin Epidemiol Unit, Stockholm, Sweden..
    Risk of disability pension in patients following rectal cancer treatment and surgery2015In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 102, no 11, p. 1426-1432Article in journal (Refereed)
    Abstract [en]

    BackgroundAspects of survivorship, such as long-term ability to work, are increasingly relevant owing to the improved survival of patients with rectal cancer. The aim of this study was to assess risk and determinants of disability pension (DP) in this patient group. MethodsUsing Swedish national clinical and population-based registers, patients with stage I-III rectal cancer aged 18-61years in 1995-2009 were identified at diagnosis and matched with population comparators. Prospectively registered records of DP during follow-up were retrieved up to 2013. Non-proportional and proportional hazards models were used to estimate the incidence rate ratio (IRR) for DP annually and overall. Potential variations in risk by demographic and clinical factors were calculated, with relapse as a time-varying exposure. ResultsA total of 2815 patients were identified and compared with 13465 population comparators. During a median follow-up of 60 (range 0-10) years, 233 per cent of the relapse-free patients and 103 per cent of the population comparators received DP (IRR 240, 95 per cent c.i. 217 to 265). An increased annual risk of DP was evident almost every year until the tenth year of follow-up. Abdominoperineal resection was associated with an increased DP risk compared with anterior resection (IRR 144, 119 to 175). Surgical complications (IRR 133, 110 to 162) and reoperation (IRR 142, 109 to 184), but not radiotherapy or chemotherapy, were associated with risk of DP. ConclusionRelapse-free patients with rectal cancer of working age are at risk of disability pension. Higher than expected

  • 22.
    Collin, Åsa
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Jung, B.
    Nilsson, E.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Folkesson, Joakim
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Impact of mechanical bowel preparation on survival after colonic cancer resection2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 12, p. 1594-1600Article in journal (Refereed)
    Abstract [en]

    Background: A randomized study in 1999-2005 of mechanical bowel preparation (MBP) preceding colonic resection found no decrease in postoperative complications. The aim of the present study was to evaluate the long-term effect of MBP regarding cancer recurrence and survival after colonic resections. Methods: The cohort of patients with colonic cancer in the MBP study was followed up for 10 years. Data were collected from registers run by the National Board of Health and Welfare. Register data were validated against information in patient charts. Cox proportional hazards model was used for multivariable analysis of factors predictive of cancer-specific survival. Results: Register analysis showed significantly fewer recurrences, and better cancer-specific and overall survival in the MBP group. After validation, 839 of 1343 patients remained for analysis (448 MBP, 391 no MBP). Eighty (17.9 per cent) of 448 patients in the MBP group and 88 (22.5 per cent) of 391 in the no-MBP group developed a cancer recurrence (P = 0.093). The 10-year cancer-specific survival rate was 84.1 per cent in the MBP group and 78.0 per cent in the no-MBP group (P = 0.019). Overall survival rates were 58.8 and 56.0 per cent respectively (P = 0.186). Conclusion: Patients receiving MBP before elective colonic cancer surgery had significantly better cancer-specific survival after 10 years.

  • 23.
    Daskalakis, Kosmas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Karakatsanis, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Stålberg, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Norlén, Olov
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Hellman, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Clinical signs of fibrosis in small intestinal neuroendocrine tumours.2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 1, p. 69-75Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In patients with small intestinal neuroendocrine tumours (SI-NETs), serotonin and other cytokines released from tumour cells may induce fibrosis, leading to carcinoid heart disease and abdominal fibrotic reactions. The aim of this study was to assess the prevalence, clinical complications and management of this reaction in the abdomen.

    METHODS: This was a retrospective cohort study of patients with SI-NETs diagnosed between 1985 and 2015. Clinical data, outcomes, radiological findings, and surgical and radiological interventions were reviewed.

    RESULTS: A total of 824 patients were diagnosed with SI-NETs in the study interval. Clinically significant abdominal signs and symptoms of fibrosis occurred in 36 patients. Of these, 20 had critically symptomatic central mesenteric fibrosis causing obstruction of mesenteric vessels, and 16 had retroperitoneal fibrosis causing obstructive uropathy with hydronephrosis. Extensive fibrosis causing mesenteric vessel obstruction and/or obstructive uropathy was more often associated with symptomatic and advanced disease encompassing lymph node metastases in the mesenteric root, para-aortic lymph node metastases, as well as liver metastases and peritoneal carcinomatosis. Palliative intervention in terms of superior mesenteric vein stenting or resection of central mesenteric metastases and/or percutaneous nephrostomy and J stent treatment was beneficial in the majority of the patients.

    CONCLUSION: Extensive abdominal fibrosis associated with clinically significant symptoms of intestinal ischaemia and/or obstructive uropathy was linked to advanced disease in patients with SI-NETs. Prompt recognition and minimally invasive intervention was effective in disease palliation.

  • 24.
    de Boniface, J.
    et al.
    Karolinska Inst, Dept Mol Med & Surg, SE-17176 Stockholm, Sweden.;Karolinska Univ Hosp, Dept Breast & Endocrine Surg, Stockholm, Sweden..
    Frisell, J.
    Karolinska Inst, Dept Mol Med & Surg, SE-17176 Stockholm, Sweden.;Karolinska Univ Hosp, Dept Breast & Endocrine Surg, Stockholm, Sweden..
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Vastmanland Cty Hosp, Dept Surg, Vasteras, Sweden..
    Andersson, Yvette
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Vastmanland Cty Hosp, Dept Surg, Vasteras, Sweden..
    Ten-year report on axillary recurrence after negative sentinel node biopsy for breast cancer from the Swedish Multicentre Cohort Study2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 3, p. 238-247Article in journal (Refereed)
    Abstract [en]

    Background: The omission of axillary lymph node dissection (ALND) in patients with breast cancer with a negative finding on sentinel node biopsy (SNB) has reduced armmorbidity substantially. Early follow-up reports have shown the rate of axillary recurrence to be significantly lower than expected, with a median false-negative rate of 7 per cent for SNB. Long-term follow-up is needed as recurrences may develop late.

    Methods: The Swedish Multicentre Cohort Study included 3518 women with breast cancer and a clinically negative axilla, in whom SNB was planned. ALND was performed only in patients with sentinel node metastasis. Twenty-six centres contributed to enrolment between September 2000 and January 2004. The primary endpoint was the axillary recurrence rate and the secondary endpoint was breast cancer-specific survival, calculated using Kaplan-Meier survival estimates.

    Results: Some 2216 sentinel node-negative patients with 2237 breast cancers were analysed. The median follow-up time was 126 (range 0-174) months. Isolated axillary recurrence was found in 35 patients (1.6 per cent). High histological grade and multifocal tumours were risk factors for axillary recurrence, whereas the removal of more than two sentinel nodes decreased the risk. Fourteen (40 per cent) of 35 patients died as a consequence of axillary recurrence.

    Conclusion: The risk of axillary recurrence remains lower than expected after a negative finding on SNB at 10-year follow-up. Axillary recurrences may occur long after primary surgery, and lead to a significant risk of breast cancer death.

  • 25.
    De Waele, J. J.
    et al.
    Ghent Univ Hosp, Dept Crit Care Med, De Pintelaan 185, B-9000 Ghent, Belgium..
    Kimball, E.
    Univ Utah, Dept Surg, Hlth Sci Ctr, Salt Lake City, UT USA..
    Malbrain, M.
    Ziekenhuis Netwerk Antwerpen Stuivenberg, Intens Care Unit, Antwerp, Belgium.;Ziekenhuis Netwerk Antwerpen Stuivenberg, High Care Burn Unit, Antwerp, Belgium..
    Nesbitt, I.
    Freeman Rd Hosp, Anaesthesia & Crit Care, Newcastle Upon Tyne, Tyne & Wear, England..
    Cohen, J.
    Rabin Med Ctr, Gen Intens Care Unit, Petah Tiqwa, Israel.;Tel Aviv Univ, Sackler Sch Med, Crit Care & Anaesthesia, IL-69978 Tel Aviv, Israel..
    Kaloiani, V.
    Tbilisi State Med Univ, Cent Clin, Dept Anaesthesiol Emergency Med & Crit Care, Tbilisi, Rep of Georgia..
    Ivatury, R.
    Virginia Commonwealth Univ, Dept Surg, Richmond, VA USA..
    Mone, M.
    Univ Utah, Dept Surg, Hlth Sci Ctr, Salt Lake City, UT USA..
    Debergh, D.
    Ghent Univ Hosp, Dept Crit Care Med, De Pintelaan 185, B-9000 Ghent, Belgium.;Artevelde Univ Coll, Ghent, Belgium..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Decompressive laparotomy for abdominal compartment syndrome2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 6, p. 709-715Article in journal (Refereed)
    Abstract [en]

    Background: The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes. Methods: This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28-day and 1-year all-cause mortality. Changes in intra-abdominal pressure (IAP) and organ function, and laparotomy-related morbidity were secondary endpoints. Results: Thirty-three patients were included in the study (20 men). Twenty-seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20-32). Median IAP was 23 (21-27) mmHg before decompressive laparotomy, decreasing to 12 (9-15), 13 (8-17), 12 (9-15) and 12 (9-14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non-survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28-day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non-survivors were no different from survivors, except that they tended to be older and on mechanical ventilation. Conclusion: Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

  • 26. den Dulk, M.
    et al.
    Marijnen, C. A. M.
    Collette, L.
    Putter, H.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Folkesson, Joakim
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Bosset, J-F.
    Rödel, C.
    Bujko, K.
    van de Velde, C. J. H.
    Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 9, p. 1066-75Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease-free, overall and cancer-specific survival. METHODS: Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival. RESULTS: Some 9.7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11.6 per cent without and 7.8 per cent with a stoma; P = 0.002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1.29 (95 per cent confidence interval 1.02 to 1.63); P = 0.034), but not with cancer-specific survival (HR 1.12 (0.83 to 1.52); P = 0.466). CONCLUSION: Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced.

  • 27. Derogar, M.
    et al.
    Blomberg, J.
    Sadr-Azodi, O.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD).
    Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort2015In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 102, no 5, p. 548-557Article in journal (Refereed)
    Abstract [en]

    Background: The association between hospital teaching status and mortality after pancreatic resection is not well explored. Although hospital volume is related to short-term mortality, the effect on long-term survival needs investigation, taking into account hospital teaching status and selective referral patterns. Methods: This was a nationwide retrospective register-based cohort study of patients undergoing pancreatic resection between 1990 and 2010. Follow-up for survival was carried out until 31 December 2011. The associations between hospital teaching status and annual hospital volume and short-, intermediate- and long-term mortality were determined by use of multivariable Cox regression models, which provided hazard ratios (HRs) with 95 per cent c.i. The analyses were mutually adjusted for hospital teaching status and volume, as well as for patients' sex, age, education, co-morbidity, type of resection, tumour site and histology, time interval, referral and hospital clustering. Results: A total of 3298 patients were identified during the study interval. Hospital teaching status was associated with a decrease in overall mortality during the latest interval (years 2005-2010) (university versus non-university hospitals: HR 0.72, 95 per cent c.i. 0.56 to 0.91; P = 0.007). During all time periods, hospital teaching status was associated with decreased mortality more than 2 years after surgery (university versus non-university hospitals: HR 0.86, 0.75 to 0.98; P = 0.026). Lower annual hospital volume increased the risk of short-term mortality (HR for 3 or fewer compared with 4-6 pancreatic cancer resections annually: 1.60, 1.04 to 2.48; P = 0.034), but not long-term mortality. Sensitivity analyses with adjustment for tumour stage did not change the results. Conclusion: Hospital teaching status was strongly related to decreased mortality in both the short and long term. This may relate to processes of care rather than volume per se. Very low-volume hospitals had the highest short-term mortality risk.

  • 28.
    Djavani, Khatereh
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Valtysson, Johann
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 6, p. 621-627Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:: The aim was to investigate the association between colonic ischaemia and intra-abdominal pressure (IAP) after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS:: Sigmoid colon perfusion was monitored with an intramucosal pH (pHi) tonometer. Patients with a pHi of 7.1 or less were treated for suspected hypovolaemia with intravenous colloids and colonoscopy. IAP was measured every 4 h. Patients with an IAP of 20 mmHg or more had neuromuscular blockade, relaparotomy or both. RESULTS:: A total of 52 consecutive patients had open rAAA repair; 30-day mortality was 27 per cent. Eight patients died shortly after surgery. Fifteen were not monitored for practical reasons; mortality in this group was 33 per cent. IAP and pHi were measured throughout the stay in intensive care in the remaining 29 patients. Monitoring led to volume resuscitation in 25 patients, neuromuscular blockade in 16, colonoscopy in 19 and relaparotomy in two. One patient died in this group. Twenty-three of 29 patients had a pHi of 7.1 or less, of whom 15 had a pHi of 6.9 or less. Sixteen had an IAP of 20 mmHg or more, of whom ten also had a pHi below 6.90. Peak IAP values correlated with the simultaneously measured pHi (r = -0.39, P = 0.003). CONCLUSION:: Raised IAP is an important mechanism behind colonic hypoperfusion after rAAA repair. Monitoring IAP and timely intervention may improve outcome.

  • 29. Eiriksson, K.
    et al.
    Fors, Diddi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Arvidsson, Dag
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 6, p. 845-852Article in journal (Refereed)
    Abstract [en]

    Background: Various recommendations exist regarding intra-abdominal pressure (IAP) during laparoscopic liver resection. A high IAP may reduce bleeding but at the same time increase the risk of gas embolism. This study investigated the effects of two different IAPs during laparoscopic left liver lobe resection in piglets. Methods: Sixteen piglets underwent laparoscopic left liver lobe resection using carbon dioxide pneumoperitoneum of either 8 or 16 mmHg (8 per group). A combination of CUSA System 200 (TM) and LigaSure (TM) instruments was used for parenchymal division. During resection, a standard injury to the left liver vein was also created to increase the risk of bleeding and/or gas embolism during the operation. Heart rate, cardiac output, and arterial, pulmonary arterial, pulmonary capillary wedge and central venous pressures were measured. Arterial blood gases were monitored continuously. Transoesophageal echocardiography was video recorded to detect and quantify gas embolism within the right cardiac ventricle. The duration of operation and bleeding were noted. Results: High IAP resulted in reduced bleeding (P = 0.016), but gas embolism occurred more frequently (P = 0.001) than with low IAP. Gas embolism disturbed gas exchange, with an increase in arterial pressure of carbon dioxide, and a decrease in arterial partial pressure of oxygen and pH. These effects were sustained for at least 30 min after surgery. Conclusion: High IAP reduces the amount of bleeding but increases the risk of gas embolism. Monitoring for gas embolism is therefore indicated if a high IAP is used during laparoscopic liver resection.

  • 30. Eklund, A.
    et al.
    Carlsson, P.
    Rosenblad, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Montgomery, A.
    Bergkvist, L.
    Rudberg, C.
    Long-term cost-minimization analysis comparing laparoscopic with open (Lichtenstein) inguinal hernia repair2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 5, p. 765-771Article in journal (Refereed)
    Abstract [en]

    Background:

    Laparoscopic surgery has emerged as a new treatment modality for inguinal hernia repair. The aim of the present study was to analyse its long-term costs in relation to those of open repair.

    Methods:

    A randomized multicentre study comparing totally extraperitoneal laparoscopic repair (TEP) with open repair by the Lichtenstein procedure was performed on men with a primary inguinal hernia. Long-term data on recurrences and complications up to 5 years after operation were collected. Taking treatment costs into consideration, a cost-minimization analysis was conducted.

    Results:

    A total of 1370 patients had an inguinal hernia repair, 665 in the TEP and 705 in the Lichtenstein group. The total hospital cost for the index operation was €710·6 higher for TEP repair (P < 0·001). Including costs associated with recurrences and complications, this difference increased to €795·1 (P < 0·001). Taking community costs into account, the difference decreased by €503·1 to €292·0 (P = 0·024).

    Conclusion:

    This cost-minimization analysis, including complications, reoperations and community costs during follow-up of 5 years, showed that laparoscopic inguinal hernia repair had a small but significant increase in overall costs compared with open repair.

  • 31.
    Eklund, Arne
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Montgomery, Agneta
    Malmö Universitets sjukhus.
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Rudberg, Claes
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Chronic pan 5 years after randomised comparison of laparoscopic and Lichtenstein inguinal hernia repair2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 4, p. 600-608Article in journal (Other academic)
    Abstract [en]

    Background: Postoperative chronic pain is a major drawback of inguinal hernia repair. The current objective was to compare the frequency of chronic pain after laparoscopic (Totally Extraperitoneal Patch – TEP) and open (Lichtenstein) repairs.

    Methods: A randomized multicentre study with five years follow-up was conducted on male patients with a primary inguinal hernia. This report concerns chronic pain which was categorized as mild, moderate or severe by blinded observers. A subgroup analysis was performed on patients who had experienced moderate or severe pain at any time during follow-up.

    Results: Overall, 1370 of 1512 randomised patients underwent surgery, 665 in the TEP and 705 in the Lichtenstein group. The total incidence of chronic pain in the TEP and the Lichtenstein groups, respectively, was: 11.0 versus 21.7 per cent (one year), 11.0 versus 24.8 per cent (two years), 9.9 versus 20.2 per cent (three years) and 9.4 versus 18.8 per cent (five years) (P < 0.001). After five years, 1.9 per cent of patients in the TEP and 3.5 per cent in the Lichtenstein group reported moderate or severe pain (P = 0.092). Of the 121 patients who had reported moderate or severe pain 72 patients (60.0%) no longer reported pain after a median period of 9.4 (6.7-10.8) years after operation.

    Conclusion: Five years after surgery only a few per cent of patients still reported moderate to severe chronic pain. Laparoscopic inguinal hernia repair led to less chronic pain than open repair.

  • 32.
    Eklund, Arne
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Rudberg, C.
    Smedberg, S.
    Enander, L.K.
    Leijonmarck, C.E.
    Österberg, Johanna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Montgomery, A.
    Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 9, p. 1060-1068Article in journal (Refereed)
    Abstract [en]

    Background: Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique.

    Methods: A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded.

    Results: Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 per cent of die patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P < 0.001), consumed fewer analgesics (P < 0.001), had a shorter period of sick leave (7 versus 12 days; P < 0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P < 0.001).

    Conclusion: The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.

  • 33.
    Folkesson, Joakim
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Johansson, Robert
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Gunnarsson, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Population-based study of local surgery for rectal cancer2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 11, p. 1421-1426Article in journal (Refereed)
    Abstract [en]

    Background: The aim was to determine long-term survival and recurrence rates after local excision of rectal cancer from a prospectively registered population-based database. Methods: Swedish Rectal Cancer Registry data from 1995 to 2001, including 10181 patients of whom 643 (6-3 per cent) had a local excision, were analysed. Complete 5-year follow-up data from 1995 to 1998 were available. Cumulative relative and cancer-specific survival rates, and rates of local recurrence and distant metastases, were calculated by actuarial methods. Results: The 5-year cancer-specific survival rate for 256 patients with stage I disease who had local excision was 95-3 (95 per cent confidence interval 91-5 to 99-1) per cent. The 5-year local recurrence rate was 7-2 per cent. After adjustment for age, sex, tumour stage and preoperative radiotherapy, the relative risk of death from cancer was the same as that after major resection. Conclusion: Population-based results after local excision of rectal cancer are the same as those reported in controlled series for early-stage tumours after abdominal resection. A low relative survival and a high median age indicate the use of local excision in patients with a high level of co-morbidity. To achieve acceptable long-term results, optimal preoperative and postoperative staging is needed.

  • 34.
    Folkesson, Joakim
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Population-based study of local surgery for rectal cancer: (Br J Surg 2007; 94: 1421-1426) - Reply2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 2, p. 262-262Article in journal (Refereed)
  • 35.
    Fredriksson, Fanny
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Christofferson, Rolf H.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Lilja, Helene Engstrand
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Adhesive small bowel obstruction after laparotomy during infancy2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 3, p. 284-289Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intra-abdominal adhesions can cause adhesive small bowel obstruction, chronic abdominal pain and female infertility. Reports on long-term outcomes following laparotomy during infancy are scarce. The aims of this study were to investigate the incidence of and risk factors for long-term adhesive small bowel obstruction and associated morbidity after laparotomy during infancy.

    METHODS: Infants who underwent laparotomy between 1976 and 2011 were identified. Data were extracted from medical records and a questionnaire was sent to the patients.

    RESULTS: Some 898 of 1185 eligible patients were included, with a median follow-up time of 14·7 (range 0·0-36·0) years. Median age at first laparotomy was 6 (range 1·0-365·0) days. There were 113 patients (12·6 per cent) with adhesive small bowel obstruction who underwent relaparotomy, 79 (69·9 per cent) occurring during the first 2 years after the initial laparotomy. The highest incidence of small bowel obstruction was found in patients with Hirschsprung's disease (19 of 65, 29 per cent), malrotation (13 of 45, 29 per cent), intestinal atresia (11 of 40, 28 per cent) and necrotizing enterocolitis (16 of 64, 25 per cent). Lengthy duration of surgery (hazard ratio (HR) 1·25, 95 per cent c.i. 1·07 to 1·45), stoma formation (HR 1·72, 1·15 to 2·56) and postoperative complications (HR 1·81, 1·12 to 2·92) were independent risk factors. Chronic abdominal pain was reported in 180 (24·0 per cent) of 750 patients, and 17 (13·8 per cent) of 123 women reported infertility.

    CONCLUSION: The incidence of adhesive small bowel obstruction after laparotomy in infants is high.

  • 36. Fränneby, U.
    et al.
    Gunnarsson, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Andersson, M.
    Heuman, R.
    Nordin, P.
    Nyrén, O.
    Sandblom, G.
    Validation of an Inguinal Pain Questionnaire for assessment of chronic pain after groin hernia repair2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 4, p. 488-493Article in journal (Refereed)
    Abstract [en]

    Background: Long-term pain is an important outcome after inguinal hernia repair. The aim of this study was to test the validity and reliability of a specific Inguinal Pain Questionnaire (IPQ). Methods: The study recruited patients aged between 15 and 85 years who had undergone primary inguinal or femoral hernia repair. To test the validity of the questionnaire, 100 patients received the IPQ and the Brief Pain Inventory (BPI) 1 and 4 weeks after surgery (group 1). To test reliability and internal consistency, 100 patients received the IPQ on two occasions 1 month apart, 3 years after surgery (group 2). Non-surgery-related pain was analysed in group 3 (2853 patients). Results: A significant decrease in IPQ-rated pain intensity was observed in the first 4 weeks after surgery (P < 0.001). Significant correlations with corresponding BPI pain intensity items corroborated the criterion validity (P < 0.050). Logical incoherence did not exceed 5.5 per cent for any item. Values for kappa in the test-retest in group 2 were higher than 0.5 for all but three items. Cronbach's alpha was 0.83 for questions on pain intensity and 0.74 for interference with daily activities. Conclusion: This study found good validity and reliability for the IPQ, making it a useful instrument for assessing pain following groin hernia repair.

  • 37. Goncalves, F. Bastos
    et al.
    Baderkhan, Hassan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Verhagen, H. J. M.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Stolker, R. J.
    Hoeks, S. E.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 7, p. 802-810Article in journal (Refereed)
    Abstract [en]

    Background: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods: Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results: Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9mm) in 142 (23.8 per cent) and major shrinkage (at least 10mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion: Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.

  • 38.
    Grip, Olivia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Kuoppala, M.
    Acosta, S.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Akeson, J.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 9, p. 1105-1112Article in journal (Refereed)
    Abstract [en]

    Background: Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications. Methods: This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA). Results: Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47.1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38.8 per cent, acute arterial thrombosis in 32.2 per cent, embolus in 22.3 per cent and popliteal aneurysm in 6.7 per cent. Concomitant heparin infusion was used in 63.2 per cent. The mean dose of rtPA administered was 21.0mg, with a mean duration of 25.2 h. Technical success was achieved in 80.2 per cent. Major amputation and death within 30 days occurred in 13.1 and 4.4 per cent respectively. Bleeding complications occurred in 227 treatments (30.3 per cent). Blood transfusion was needed in 104 (13.9 per cent). Three patients (0.4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation-free survival was 83.6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2.98; P < 0 001). Independent risk factors for fasciotomy were severe ischaemia (OR 2.94) and centre (OR 6 50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0.30; P = 0.003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3.82) and renal insufficiency (OR 3.86). Conclusion: Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra-arterial thrombolysis appeared to offer no advantage.

  • 39.
    Gustafsson, Ulla Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 10, p. 1202-1207Article in journal (Refereed)
    Abstract [en]

    Background: Endoanal advancement flap repair is widely used in sphincter-preserving surgery for anal fistula, but the high recurrence rate is a major problem. A possible cause of non-healing is local infection of the flap. The aim of this study was to evaluate whether local antibiotic treatment with gentamicin-collagen improves healing after endoanal advancement flap repair for anal fistula.

    Methods: Eighty-three patients (52 men and 31 women; mean age 47 (range 17-71) years) who had endoanal advancement flap repair for anal fistula between September 1998 and January 2004 were randomized to surgery with (42 patients) or without (41 patients) application of gentamicin-collagen beneath the flap. Patients were evaluated at 1-3 and 12 months after surgery for healing and/or recurrence.

    Results: The overall healing rate with no recurrence at 1 year after surgery was 57 per cent (47 of 83). Twenty-six of 42 patients randomized to gentamicin-collagen healed primarily compared with 21 of 41 patients randomized to surgery only. There were no overall differences in healing rate according to sex, previous fistula surgery, complexity of fistula, smoking habit or body mass index.

    Conclusion: Endoanal advancement flap repair for anal fistula has a fairly high primary recurrence rate. Healing was not significantly improved by local application of gentamicin-collagen.

  • 40.
    Gürtelschmid, Mikael
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Comparison of three ultrasound methods of measuring the diameter of the abdominal aorta2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 6, p. 633-636Article in journal (Refereed)
    Abstract [en]

    Background: Three ultrasound methods of measuring the diameter of the abdominal aorta exist: the outer-to-outer (OTO) method, where callipers are placed on the outer layer of the aortic wall; the inner-to-inner (ITI) method, where callipers are placed on the inner layer of the aortic wall; and the leading edge-to-leading edge (LELE) method, where callipers are placed on the outer layer of the anterior wall and the inner layer of the posterior wall. The aim was to determine the variability of the three methods, differences between them, and the consequences on prevalence estimates. Methods: Some 127 consecutive patients with a small abdominal aortic aneurysm (AAA) were included. The maximal anteroposterior diameter was measured using the OTO, ITI and LELE methods by two vascular sonographers who were blinded to each other's measurements. The variability was described as the standard deviation. Results: The variability was 2.7 (95 per cent limits of agreements +/- 5.4) mmfor the OTO, 2.3 (+/- 4.6) mm for the ITI and 2.0 (+/- 4.0) mm for the LELE method. The corresponding coefficients of variability were 6.4, 6.1 and 5.0 per cent. The difference was 4.1mm between ITI and OTO (P < 0.001), 2.0 mm between ITI and LELE (P < 0.001), and 2.1mm between LELE and OTO (P < 0.001). Conclusion: LELE measurement was the most reproducible method of measuring the abdominal aorta. All methods showed a high degree of variability.

  • 41.
    Hassan, Baderkhan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imagingIn: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168Article in journal (Refereed)
  • 42.
    Hessman, Ola
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Westerdahl, J.
    Al-Suliman, N.
    Christiansen, P.
    Hellman, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Bergenfelz, A.
    Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 2, p. 177-184Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies of video-assisted techniques for parathyroidectomy in patients with primary hyperparathyroidism have found similar or better results compared with bilateral neck exploration. The aim of the present study was to compare open minimally invasive parathyroidectomy with the video-assisted technique for primary hyperparathyroidism in a multicentre randomized trial. METHODS: Some 143 patients were randomized to open (n = 75) or video-assisted (n = 68) parathyroidectomy after positive sestamibi scintigraphy. There were no differences in preoperative data. The open operation was performed through a 15-mm incision. The video-assisted techniques used were minimally invasive video-assisted parathyroidectomy (MIVAP) or video-assisted parathyroidectomy using the lateral approach (VAPLA). Data were collected prospectively including postoperative pain scoring. RESULTS: The procedure was significantly quicker for the open compared to the video assisted operations: mean(s.d.) 60(35) versus 84(47) min (P = 0.001). Both groups of patients had similar conversion rates and the same outcome, with comparable incision lengths, low scores for postoperative neck discomfort, high cosmetic satisfaction and low complication rates. CONCLUSION: Open minimally invasive parathyroidectomy for primary hyperparathyroidism was quicker than either video-assisted technique.

  • 43. Jaafar, G.
    et al.
    Persson, G.
    Svennblad, Bodil
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Sandblom, G.
    Outcomes of antibiotic prophylaxis in acute cholecystectomy in a population-based gallstone surgery registry2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 2, p. 69-73Article in journal (Refereed)
    Abstract [en]

    Background

    The aim of this study was to assess the effect of antibiotic prophylaxis (AP) on postoperative infections in acute cholecystectomy.

    Methods

    The study was based on acute cholecystectomies registered in the nationwide Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2006 and 2010. The association between AP and the risk of postoperative infectious complications was tested in a multivariable regression analysis, with stepwise addition of age, sex, duration of operation, indication for surgery, surgical approach (laparoscopic versus open) and American Society of Anesthesiologists (ASA) fitness grade as co-variables. Postoperative infections requiring antibiotic treatment and postoperative abscesses were defined as outcome measures.

    Results

    AP was given to 9549 (68<bold>6</bold> per cent) of 13 911 patients. Postoperative infections requiring antibiotic treatment occurred following 1070 procedures (7<bold>7</bold> per cent), including 805 patients (8<bold>4</bold> per cent) who received AP (P < 0<bold>001</bold> versus patients without AP). Postoperative abscesses developed after 273 procedures (2<bold>0</bold> per cent), including 208 patients (2<bold>2</bold> per cent) who received AP (P = 0<bold>007</bold>). In univariable analysis, the odds ratio for development of infectious complications necessitating treatment with antibiotics was 1<bold>42</bold> (95 per cent confidence interval 1<bold>23</bold> to 1<bold>64</bold>) for those who received APversus those who did not, and for postoperative abscesses it was 1<bold>47</bold> (1<bold>11</bold> to 1<bold>95</bold>). In multivariable analysis, adjusting for confounders, the odds ratios were 0<bold>93</bold> (0<bold>79</bold> to 1<bold>10</bold>) and 0<bold>88</bold> (0<bold>64</bold> to 1<bold>21</bold>) respectively.

    Conclusion

    The present study suggests that AP provides no benefit in acute cholecystectomy. No benefit from antibiotics

  • 44.
    Jestin, Pia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Nilsson, J.
    Heurgren, M.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Glimelius, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Oncology, Radiology and Clinical Immunology.
    Gunnarsson, U.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Emergency surgery for colonic cancer in a defined population2005In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 92, no 1, p. 94-100Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery. METHODS: Data from the colonic cancer registry (1997-2001) of the Uppsala/Orebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register. RESULTS: Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29.8 versus 52.4 per cent; P < 0.001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P < 0.001). Emergency surgery was associated with a longer hospital stay (mean 18.0 versus 10.0 days; P < 0.001) and higher costs (relative cost 1.5 (95 per cent confidence interval 1.4 to 1.6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r(2) = 0.52, P < 0.001). CONCLUSION: Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.

  • 45. Johannsson, Helgi O
    et al.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Authors' reply: Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy (Br J Surg 2006; 93: 1208-1214)2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 1, p. 122-122Article in journal (Refereed)
  • 46.
    Johannsson, Helgi Örn
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Center for Clinical Research Dalarna.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 10, p. 1208-1214Article in journal (Refereed)
    Abstract [en]

    Background: Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy.

    Methods: A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale.

    Results: Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047).

    Conclusion: Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction.

  • 47. Jung, Bärbel
    et al.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Authors' reply: Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection (Br J Surg 2007; 94: 689-695)2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 10, p. 1306-Article in journal (Refereed)
  • 48. Jung, Bärbel
    et al.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Nyström, P-O.
    Nilsson, E.
    Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 6, p. 689-695Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery. METHODS: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days. RESULTS: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not. CONCLUSION: MBP does not lower the complication rate and can be omitted before elective colonic resection.

  • 49.
    Karakatsanis, Andreas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Daskalakis, Kosmas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Stålberg, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Olofsson, H
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical and experimental pathology.
    Andersson, Y
    Department of Surgery, Västmanlands County Hospital, Västerås, Sweden.
    Eriksson, S
    Department of Surgery, Västmanlands County Hospital, Västerås, Sweden.
    Bergkvist, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Wärnberg, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Superparamagnetic iron oxide nanoparticles as the sole method for sentinel node biopsy detection in patients with breast cancer2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 12, p. 1675-1685Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Sentinel node biopsy (SNB) using superparamagnetic iron oxide (SPIO) nanoparticles is a novel method in breast cancer. Several studies have verified the non-inferiority of SPIO compared with the standard use of radioisotope (99m) Tc with or without blue dye. The aim of the MONOS study presented here was to evaluate the use of SPIO as a sole tracer and the efficacy of tracer injection in the preoperative setting.

    METHODS: This prospective cohort study was carried out in two hospitals, one using (99m) Tc and the other SPIO. (99m) Tc was injected in the morning of the day of surgery or the day before. SPIO was either injected before surgery in the outpatient clinic or 1 h before the operation.

    RESULTS: A total of 338 consecutive patients with breast cancer underwent 343 procedures; SPIO nanoparticles were used in 184 procedures and (99m) Tc-labelled tracer in 159. Detection rates for SPIO and (99m) Tc were 95·6 and 96·9 per cent respectively (P = 0·537). All nodes with SPIO uptake were coloured brown. Fewer nodes were retrieved with SPIO (mean 1·35 versus 1·89), regardless of whether blue dye was used (P < 0·001). Preoperative SPIO injection (58·7 per cent of procedures), a median of 16 (range 2-27) days before the procedure, was associated with a better tracer-specific detection rate (95·3 versus 86 per cent; P = 0·031) and retrieval of more nodes (mean 1·43 versus 1·03; P < 0·001) than perioperative administration. Skin staining was present in 39·9 per cent of patients, and was related to breast-conserving surgery and periareolar injection.

    CONCLUSION: The use of SPIO alone is a safe alternative, with results comparable to those of the standard dual technique using (99m) Tc and blue dye. The efficacy of injection in the preoperative setting simplifies logistics and improves performance. Skin staining can be prevented by a deeper peritumoral injection.

  • 50.
    Karthikesalingam, A.
    et al.
    St Georges Vasc Inst, London, England..
    Brownrigg, J.
    St Georges Vasc Inst, London, England..
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Holt, P.
    St Georges Vasc Inst, London, England..
    Lessons from Comparing Elective AAA Repair in England and Sweden2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, p. 11-11Article in journal (Other academic)
12 1 - 50 of 91
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