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  • 1. Abu Hilal, M
    et al.
    Richardson, J R C
    de Rooij, T
    Dimovska, Eleonora
    Al-Saati, H
    Besselink, M G
    Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results.2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 9, p. 3830-8Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic left pancreatectomy has been well described for benign pancreatic lesions, but its role in pancreatic adenocarcinoma remains open to debate. We report our results adopting a laparoscopic technique that obeys established oncologic principles of open distal pancreatosplenectomy.

    METHODS: This is a post hoc analysis of a prospectively kept database of 135 consecutive patients undergoing laparoscopic left pancreatectomy, performed across two sites in the UK and the Netherlands (07/2007-07/2015 Southampton and 10/2013-07/2015 Amsterdam). Primary outcomes were resection margin and lymph node retrieval. Secondary endpoints were other perioperative outcomes, including post-operative pancreatic fistula. Definition of radical resection was distance tumour to resection margin >1 mm. All patients underwent 'laparoscopic radical left pancreatosplenectomy' (LRLP) which involves 'hanging' the pancreas including Gerota's fascia, followed by clockwise dissection, including formal lymphadenectomy.

    RESULTS: LRLP for pancreatic adenocarcinoma was performed in 25 patients. Seven of the 25 patients (28 %) had extended resections, including the adrenal gland (n = 3), duodenojejunal flexure (n = 2) or transverse mesocolon (n = 3). Mean age was 68 years (54-81). Conversion rate was 0 %, mean operative time 240 min and mean blood loss 340 ml. Median intensive/high care and hospital stay were 1 and 5 days, respectively. Clavien-Dindo score 3+ complication rate was 12 % and ISGPF grade B/C pancreatic fistula rate 28 %; 90-day (or in-hospital) mortality was 0 %. The pancreatic resection margin was clear in all patients, and the posterior margin was involved (<1 mm) in 6 patients, meaning an overall R0 resection rate of 76 %. No resection margin was microscopically involved. Median nodal sample was 15 nodes (3-26). With an average follow-up of 17.2 months, 1-year survival was 88 %.

    CONCLUSIONS: A standardised laparoscopic approach to pancreatic adenocarcinoma in the left pancreas can be adopted safely. Our study shows that these results can be reproduced across multiple sites using the same technique.

  • 2. Abu Hilal, Mohammed
    et al.
    Di Fabio, Francesco
    Syed, Shareef
    Wiltshire, Robert
    Dimovska, Eleonora
    Turner, David
    Primrose, John N
    Pearce, Neil W
    Assessment of the financial implications for laparoscopic liver surgery: a single-centre UK cost analysis for minor and major hepatectomy.2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 7, p. 2542-50Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic hepatectomy is progressively gaining popularity. However, it is still unclear whether the laparoscopic approach offers cost advantages compared with the open approach, especially when major hepatectomies are required. Data providing useful insights into the costs of the laparoscopic approach for clinicians and hospitals are needed. The aim of this study is to assess the financial implications of the laparoscopic approach for two standardized minor and major hepatectomies: left lateral sectionectomy and right hepatectomy.

    METHODS: A cost comparison analysis of patients undergoing laparoscopic right hepatectomy (LRH) and laparoscopic left lateral sectionectomy (LLLS) versus the open counterparts was performed. Data considered for the comparison analysis were operative costs (theatre cost, consumables and surgeon/anaesthetic labour cost), postoperative costs (hospital stay, complication management and readmissions) and overall costs.

    RESULTS: A total of 149 patients were included: 38 patients underwent LRH and 46 open right hepatectomy (ORH); 46 patients underwent LLLS and 19 open left lateral sectionectomy (OLLS). For LRH the mean operative, postoperative and overall costs were £10,181, £4,037 and £14,218; for ORH the mean operative, postoperative and overall costs were £6,483 (p < 0.0001), £10,304 (p < 0.0001) and £16,787 (p = 0.886). Regarding LLLS, the mean operative, postoperative and overall costs were £5,460, £2,599 and £8,059; for OLLS the mean operative, postoperative and overall costs were £5,841 (p = 0.874), £5,796 (p < 0.0001) and £11,637 (p = 0.0001).

    CONCLUSION: Our data support the cost advantage of the laparoscopic approach for left lateral sectionectomy and the cost neutrality for right hepatectomy.

  • 3.
    Blohm, My
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Center for Clinical Research Dalarna. Karolinska Inst, Dept Clin Sci Intervent & Technol, Stockholm, Sweden.;Mora Hosp, Dept Surg, Mora, Sweden.
    Sandblom, Gabriel
    Karolinska Inst, Dept Clin Sci & Educ, Sodersjukhuset, Stockholm, Sweden.
    Enochsson, Lars
    Umeå Univ, Dept Surg & Perioperat Sci, Surg, Umeå, Sweden.
    Cengiz, Yucel
    Umeå Univ, Dept Surg & Perioperat Sci, Surg, Umeå, Sweden.
    Austrums, Edmunds
    Cent Hosp Kristianstad, Dept Surg, Kristianstad, Sweden.
    Abdon, Elisabeth
    Östersund Hosp, Dept Surg, Östersund, Sweden.
    Hennings, Joakim
    Umeå Univ, Dept Surg & Perioperat Sci, Surg, Umeå, Sweden.
    Hedberg, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Center for Clinical Research Dalarna. Mora Hosp, Dept Surg, Mora, Sweden.
    Gustafsson, Ulf
    Karolinska Inst, Danderyd Hosp, Dept Clin Sci, Div Surg, Stockholm, Sweden.
    Diaz-Pannes, Angelica
    Södertälje Hosp, Dept Surg, Södertälje, Sweden.
    Österberg, Johanna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Center for Clinical Research Dalarna. Karolinska Inst, Dept Clin Sci Intervent & Technol, Stockholm, Sweden.;Mora Hosp, Dept Surg, Mora, Sweden.
    Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy2022In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 36, no 6, p. 4602-4613Article in journal (Refereed)
    Abstract [en]

    Background Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC).

    Methods The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

    Results Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001).

    Conclusions Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

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  • 4.
    Dahlstrand, Ursula
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Sandblom, Gabriel
    Ljungdahl, Mikael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wollert, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gunnarsson, Ulf
    TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 10, p. 3632-3638Article in journal (Refereed)
    Abstract [en]

    Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain. Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)]. A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups. Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

  • 5.
    Deijen, Charlotte L.
    et al.
    Vrije Univ Amsterdam.
    Vasmel, Jeanine E.
    Vrije Univ Amsterdam.
    de Lange-de Klerk, Elly S. M.
    Vrije Univ Amsterdam.
    Cuesta, Miguel A.
    Vrije Univ Amsterdam.
    Coene, Peter-Paul L. O.
    Maasstad Hosp, Rotterdam, Netherlands..
    Lange, Johan F.
    Erasmus MC, Rotterdam, Netherlands..
    Meijerink, W. J. H. Jeroen
    Vrije Univ Amsterdam.
    Jakimowicz, Jack J.
    Delft Univ Technol.
    Jeekel, Johannes
    Erasmus MC, Dept Surg, Rotterdam.
    Kazemier, Geert
    Vrije Univ Amsterdam.
    Janssen, Ignace M. C.
    Rijnstate Hosp, Dept Surg, Arnhem.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Haglind, Eva
    Sahlgrens Univ Hosp.
    Bonjer, H. Jaap
    Vrije Univ Amsterdam.
    Ten-year outcomes of a randomised trial of laparoscopic versus open surgery for colon cancer2017In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 31, no 6, p. 2607-2615Article in journal (Refereed)
    Abstract [en]

    Laparoscopic surgery for colon cancer is associated with improved recovery and similar cancer outcomes at 3 and 5 years in comparison with open surgery. However, long-term survival rates have rarely been reported. Here, we present survival and recurrence rates of the Dutch patients included in the COlon cancer Laparoscopic or Open Resection (COLOR) trial at 10-year follow-up. Between March 1997 and March 2003, patients with non-metastatic colon cancer were recruited by 29 hospitals in eight countries and randomised to either laparoscopic or open surgery. Main inclusion criterion for the COLOR trial was solitary adenocarcinoma of the left or right colon. The primary outcome was disease-free survival at 3 years, and secondary outcomes included overall survival and recurrence. The 10-year follow-up data of all Dutch patients were collected. Analysis was by intention-to-treat. The trial was registered at ClinicalTrials.gov (NCT00387842). In total, 1248 patients were randomised, of which 329 were Dutch. Fifty-eight Dutch patients were excluded and 15 were lost to follow-up, leaving 256 patients for 10-year analysis. Median follow-up was 112 months. Disease-free survival rates were 45.2 % in the laparoscopic group and 43.2 % in the open group (difference 2.0 %; 95 % confidence interval (CI) -10.3 to 14.3; p = 0.96). Overall survival rates were 48.4 and 46.7 %, respectively (difference 1.7 %; 95 % CI -10.6 to 14.0; p = 0.83). Stage-specific analysis revealed similar survival rates for both groups. Sixty-two patients were diagnosed with recurrent disease, accounting for 29.4 % in the laparoscopic group and 28.2 % in the open group (difference 1.2 %; 95 % CI -11.1 to 13.5; p = 0.73). Seven patients had port- or wound-site recurrences (laparoscopic n = 3 vs. open n = 4). Laparoscopic surgery for non-metastatic colon cancer is associated with similar rates of disease-free survival, overall survival and recurrences as open surgery at 10-year follow-up.

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  • 6.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Ottosson, Johan
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 5, p. 2011-2015Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively.

    METHODS: Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size.

    RESULTS: Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year.

    CONCLUSION: A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.

  • 7. Eiriksson, Kristinn
    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.
    Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques2009In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 5, p. 1038-1042Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Laparoscopic liver surgery is evolving and the best technique for dividing the liver parenchyma is currently under debate. The aim of this study was to study different techniques during a full laparoscopic lobe resection, and determine the efficacy and risks of bleeding and gas embolism. METHODS: Sixteen pigs were randomized to two groups: group US underwent an operation with Ultracision shears (AutoSonix) and ultrasonic dissector (CUSA) and group VS with a vessel sealing system (Ligasure) and ultrasonic dissector. A left lobe resection was performed. Transesophageal endoscopic echocardiography (TEE) was used to detect gas emboli in the right side of the heart and pulmonary artery. The operations and TEE were recorded for later assessment. RESULTS: Compared with group VS, group US exhibited significantly more intraoperative bleeding (p = 0.02), a trend towards a longer operation time (p = 0.08), and a trend towards more embolization for grade I emboli. In total, 10 of 15 animals had emboli during the operation. CONCLUSIONS: This study showed that a laparoscopic left lobe resection can be performed with a combination of AutoSonix and CUSA as well as with Ligasure and CUSA instrumentation. In our hands, less bleeding was incurred with Ligasure than with AutoSonix.

  • 8.
    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.
    Rudberg, C.
    Leijonmarck, C-E.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Spangen, L.
    Wickbom, G.
    Wingren, U.
    Montgomery, A.
    Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair2007In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 21, no 4, p. 634-640Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence. METHODS: This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique. RESULTS: A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group. CONCLUSION: The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

  • 9.
    Hedberg, Jakob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Hedenström, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 7, p. 2302-2307Article in journal (Refereed)
    Abstract [en]

    Background

    The number of gastric bypass operations being preformed is increasing rapidly due to good weight loss and alleviation of co-morbidities in combination with low mortality and morbidity. Stomal ulcers are, however, a clinical problem after gastric bypass, giving patients discomfort, risk of bleeding or even perforation. To measure the acidity in the proximal jejunum, we adopted the wire-less pH-metry (BRAVO-system) developed for evaluating reflux esophagitis.

    Methods

    25 patients (4 men, median age 44 years, BMI 29.3) who had undergone RYGBP 4 years earlier were recruited. Twenty-one asymptomatic, non-PPI users and in addition, four symtomatic patients (ongoing or stopped PPI-treatment) were studied. The wire-less BRAVO-capsule was positioned at the level of the gastrojejunal anastomosis under visual control with the endoscope. pH was registered for up to 48 hours. Time with pH<4 was calculated. Two patients were studied with two capsules.

    Results

    Of the 25 recruited patients capsule placement was successful in all but 2 patients, and in 3 patients a constant neutral environment was seen before a premature loss of signal, indicating early loss of position, thus 20 successful measurements were made. The mean time of registration was 25.7 hours (6.1-47.4, n=20). In the 16 asymtomatic patients, median percentage of time with pH<4 at the gastrojejunostomy was 10.6% (range 0.4 -37.7%). When dividing the registration time in day (08.00-22.00) and night (22.00-06.00), the median percentage of time with pH<4 was 8.4 and 6.3, respectively, (p=0.08). The two double measurements gave similar results indicating consistency. No complications occurred.

    Conclusion

    Wire-less pH-measurements in the proximal jejunum after gastric bypass are feasible and safe. The acidity was significant (10.5% of the registration time) even in asymptomatic patients with small gastric pouches. The described method could be useful in evaluation of epigastralgia after gastric bypass and in appraisal of PPI treatment of stomal ulcer.

     

  • 10. Jersenius, U.
    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
    Laparoscopic parenchymal division of the liver in a porcine model: comparison of the efficacy and safety of three different techniques2007In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 21, no 2, p. 315-320Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Bleeding is a known and CO2 embolization a suggested risk factor for increased morbidity after laparoscopic liver resection. Devices for laparoscopic liver parenchymal transection must be evaluated for safety in this context. METHOD: Twelve piglets underwent laparoscopic surgery during CO2 pneumoperitoneum, each animal receiving three 6 cm long transections into the liver parenchyma made with ultrasonic dissector, ultrasonic shears and vessel sealing system, respectively. Endpoints were bleeding, operation time and gas embolization. The transections and embolization events, evaluated with transesophageal echocardiography, were video recorded. Bleeding and embolization were also assessed on video tapes and operating time measured. Arterial blood gases were recorded on line. RESULTS: The ultrasonic dissector was least advantageous in terms of bleeding and operation time. Gas embolization was more frequent with the vessel sealing system than with the ultrasonic dissector and ultrasonic shears. During two episodes of gas embolization, pCO2 increased and pO2 and pH decreased. CONCLUSIONS: Use of all three devices is feasible. Bleeding and operation time are greatest with the ultrasonic dissector. Gas embolization occurs during transection, though in most instances it is completely harmless. Laparoscopic liver surgery with these techniques used may pose a risk of gas embolization with clinical implications. Monitoring for such events is probably to be recommended.

  • 11.
    Langerth, Ann
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Isaksson, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Karlson, Britt-Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Urdzik, Jozef
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Linder, Stefan
    Karolinska Inst, Karolinska Univ Hosp, Ctr Digest Dis, Div Surg,CLINTEC, Stockholm, Sweden.
    ERCP‑related perforations: a population‑based study of incidence,mortality, and risk factors2020In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 34, p. 1939-1947Article in journal (Refereed)
    Abstract [en]

    Background: Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study.

    Methods: Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1-3) groups. Furthermore, fatal group patients' records were reviewed.

    Results: Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8-21.6), age over 80 years (OR 3.8, 95% CI 2.0-7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1-7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1-3 centers mortality was higher (45% vs. 21%, p = 0.024).

    Conclusions: ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.

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  • 12. Lindberg, F
    et al.
    Bergqvist, D
    Björck, M
    Rasmussen, I
    Renal hemodynamics during carbon dioxide pneumoperitoneum: an experimental study in pigs.2003In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 17, no 3, p. 480-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic living donor nephrectomy is increasingly being performed, although the effects of carbon dioxide pneumoperitoneum (CO2 PP) on renal function and hemodynamics and the levels of vasopressin are not well studied.

    METHODS: Renal blood flow, renal venous pressure, urine output, and vasopressin concentrations in renal venous blood were measured in pigs subjected to 12 mmHg of CO2 PP for 150 min.

    RESULTS: Renal blood flow was decreased at induction of PP and increased during the first 30 min after exsufflation. Renal venous pressure was increased during PP. There was indirect evidence of a decrease in urine output during PP. No changes in renal venous vasopressin concentrations were seen.

    CONCLUSION: A CO2 PP of 12 mmHg causes changes in renal hemodynamics and urine output. No changes in vasopressin levels were seen in this pig model, suggesting that other explanations for the observed changes must be sought.

  • 13. Lindberg, F
    et al.
    Bergqvist, D
    Rasmussen, I
    Haglund, U
    Hemodynamic changes in the inferior caval vein during pneumoperitoneum. An experimental study in pigs.1997In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 11, no 5, p. 431-7Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Laparoscopic procedures of increasing difficulty and duration are becoming more and more common. This may cause significant challenges to the circulatory system and possibly influence thrombogenicity.

    METHODS: Experimental study of carbon dioxide pneumoperitoneum in pigs.

    RESULTS: Inferior caval vein blood flow remained unchanged, whereas inferior caval vein pressure increased during pneumoperitoneum. Inferior caval vein, pulmonary, and systemic vascular resistance increased during pneumoperitoneum and remained increased after exsufflation.

    CONCLUSIONS: Pneumoperitoneum leads to an increased inferior caval vein pressure, which could cause a dilation of peripheral veins. The similar patterns of vascular resistance in the inferior caval vein, pulmonary artery, and systemic arteries (a gradual increase remaining elevated after exsufflation) suggest a common humoral factor or increased sympathetic nerve activity.

  • 14.
    Lindberg, F.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Björck, Martin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Bergqvist, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Current use of thromboembolism prophylaxis for laparoscopic cholecystectomy patients in Sweden2005In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 19, no 3, p. 386-388Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The need for thromboembolism (TE) prophylaxis during laparoscopic surgery is not well established. The aim of this study was to investigate current TE prophylaxis in patients undergoing laparoscopic cholecystectomy (LC) in Sweden. METHODS: Mail questionnaire to all Surgical Departments in Sweden about the current use of thromboembolism prophylaxis in patients undergoing laparoscopic cholecystectomy. RESULTS: The response rate was 78 of 80 departments of surgery (98%). Seventy reported performing LC. Thirty-six percent used thromboembolism prophylaxis in all patients, 17% in most, 9% in half their patients and 39% only rarely. The current use of thromboembolism prophylaxis ranged from low-molecular-weight heparin for 7 days + stockings in all patients to no prophylaxis at all in the majority of patients. CONCLUSIONS: The use of thromboembolism prophylaxis in LC patients is highly variable, even in the small and homogenous country of Sweden. Further studies concerning the risk of TE complications after laparoscopic surgery are warranted.

  • 15. Lindberg, F
    et al.
    Rasmussen, I
    Siegbahn, A
    Bergqvist, D
    Coagulation activation after laparoscopic cholecystectomy in spite of thromboembolism prophylaxis.2000In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 14, no 9, p. 858-61Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to determine whether laparoscopic cholecystectomy (LC), in spite of its minimally invasive nature, causes coagulation activation.

    METHODS: Sixty-four patients undergoing LC were included prospectively. All received either dextran or low-molecular-weight heparin (LMWH). Blood samples taken the morning of the operation and the following morning were analyzed for TAT, FM, fragment 1+2, tPA, PAI-1, vWf, D-dimer, Hb, hematocrit, and APC resistance.

    RESULTS: Significant increases in TAT, FM, fragment 1+2, and D-dimer were seen, whereas APC resistance, Hb, and hematocrit decreased significantly. Dextran led to a decrease in vWf and no change in tPA, whereas LMWH led to an increase in both these parameters.

    CONCLUSIONS: Laparoscopic cholecystectomy causes coagulation activation. There are differences in the response between patients receiving dextran and LMWH as thromboembolism prophylaxis. Since most patients are discharged the day after the operation, there could be practical as well as theoretical advantages to using dextran.

  • 16.
    Ljungdahl, Mikael
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial2006In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 20, no 8, p. 1248-1251Article in journal (Refereed)
    Abstract [en]

    Background: Percutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety. Methods: This study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure. Results: The procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference). Conclusion: The findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.

  • 17. Nasser, Hassan
    et al.
    Ivanics, Tommy
    Carlin, Arthur M.
    Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass2020In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218Article in journal (Refereed)
  • 18. Nasser, Hassan
    et al.
    Ivanics, Tommy
    Varban, Oliver A.
    Finks, Jonathan F.
    Bonham, Aaron
    Ghaferi, Amir A.
    Carlin, Arthur M.
    Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m22020In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218Article in journal (Refereed)
  • 19.
    Oussi, Ninos
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Loukas, Constantinos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Kjellin, Ann
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Lahanas, Vasileios
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Georgiou, Konstantinos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Henningsohn, Lars
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Urol, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Felländer-Tsai, Li
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Orthoped & Biotechnol, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.
    Georgiou, Evangelos
    Univ Athens, Sch Med, Med Phys Lab, Simulat Ctr, Athens.
    Enochsson, Lars
    Karolinska Univ Hosp, CAMST, Stockholm.; Karolinska Inst, Div Surg, Dept Clin ScienceIntervent & Technol CLINTEC, Stockholm.; Umeå Univ, Dept Surg & Perioperat Sci, Div Surg, Umeå.; Umeå Univ, Dept Surg & Perioperat Sci, Div Surg, Luleå.
    Video analysis in basic skills training: a way to expand the value and use of BlackBox training?2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 1, p. 87-95Article in journal (Refereed)
    Abstract [en]

    Background

    Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

    Methods

    Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

    Results

    31 students (19 females and 12 males), mean age of 26.2 ± 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

    Conclusions

    Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

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  • 20.
    Persson, Jan
    et al.
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Smedh, Ulrika
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Johnsson, Åse
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Radiol,Inst Clin Sci, Gothenburg, Sweden.
    Ohlin, Bo
    Blekinge Hosp, Dept Surg, Karlskrona, Sweden.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Nilsson, Magnus
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Lundell, Lars
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Sund, Berit
    Karolinska Inst, Karolinska Univ Hosp, Div Surg, Dept Surg Gastroenterol,CLINTEC, Stockholm, Sweden.
    Johnsson, Erik
    Univ Gothenburg, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Surg,Inst Clin Sci, S-41345 Gothenburg, Sweden.
    Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial.2017In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 31, no 10, p. 4025-4033Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated.

    METHODS: Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter.

    RESULTS: There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083).

    CONCLUSION: In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.

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  • 21. Sandbu, R
    et al.
    Birgisdottir, B
    Arvidsson, D
    Sjöstrand, U
    Rubertsson, Sten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Optimal positive end-expiratory pressure (PEEP) settings in differential lung ventilation during simultaneous unilateral pneumothorax and laparoscopy: an experimental study in pigs.2001In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 15, no 12, p. 1478-83Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A combined thoraco-laparoscopic technique for esophageal resection is technically possible, but it requires special attention to ventilation. The positive insufflation pressure normally used in laparoscopy will, when communication between thorax and abdomen is established, create a pneumothorax.

    METHODS: We performed an experimental study of differential lung ventilation with different levels of positive end-expiratory pressure (PEEP) settings during thoraco-laparoscopy in anesthetized pigs.

    RESULTS: Positive pressure insufflation of carbon dioxide (CO2) resulted in elevated pulmonary capillary wedge pressure, hypercarbia, and respiratory acidosis. Hypoxemia, however, developed only at lower settings of PEEP. Heart rate, mean arterial pressure, and cardiac output remained relatively stable.

    CONCLUSION: Pneumopleuroperitoneum under positive CO2 insufflation pressure had adverse effects on blood gases. Hypercarbia, respiratory acidosis, and hypoxemia were early manifestations that occurred even in the presence of hemodynamic stability. The application of PEEP equal to or above CO2 insufflation pressure improved blood gases; in particular, the hypoxia could be avoided. No beneficial effects of differential lung ventilation were documented.

  • 22. Schölin, Johnna
    et al.
    Buunen, Mark
    Hop, Wim
    Bonjer, Jaap
    Anderberg, Bo
    Cuesta, Miguel
    Delgado, Salvadora
    Ibarzabal, Ainitze
    Ivarsson, Marie-Louise
    Janson, Martin
    Lacy, Antonio
    Lange, Johan
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Skullman, Stefan
    Haglind, Eva
    Bowel obstruction after laparoscopic and open colon resection for cancer: results of 5 years of follow-up in a randomized trial2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 12, p. 3755-3760Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared.

    METHODS: A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery.

    RESULTS: Baseline characteristics for the evaluated laparoscopic (n = 383) and open (n = 403) groups were comparable. The cumulative obstruction percentages at 5 years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant.

    CONCLUSIONS: This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery.

  • 23. Siegel, R.
    et al.
    Cuesta, M. A.
    Targarona, E.
    Bader, F. G.
    Morino, M.
    Corcelles, R.
    Lacy, A. M.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Haglind, E.
    Bujko, K.
    Bruch, H. P.
    Heiss, M. M.
    Eikermann, M.
    Neugebauer, E. A. M.
    Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)2011In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 8, p. 2423-2440Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

    METHODS:

    An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

    RESULTS:

    Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

    CONCLUSIONS:

    Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

  • 24.
    Sima, Eduardo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Hedberg, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastrointestinal symptoms, weight loss and patient satisfaction 5 years after gastric bypass: a study of three techniques for the gastrojejunal anastomosis.2016In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 30, no 4, p. 1553-1558Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The optimal operative technique in gastric bypass (RYGB) is still under debate. We have studied patient-reported gastrointestinal symptoms and weight loss 5 years after RYGB performed with three different stapling techniques for the gastrojejunal anastomosis (GJ).

    METHODS: Out of 593 patients operated with RYGB, 489 patients [80.2 % women, body mass index (BMI) 44.9 (33-68) kg/m(2)] answered our 5-year follow-up questionnaire concerning gastrointestinal symptoms (vomiting, reflux, dumping, abdominal pain or diarrhea), weight loss, need for postoperative endoscopic interventions and overall satisfaction with the procedure. We compared the results for three different GJ techniques: linear stapler (LS, n = 103), 21-mm circular stapler (C21, n = 88) and 25-mm circular stapler (C25, n = 298).

    RESULTS: Dumping was the most commonly reported symptom (14.1 % of all patients on a weekly to daily basis), however, less frequently reported in the C25 group (p < 0.05). Vomiting, prevalent in 2.9 % of all patients, was more frequently reported in the C21 group (p < 0.01). No group consistently showed greater weight loss compared to the other two groups. A higher incidence of endoscopic dilatations due to strictures was reported in the C21 group (12.5 % compared to 4.5 % of all patients, p < 0.05). Overall patient satisfaction was high (88 %).

    CONCLUSION: Our data suggest that the technique for the construction of the GJ in RYGB affects gastrointestinal symptoms 5 years postoperatively. The difference is moderate but indicates that a narrow GJ results in increased frequency of vomiting and need for endoscopic interventions without improving the weight result.

  • 25.
    Syrén, Eva-Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Enochsson, Lars
    Department of Surgical and Perioperative Sciences, Sunderby Research Unit, Umeå University, Surgery, Umeå, Sweden.
    Eriksson, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Eklund, Arne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research, County of Västmanland.
    Isaksson, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sandblom, Gabriel
    Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden.
    Cardiovascular complications after common bile duct stone extrations2021In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 35, no 7, p. 3296-3302Article in journal (Refereed)
    Abstract [en]

    Background Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy.

    Methods The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006–2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention.

    Results A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group.

    Conclusions Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. More studies are required to provide reliable guidelines for the management of CBDS.

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  • 26.
    Syrén, Eva-Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research, County of Västmanland. Akad Hosp, Dept Surg, Uppsala, Sweden..
    Sandblom, Gabriel
    Karolinska Inst, Dept Clin Sci & Educ Sodersjukhuset, Stockholm, Sweden.;Soder Sjukhuset, Dept Surg, Stockholm, Sweden..
    Enochsson, Lars
    Umeå Univ, Dept Surg & Perioperat Sci, Surg, Umeå, Sweden..
    Eklund, Arne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research, County of Västmanland. Hosp Vastmanland, Dept Surg, Västerås, Sweden..
    Isaksson, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Akad Hosp, Dept Surg, Uppsala, Sweden..
    Osterberg, Johanna
    Mora Hosp, Dept Surg, Mora, Sweden.;Karolinska Inst, Dept Clin Sci Intervent & Technol CLINTEC, Stockholm, Sweden..
    Eriksson, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Clinical Research Sörmland. Hosp Vastmanland, Dept Surg, Västerås, Sweden..
    Outcome of ERCP related to case-volume2022In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 36, no 7, p. 5339-5347Article in journal (Refereed)
    Abstract [en]

    Background and aims In some studies, high endoscopic retrograde cholangiopancreatography (ERCP) case-volume has been shown to correlate to high success rate in terms of successful cannulation and fewer adverse events. The aim of this study was to analyze the association between ERCP success and complications, and endoscopist and centre case-volumes. Methods Data were obtained from the Swedish National Register for Gallstone Surgery and ERCP (GallRiks) on all ERCPs performed for Common Bile Duct Stone (CBDS) (n = 17,873) and suspected or confirmed malignancy (n = 6152) between 2009 and 2018. Successful cannulation rate, procedure time, intra- and postoperative complication rates and post-ERCP pancreatitis (PEP) rate, were compared with endoscopist and centre ERCP case-volumes during the year preceding the procedure as predictor. Results In multivariable analyses of the CBDS group adjusting for age, gender and year, a high endoscopist case-volume was associated with higher successful cannulation rate, lower complication and PEP rates, and shorter procedure time (p < 0.05). Centres with a high annual case-volume were associated with high successful cannulation rate and shorter procedure time (p < 0.05), but not lower complication and PEP rates. When indication for ERCP was malignancy, a high endoscopist case-volume was associated with high successful cannulation rate and low PEP rates (p < 0.05), but not shorter procedure time or low complication rate. Centres with high case-volume were associated with high successful cannulation rate and low complication and PEP rates (p < 0.05), but not shorter procedure time. Conclusions The results suggest that higher endoscopist and centre case-volumes are associated with safer ERCP and successful outcome.

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  • 27.
    Syrén, Eva-Lena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Västmanland Hosp, Clin Res Ctr, Västerås, Sweden..
    Sandblom, Gabriel
    Karolinska Inst, Dept Clin Sci & Educ, Sodersjukhuset, Stockholm, Sweden.;Soder Sjukhuset, Dept Surg, Stockholm, Sweden..
    Eriksson, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Västmanland Hosp, Clin Res Ctr, Västerås, Sweden..
    Eklund, Arne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Västmanland Hosp, Clin Res Ctr, Västerås, Sweden..
    Isaksson, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Enochsson, Lars
    Umeå Univ, Sunderby Res Unit, Dept Surg & Perioperat Sci, Surg, Umeå, Sweden..
    Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis2020In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 34, no 11, p. 4883-4889Article in journal (Refereed)
    Abstract [en]

    Background Rendezvous endoscopic retrograde cholangiopancreaticography (ERCP) is a well-established method for treatment of choledocholithiasis. The primary aim of this study was to determine how different techniques for management of common bile duct stone (CBDS) clearance in patients undergoing cholecystectomy have changed over time at tertiary referral hospitals (TRH) and county/community hospitals (CH). The secondary aim was to see if postoperative rendezvous ERCP is a safe, effective and feasible alternative to intraoperative rendezvous ERCP in the management of CBDS. Methods Data were retrieved from the Swedish registry for cholecystectomy and ERCP (GallRiks) 2006-2016. All cholecystectomies, where CBDS were found at intraoperative cholangiography, and with complete 30-day follow-up (n = 10,386) were identified. Data concerning intraoperative and postoperative complications, readmission and reoperation within 30 days were retrieved for patients where intraoperative ERCP (n = 2290) and preparation for postoperative ERCP were performed (n = 2283). Results Intraoperative ERCP increased (7.5% 2006; 43.1% 2016) whereas preparation for postoperative ERCP decreased (21.2% 2006; 17.2% 2016) during 2006-2016. CBDS management differed between TRHs and CHs. Complications were higher in the postoperative rendezvous ERCP group: Odds Ratio [OR] 1.69 (95% confidence interval [CI] 1.16-2.45) for intraoperative complications and OR 1.50 (CI 1.29-1.75) for postoperative complications. Intraoperative bleeding OR 2.46 (CI 1.17-5.16), postoperative bile leakage OR 1.89 (CI 1.23-2.90) and postoperative infection with abscess OR 1.55 (CI 1.05-2.29) were higher in the postoperative group. Neither post-ERCP pancreatitis, postoperative bleeding, cholangitis, percutaneous drainage, antibiotic treatment, ICU stay, readmission/reoperation within 30 days nor 30-day mortality differed between groups. Conclusions Techniques for management of CBDS found at cholecystectomy have changed over time and differ between TRH and CH. Rendezvous ERCP is a safe and effective method. Even though intraoperative rendezvous ERCP is the preferred method, postoperative rendezvous ERCP constitutes an acceptable alternative where ERCP resources are lacking or limited.

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  • 28. Videhult, Per
    et al.
    Sandblom, Gabriel
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Rasmussen, Ib Christian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    How reliable is intraoperative cholangiography as a method for detecting common bile duct stones?: A prospective population-based study on 1171 patients2009In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 2, p. 304-12Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large nonselected patient samples. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation. METHODS: All patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala in Sweden, a county with a population of 302,000 in December 2004, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course. RESULTS: 1171 patients were registered, and among these IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS. CONCLUSION: Intraoperative cholangiography is a safe and accurate method for detecting common bile duct stones.

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