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  • 251. Dormagen, Johann B.
    et al.
    Tötterman, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Røise, Olav
    Sandvik, Leiv
    Kløw, Nils-E.
    Efficacy of plain radiography and computer tomography in localizing the site of pelvic arterial bleeding in trauma patients2010In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455, Vol. 51, no 1, p. 107-16Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Immediate angiography is warranted in pelvic trauma patients with suspected arterial injury (AI) in order to stop ongoing bleeding. Prior to angiography, plain pelvic radiography (PPR) and abdominopelvic computer tomography (CT) are performed to identify fracture and hematoma sites. PURPOSE: To investigate if PPR and CT can identify the location of AI in trauma patients undergoing angiography. MATERIAL AND METHODS: 95 patients with pelvic fractures on PPR (29 women, 66 men), at a mean age of 44 (9-92) years, underwent pelvic angiography for suspected AI. Fifty-six of them underwent CT additionally. Right and left anterior and posterior fractures on PPR were registered, and fracture displacement was recorded for each quadrant. Arterial blush on CT was registered, and the size of the hematoma in each region was measured in cm(2). AIs were registered for anterior and posterior segments of both internal iliac arteries. Presence of fractures, arterial blush, and hematomas were correlated with AI. RESULTS: Presence of fracture in the corresponding skeletal segment on PPR showed sensitivity and specificity of 0.86 and 0.58 posteriorly, and 0.87 and 0.44 anteriorly. The area under the curve (AUC) was 0.77 and 0.69, respectively. Fracture displacement on PPR >0.9 cm posteriorly and >1.9 cm anteriorly revealed specificity of 0.84. Sensitivities of arterial blush and hematoma on CT were 0.38 and 0.82 posteriorly, and 0.24 and 0.82 anteriorly. The specificities were 0.96 and 0.58 posteriorly, and 0.79 and 0.53 anteriorly, respectively. For hematomas, the AUC was 0.79 posteriorly and 0.75 anteriorly. Size of hematoma >22 cm(2) posteriorly and >29 cm(2) anteriorly revealed specificity of 0.85 and 0.86, respectively. CONCLUSION: CT findings of arterial blush and hematoma predicted site of arterial bleeding on pelvic angiography. Also, PPR predicted the site of bleeding using location of fracture and size of displacement. In the hemodynamically unstable patient, PPR may contribute equally to effective assessment of injured arteries.

  • 252.
    Dorner, Thomas E.
    et al.
    Med Univ Vienna, Ctr Publ Hlth, Dept Social & Prevent Med, Kinderspitalgasse 15-1, A-1090 Vienna, Austria.
    Helgesson, Magnus
    Karolinska Inst, Div Insurance Med, Dept Clin Neurosci, Berzeliusv 3, S-17177 Stockholm, Sweden.
    Nilsson, Kerstin
    Karolinska Inst, Div Insurance Med, Dept Clin Neurosci, Berzeliusv 3, S-17177 Stockholm, Sweden.
    Pazarlis, Konstantinos A.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Ropponen, Annina
    Karolinska Inst, Div Insurance Med, Dept Clin Neurosci, Berzeliusv 3, S-17177 Stockholm, Sweden;Finnish Inst Occupat Hlth, POB 18, Helsinki 00390, Finland.
    Svedberg, Pia
    Karolinska Inst, Div Insurance Med, Dept Clin Neurosci, Berzeliusv 3, S-17177 Stockholm, Sweden.
    Mittendorfer-Rutz, Ellenor
    Karolinska Inst, Div Insurance Med, Dept Clin Neurosci, Berzeliusv 3, S-17177 Stockholm, Sweden.
    Course and characteristics of work disability 3 years before and after lumbar spine decompression surgery: a national population-based study2018In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 8, article id 11811Article in journal (Refereed)
    Abstract [en]

    Despite decompression surgery being a widespread intervention for patients with dorsopathies (i.e. back pain) affecting the lumbar spine, the scientific knowledge on patterns and characteristics of work disability before and after the surgery is limited. Sickness absence (SA) and disability pension (DP) were examined three years before and after surgery in 8558 patients aged 25-60 years who underwent lumbar spine decompression surgery in Sweden. They were compared to individuals with diagnosed dorsopathies but no surgery and individuals from the general population as matched comparison groups. According to Group Based Trajectory models, in patients with decompression surgery, 39% had low levels of SA/DP during the entire study period and 15% started with low levels of SA/DP, which increased in the year before, and declined to almost zero in the second year after surgery. Three trajectory groups (12%, 17%, and 18%) started at different levels of SA/DP, which increased in the years before, and declined in the third year after surgery. The trajectory groups in the comparison groups showed lower levels of work disability. Sex, education, and the use of antidepressants and analgesics the year before surgery played an important role to explain the variance of trajectory groups in patients with surgery.

  • 253.
    Droeser, Raoul A.
    et al.
    Skane Univ Hosp, Dept Surg, Lund, Sweden..
    Ottosson, Johan
    Univ Orebro, Fac Med & Hlth, Dept Surg, Orebro, Sweden..
    Muth, Andreas
    Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Surg, Gothenburg, Sweden..
    Hultin, Hella
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Lindwall-Ahlander, Karin
    Gavle Cty Hosp, Dept Surg, Gavle, Sweden..
    Bergenfelz, Anders
    Skane Univ Hosp, Dept Surg, S-22185 Lund, Sweden..
    Almquist, Martin
    Skane Univ Hosp, Dept Surg, S-22185 Lund, Sweden.;Lund Univ, S-22185 Lund, Sweden..
    Hypoparathyroidism after total thyroidectomy in patients with previous gastric bypass2017In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 402, no 2, p. 273-280Article in journal (Refereed)
    Abstract [en]

    Purpose Case reports suggest that patients with previous gastric bypass have an increased risk of severe hypocalcemia after total thyroidectomy, but there are no population-based studies. The prevalence of gastric bypass before thyroidectomy and the risk of hypocalcemia after thyroidectomy in patients with previous gastric bypass were investigated. Methods By cross-linking The Scandinavian Quality Registry for Thyroid, Parathyroid and Adrenal Surgery with the Scandinavian Obesity Surgery Registry patients operated with total thyroidectomy without concurrent or previous surgery for hyperparathyroidism were identified and grouped according to previous gastric bypass. The risk of treatment with intravenous calcium during hospital stay, and with oral calcium and vitamin D at 6 weeks and 6 months postoperatively was calculated by using multiple logistic regression in the overall cohort and in a 1:1 nested case-control analysis. Results We identified 6115 patients treated with total thyroidectomy. Out of these, 25 (0.4 %) had undergone previous gastric bypass surgery. In logistic regression, previous gastric bypass was not associated with treatment with i.v. calcium (OR 2.05, 95 % CI 0.48-8.74), or calcium and/or vitamin D at 6 weeks (1.14 (0.39-3.35), 1.31 (0.39-4.42)) or 6 months after total thyroidectomy (1.71 (0.40-7.32), 2.28 (0.53-9.75)). In the nested case-control analysis, rates of treatment for hypocalcemia were similar in patients with and without previous gastric bypass. Conclusion Previous gastric bypass surgery was infrequent in patients undergoing total thyroidectomy and was not associated with an increased risk of postoperative hypocalcemia.

  • 254. Dueland, Svein
    et al.
    Guren, Tormod K.
    Hagness, Morten
    Glimelius, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Oncology.
    Line, Pal-Dag
    Pfeiffer, Per
    Foss, Aksel
    Tveit, Kjell M.
    Chemotherapy or Liver Transplantation for Nonresectable Liver Metastases From Colorectal Cancer?2015In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 261, no 5, p. 956-960Article in journal (Refereed)
    Abstract [en]

    Objective: The primary objective was to compare overall survival (OS) in patients with colorectal cancer (CRC) with nonresectable liver-only metastases treated by liver transplantation or chemotherapy. Background: CRC is the third most common cancer worldwide. About 50% of patients will develop metastatic disease primarily to the liver and the lung. The majority of patients with liver metastases receive palliative chemotherapy, with a median OS of trial patients of about 2 years, and less than 10% are alive at 5 years. Methods: Patients with nonresectable liver-only CRC metastases underwent liver transplantation in the SECA study (n = 21). Disease-free survival (DFS) and OS of patients included in the SECA study were compared with progression-free survival (PFS) and OS in a similar cohort of CRC patients with liver-only disease included in a first-line chemotherapy study, the NORDIC VII study (n = 47). PFS/DFS and OS were estimated by the Kaplan-Meier method. Results: DFS/PFS in both groups were 8 to 10 months. However, a dramatic difference in OS was observed. The 5-year OS rate was 56% in patients undergoing liver transplantation compared with 9% in patients starting first-line chemotherapy. The reason for the large difference in OS despite similar DFS/PFS is likely different metastatic patterns at relapse/progression. Relapse in the liver transplantation group was often detected as small, slowly growing lung metastases, whereas progression of nonresectable liver metastases was observed in the chemotherapy group. Conclusions: Compared with chemotherapy, liver transplantation resulted in a marked increased OS in CRC patients with nonresectable liver-only metastases.

  • 255. Early Breast Cancer Trialists' Group, (EBCTCG)
    et al.
    Darby, S
    McGale, P
    Correa, C
    Taylor, C
    Arriagada, R
    Clarke, M
    Cutter, D
    Davie, C
    Ewertz, M
    Godwin, J
    Gray, R
    Pierce, L
    Whelan, T
    Wang, Y
    Peto, R
    Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient daga for 10,801 women in 17 randomised trials.2011In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 378, no 9804, p. 1707-1716Article in journal (Refereed)
    Abstract [en]

    Background After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk. Methods We undertook a meta-analysis of individual patient data for 10 801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease. Findings Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35.0% to 19.3% (absolute reduction 15.7%, 95% CI 13.7-17.7, 2p<0.00001) and reduced the 15-year risk of breast cancer death from 25.2% to 21.4% (absolute reduction 3.8%, 1.6-6.0, 2p=0.00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31.0% to 15.6% (absolute recurrence reduction 15.4%, 13.2-17.6, 2p<0.00001) and from 20.5% to 17.2% (absolute mortality reduction 3.3%, 0.8-5.8, 2p=0.005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (>= 20%), intermediate (10-19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7.8% (95% CI 3.1-12.5), 1.1% (-2.0 to 4.2), and 0.1% (-7.5 to 7.7) respectively (trend in absolute mortality reduction 2p=0.03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63.7% to 42.5% (absolute reduction 21.2%, 95% CI 14.5-27.9, 2p<0.00001) and the 15-year risk of breast cancer death from 51.3% to 42.8% (absolute reduction 8.5%, 1.8-15.2, 2p=0.01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease. Interpretation After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made.

  • 256.
    Edfeldt, Lennart
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Otolaryngology and Head and Neck Surgery.
    Strömbäck, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Otolaryngology and Head and Neck Surgery.
    Surgical treatment of congenital aural atresia - is it still justified?2015In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 135, no 3, p. 226-232Article in journal (Refereed)
    Abstract [en]

    Conclusion: Surgery candidacy based on the surgical accessibility of the middle ear seems more valuable than the use of a preoperative grading system. Also patients with severe malformations can benefit from surgical reconstruction. Objective: To evaluate the long-term results of the primary surgical treatment of patients with congenital auricular atresia (CAA). Methods: One hundred patients with CAA underwent surgical reconstruction between 1985 and 2010. The mean follow-up time was 40 months. All patients were retrospectively scored using the Jahrsdoerfer grading scale and divided into two groups according to the grade of their malformation. Group 1 included 20 patients with scores of 4-6 and group 2 included 80 patients with scores of 7-10. Pre- and postoperative air conduction (AC), bone conduction (BC), pure-tone average 'air-bone gap' (PTA(4)-ABG), surgical findings, postoperative complications, and revision surgeries performed were determined and compared between the two groups. Results: For 90% of the patients in group 1 and 79% of the patients in group 2, the postoperative ABG was within 0 and 30 dB. The most common complications were recurrent infection, lateralization of the tympanic membrane, and restenosis of the ear canal.

  • 257.
    Edholm, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. Linkoping Univ, Dept Surg & Clin & Expt Med, Linkoping, Sweden.
    Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry2018In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 9, p. 1256-1260Article in journal (Refereed)
    Abstract [en]

    Background: Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications.

    Objective: The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. Setting: Retrospective nationwide registry study.

    Methods: The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine.

    Results: Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n=8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48.85) or high (odds ratio .52 95% confidence interval .42.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens.

    Conclusion: Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of > 100 procedures have a lower risk of severe complications. (C) 2018 American Society for Bariatric Surgery. 

  • 258.
    Edholm, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Gastric Bypass: Facilitating the Procedure and Long-term Results2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Gastric bypass achieves weight loss in the morbidly obese. Preoperative weight loss is used to reduce the enlarged fatty liver that otherwise reduces visibility during surgery. The purpose of gastric bypass is to provide patients with long-term weight loss. The aim of this thesis was to investigate the result of preoperative low calorie diet on liver volume and to evaluate the long-term result of gastric bypass.

    Paper I showed that four weeks of low calorie diet reduces intrahepatic fat by 40% and facilitates surgery mainly through improved visualisation. Paper II demonstrated that all of the reduction of liver volume occurs during the first two weeks of treatment with low calorie diet.  In paper I liver volume was reduced by 12% and in paper II by 18%. Paper III focused on long-term results and showed that gastric bypass achieves a mean 63% excess body mass index loss in obese patients after 11 years. However, of these 40% undergo abdominoplasty and 2% require additional bariatric surgery. Only 24% adhere to the lifelong recommendation on multivitamins and 72% to Vitamin B12 recommendations. Paper IV evaluated gastric bypass as a revisional procedure after earlier restrictive surgery had failed. Similar weight results as after primary gastric bypass are attained. No patient taking vitamin B12 supplementation was deficient at follow-up, regardless of whether the vitamin was taken as a pill or as intramuscular injections.

    List of papers
    1. Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese
    Open this publication in new window or tab >>Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese
    Show others...
    2011 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 3, p. 345-350Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: The aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4 weeks of low-calorie diet (LCD) before surgery and to investigate if these changes would facilitate the following laparoscopic gastric bypass.

    METHODS: Fifteen female patients (121.3 kg, BMI 42.9) were treated preoperatively in an open study with LCD (800-1,100 kcal/day) during 4 weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment.

    RESULTS: Liver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4 kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5 kg, giving a mean weight of 113.9 kg at surgery. Liver volume decreased by 12% (p < 0.001) and intrahepatic fat by 40% (p < 0.001). According to the preoperative scoring, the size of the left liver lobe, sharpness of the liver edge, and exposure of the hiatal region were improved in the LCD group compared to the controls (all p < 0.05).

    CONCLUSIONS: The overall complexity of the surgery was perceived lower in the LCD group (p < 0.05), due to improved exposure and reduced psychological stress (both p < 0.05). Four weeks of preoperative LCD resulted in a significant decrease in liver volume and intrahepatic fat content, and facilitated the subsequent laparoscopic gastric bypass as scored by the surgeon

    Keywords
    Gastric bypass, Laparoscopy, Low-calorie diet, Magnetic resonance, Morbid obesity
    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-142256 (URN)10.1007/s11695-010-0337-2 (DOI)000287523200013 ()21181291 (PubMedID)
    Available from: 2011-01-13 Created: 2011-01-13 Last updated: 2018-05-30Bibliographically approved
    2. Low calorie diet during four weeks prior to laparoscopic gastric bypass – no further reduction in liver volume after two weeks
    Open this publication in new window or tab >>Low calorie diet during four weeks prior to laparoscopic gastric bypass – no further reduction in liver volume after two weeks
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-213789 (URN)
    Available from: 2014-01-03 Created: 2014-01-03 Last updated: 2014-02-10
    3. Long-term results 11 years after primary gastric bypass in 384 patients
    Open this publication in new window or tab >>Long-term results 11 years after primary gastric bypass in 384 patients
    Show others...
    2013 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 9, no 5, p. 708-713Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND:

    Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass.

    METHODS:

    All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied.

    RESULTS: 

    Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m2 at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m2, corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%.

    CONCLUSION:

    At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-181684 (URN)10.1016/j.soard.2012.02.011 (DOI)000325782900023 ()22551577 (PubMedID)
    Available from: 2012-09-27 Created: 2012-09-27 Last updated: 2017-12-07Bibliographically approved
    4. Twelve-year results for revisional gastric bypass after failed restrictive surgery in 131 patients
    Open this publication in new window or tab >>Twelve-year results for revisional gastric bypass after failed restrictive surgery in 131 patients
    Show others...
    2014 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 10, no 1, p. 44-48Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Gastric banding (GB) and vertical banded gastroplasty (VBG) may result in unsatisfactory weight loss or intolerable side effects. Such outcomes are potential indications for additional bariatric surgery, and Roux-en-Y gastric bypass is frequently used at such revisions (rRYGB). The present study examined long-term results of rRYGB.

    METHODS: In total, 175 patients who had undergone rRYGB between 1993 and 2003 at 2 university hospitals received a questionnaire regarding their current status. The questionnaire was returned by 131 patients (75% follow-up rate, 66 VBG and 65 GB patients). Blood samples were obtained and medical charts studied. The reason for conversion was mainly unsatisfactory weight loss among the VBG patients and intolerable side effects among GB patients.

    RESULTS: The 131 patients (112 women), mean age 41.8 years at rRYGB, were evaluated at mean 11.9 years (range 7-17) after rRYGB. Mean body mass index of those with prior unsatisfactory weight loss was reduced from 40.1 kg/m(2) (range 28.7-52.2) to 32.6 kg/m(2) (range 19.1-50.2) (P<.01). Only 2 patients (2%) underwent additional bariatric surgery after rRYGB. The overall result was satisfactory for 74% of the patients. Only 21% of the patients adhered to the recommendation of lifelong multivitamin supplements while 76% took vitamin B12. Anemia was present in 18%.

    CONCLUSIONS: rRYGB results in sustained weight loss and satisfied patients when VBG or GB have failed. Subsequent bariatric surgery was rare but micronutrient deficiencies were frequent.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-213784 (URN)10.1016/j.soard.2013.05.011 (DOI)000331773800007 ()24094870 (PubMedID)
    Available from: 2014-01-03 Created: 2014-01-03 Last updated: 2017-12-06Bibliographically approved
  • 259.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Axer, S
    Department of Surgery, Torsby Hospital, Torsby, Sweden.
    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.
    Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry2017In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 106, no 3, p. 230-234Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS:

    Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden.

    MATERIAL AND METHODS:

    The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m2, 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients.

    RESULTS:

    The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p < 0.001). There was one conversion to open surgery. Patients undergoing Lap-DS had a shorter length of stay than O-DS, 3.3 versus 6.6 days, p = 0.02. No significant differences in overall complications within 30 days were seen (12% and 17%, respectively). Interestingly, the two leaks in Lap-DS were located at the entero-enteric anastomosis, while three out of four leaks in O-DS occurred at the top of the gastric tube.

    CONCLUSION:

    Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

  • 260.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Kullberg, Joel
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
    Karlsson, F Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism.
    Haenni, Arvo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Geriatrics.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Changes in liver volume and body composition during 4 weeks of low calorie diet before laparoscopic gastric bypass2015In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 11, no 3, p. 602-606Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is desirable, because it can reduce liver volume and thereby facilitate the procedure. The optimal duration of a low-calorie diet (LCD) has not been established. The objective of this study was to assess changes in liver volume and body composition during 4 weeks of LCD.

    METHODS:

    Ten women (aged 43±8.9 years, 114±12.1 kg, and body mass index 42±2.6 kg/m2) were examined on days 0, 3, 7, 14, and 28 after commencing the LCD. At each evaluation, body composition was assessed through bioelectric impedance analysis, and liver volume and intrahepatic fat content were assessed by magnetic resonance imaging. Serum and urine samples were obtained. Questionnaires regarding quality of life and LCD-related symptoms were administered.

    RESULTS:

    In total, mean weight decreased by 7.4±1.2 kg (range 5.7-9.1 kg), and 71% of the weight loss consisted of fat mass according to bioelectric impedance analysis. From day 0 to day 3, the weight loss (2.0 kg) consisted mainly of water. Liver volume decreased by 18%±6.2%, from 2.1 to 1.7 liters (P<.01), during the first 2 weeks with no further change thereafter. A continuous 51%±16% decrease was seen in intrahepatic fat content. Systolic blood pressure, insulin, and lipids improved, while liver enzymes, glucose levels, and quality of life were unaffected.

    CONCLUSION:

    A significant decrease in liver volume (18%) occurred during the first 2 weeks of LCD treatment, and intrahepatic fat gradually decreased throughout the study period. A preoperative 2-week LCD treatment seems sufficient in similar patients.

  • 261.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Kullberg, Joel
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science.
    Karlsson, F. Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Hänni, Arvo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Ahlström, Håkan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science.
    Sundbom, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Low calorie diet during four weeks prior to laparoscopic gastric bypass – no further reduction in liver volume after two weeksManuscript (preprint) (Other academic)
  • 262.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Näslund, Ingmar
    Anastomotic techniques in open Roux-en-Y gastric bypass: primary open surgery and converted procedures2016In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 12, no 4, p. 784-788Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Open Roux-en-Y gastric bypass (RYGB) may be chosen because of known widespread adhesions or as a result of conversion during laparoscopic surgery. Although conversions are rare, they occur even in experienced hands. The gastrojejunostomy may be performed with a circular stapler (CS) or a linear stapler (LS) or may be entirely hand sewn (HS). Our aim was to study differences in outcomes regarding the anastomotic techniques utilized in open surgery.

    SETTING: Nationwide cohort.

    METHODS: Data on open surgery, both primary open and converted procedures from Scandinavian Obesity Surgery Registry were analyzed for the years 2007-2013. Outcomes were assessed through multivariate analysis, adjusting for gender, age, preoperative body mass index, diabetes, conversion, and technique used for the gastrojejunostomy.

    RESULTS: CS was the most common method used for primary open RYGB (58%), whereas LS was the most common for converted RYGB (63%). HS was uncommon in both groups. Operative time was shorter for LS than for CS in the primary open RYGB (110±40 min versus 132±46 min; P<.001). Anastomotic leakage rates were similar in primary open RYGB (1.0%-2.4%), but leakage rates for LS in converted procedures was 10.1%, thus higher compared with 2.1% in converted CS patients (P = .02). Odds ratio for leakage was 2.87 (95% confidence interval 1.18-6.97) for LS using CS as a reference when adjusting for variables above.

    CONCLUSION: LS was associated to increased risk of leakage in patients with conversion from laparoscopic RYGB to open RYGB. Conversion to open surgery was associated to increased risk of leakage. Technique used for the gastrojejunostomy did not affect weight loss.

  • 263.
    Edholm, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Näslund, Ingmar
    Univ Orebro, Dept Surg Sci, Orebro, Sweden.
    Reply to comment on: Anastomotic techniques in open Roux-en-Y gastric bypass-Primary open surgery and converted procedures.2016In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 12, no 7, p. 1436-1436Article in journal (Other academic)
  • 264.
    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 %.

  • 265.
    Edholm, David
    et al.
    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.
    Comparison between circular- and linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass-a cohort from the Scandinavian Obesity Registry.2015In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 11, no 6, p. 1233-1236Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure worldwide, no consensus on the optimal technique for the gastrojejunostomy (GJ) has been reached. Circular stapling (CS) immediately results in a GJ of standardized width, whereas linear stapling (LS) requires a technically challenging closure of the stapler defect. The aim was to study differences in outcomes between CS and LS.

    SETTING: Nationwide Swedish cohort.

    METHODS: The Scandinavian Obesity Registry (SOReg) included prospective data from 34,284 primary LRYGB patients operated on in 2007-2013. We studied operative time, length of hospital stay, postoperative complications, and percent excess body mass index loss (%EBMIL) after 1 year. Outcomes were assessed through multivariate analysis adjusting for gender, age, preoperative body mass index (BMI), and diabetes.

    RESULTS: Preoperatively the groups were similar (40.9 yr, BMI 42.4 kg/m(2), 76% female). For CS and LS, operative time and hospital stay were 114 and 73 minutes (P<.001) and 4.6 and 2.0 days (P<.001), respectively. Using LS as a reference, adjusted odds ratio (OR) for CS patients to have anastomotic leakage was 2.8 (95% CI 1.5-5.0), postoperative hemorrhage 1.9 (95% CI 1.2-2.9), wound complication 9.7 (95% CI 6.8-13.9), and marginal ulcer 3.1 (95% CI 1.8-5.3). The %EBMIL at 1 year was 80% for both techniques and 31% of total weight was lost. Follow-up rate at 6 weeks and 1 year was 96% and 73%, respectively.

    CONCLUSION: CS was found to be associated with disadvantages regarding operative time, hospital stay, and postoperative complications compared with LS.

  • 266.
    Edholm, David
    et al.
    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.
    Reply to comment on "Comparison between circular-and linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass-a cohort from the Scandinavian Obesity Registry"2016In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 12, no 3, p. 724-724Article in journal (Refereed)
  • 267. Edlund, C
    et al.
    Karström, A
    Fransén, Jian
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.
    Huss, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.
    Optimization of storage conditions when banking autologous split-thickness skin grafts.2017In: Annals of Burns and Fire Disasters, ISSN 1121-1539, E-ISSN 1592-9558, Vol. 15Article in journal (Refereed)
  • 268.
    Edsfeldt, Sara
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Intrasynovial flexor tendon injuries and repair2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Complications after surgical repair of intrasynovial flexor tendon injuries in the hand occur despite advanced suture techniques and structured postoperative rehabilitation regimens. Early controlled tendon mobilization prevents adhesion formations and improves tendon healing as well as digit range of motion. To allow early postoperative rehabilitation, the strength of the repair must withstand forces created during the rehabilitation maneuvers. Improvements in suture biomechanics have increased repair strength, but up to 18 percent of repaired tendons still rupture. The overarching aim of this thesis was to investigate how to best treat intrasynovial flexor tendon injuries with limited risk of repair rupture, decreased adhesion formations, and to estimate the effect of individual patient and injury characteristics on functional outcome.

    In two observational studies, we identified risk factors for rupture of repaired intrasynovial flexor digitorum profundus (FDP) tendons, and studied effects of these risk factors on the long-term outcome. Age was associated with increased risk of repair rupture and impaired digital mobility the first year after surgical repair. Concomitant flexor digitorum superficialis (FDS) transection was associated with increased risk of repair rupture without affecting digital mobility. Concomitant nerve transection lowered the rupture risk without affecting digital mobility.

    To better understand forces generated in the flexor tendons during rehabilitation maneuvers, we measured in vivo forces in the index finger FDP and FDS tendons during rehabilitation exercises. Highest forces were measured during isolated FDP and FDS flexion for the FDP and FDS respectively. For the FDS tendon, higher forces were observed with the wrist at 30° flexion compared to neutral position, and for the FDP tendon, forces were higher during active finger flexion compared to place and hold.

    PXL01 is a lactoferrin peptide with anti-adhesive effects previously demonstrated in animal studies and a clinical trial to improve digital mobility when administrated around repaired tendons. We studied the mechanism of action of its corresponding rabbit peptide, rabPXL01 in sodium hyaluronate (HA) in a rabbit model of flexor tendon transection and repair and used RT-qPCR to assess mRNA levels for different genes. Increased levels of PRG4 (encoding lubricin) were observed in rabPXL01 in HA treated tendons. The expression of Interleukin 1β, 6, and 8 was repressed in tendon sheaths. RabPXL01 in HA might stimulate the release of lubricin and diminish inflammation, which correspondingly reduces tendon-gliding resistance and adhesion formations during postoperative rehabilitation exercises.

    The results of this thesis suggest individually adapted treatment plans, depending on repair strength, patient and injury characteristics, as a possible way to improve outcome after flexor tendon repair.

    List of papers
    1. Risk factors for rupture of repaired flexor tendons in zone I and II
    Open this publication in new window or tab >>Risk factors for rupture of repaired flexor tendons in zone I and II
    (English)Article in journal (Other academic) Submitted
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-316557 (URN)
    Available from: 2017-03-02 Created: 2017-03-02 Last updated: 2017-03-15
    2. Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair - Long-term follow-up on 311 patients treated with active extension-passive flexion with rubber bands
    Open this publication in new window or tab >>Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair - Long-term follow-up on 311 patients treated with active extension-passive flexion with rubber bands
    (English)Article in journal (Other academic) Submitted
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-316558 (URN)
    Available from: 2017-03-02 Created: 2017-03-02 Last updated: 2017-03-15
    3. In vivo flexor tendon forces generated during different rehabilitation exercises
    Open this publication in new window or tab >>In vivo flexor tendon forces generated during different rehabilitation exercises
    Show others...
    2015 (English)In: Journal of Hand Surgery, European Volume, ISSN 1753-1934, E-ISSN 2043-6289, Vol. 40, no 7, p. 705-710Article in journal (Refereed) Published
    Abstract [en]

    We measured in vivo forces in the flexor digitorum profundus and the flexor digitorum superficialis tendons during commonly used rehabilitation manoeuvres after flexor tendon repair by placing a buckle force transducer on the tendons of the index finger in the carpal canal during open carpal tunnel release of 12 patients. We compared peak forces for each manoeuvre with the reported strength of a flexor tendon repair. Median flexor digitorum profundus force (24 N) during isolated flexor digitorum profundus flexion and median flexor digitorum superficialis force (13 N) during isolated flexor digitorum superficialis flexion were significantly higher than during the other manoeuvres. Significantly higher median forces were observed in the flexor digitorum superficialis with the wrist at 30° flexion (6 N) compared with the neutral wrist position (5 N). Median flexor digitorum profundus forces were significantly higher during active finger flexion (6 N) compared with place and hold (3 N). Place and hold and active finger flexion with the wrist in the neutral position or tenodesis generated the lowest forces; isolated flexion of these tendons generated higher forces along the flexor tendons.

    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-284410 (URN)10.1177/1753193415591491 (DOI)26115682 (PubMedID)
    Available from: 2016-04-18 Created: 2016-04-18 Last updated: 2017-08-22Bibliographically approved
    4. PXL01 in sodium hyaluronate results in increased PRG4 expression: a potential mechanism for anti-adhesion
    Open this publication in new window or tab >>PXL01 in sodium hyaluronate results in increased PRG4 expression: a potential mechanism for anti-adhesion
    Show others...
    2017 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 122, no 1, p. 28-34Article in journal (Refereed) Published
    Abstract [en]

    PURPOSE: To investigate the anti-adhesive mechanisms of PXL01 in sodium hyaluronate (HA) by using the rabbit lactoferrin peptide, rabPXL01 in HA, in a rabbit model of healing tendons and tendon sheaths. The mechanism of action for PXL01 in HA is interesting since a recent clinical study of the human lactoferrin peptide PXL01 in HA administered around repaired tendons in the hand showed improved digit mobility.

    MATERIALS AND METHODS: On days 1, 3, and 6 after tendon injury and surgical repair, reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) was used to assess mRNA expression levels for genes encoding the mucinous glycoprotein PRG4 (also called lubricin) and a subset of matrix proteins, cytokines, and growth factors involved in flexor tendon repair. RabPXL01 in HA was administered locally around the repaired tendons, and mRNA expression was compared with untreated repaired tendons and tendon sheaths.

    RESULTS: We observed, at all time points, increased expression of PRG4 mRNA in tendons treated with rabPXL01 in HA, but not in tendon sheaths. In addition, treatment with rabPXL01 in HA led to repression of the mRNA levels for the pro-inflammatory mediators interleukin (IL)-1β, IL-6, and IL-8 in tendon sheaths.

    CONCLUSIONS: RabPXL01 in HA increased lubricin mRNA production while diminishing mRNA levels of inflammatory mediators, which in turn reduced the gliding resistance and inhibited the adhesion formation after flexor tendon repair.

    Keywords
    Carcinoid heart disease, Cardiac imaging, Heart metastases, Neuroendocrine tumors
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-309615 (URN)10.1080/03009734.2016.1230157 (DOI)000396476600004 ()27658527 (PubMedID)
    Funder
    Swedish Foundation for Strategic Research
    Available from: 2016-12-06 Created: 2016-12-06 Last updated: 2017-11-29Bibliographically approved
  • 269.
    Edsfeldt, Sara
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Eklund, Martin
    Wiig, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair - Long-term follow-up on 311 patients treated with active extension-passive flexion with rubber bandsArticle in journal (Other academic)
  • 270.
    Edsfeldt, Sara
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery. Uppsala Univ Hosp, Dept Orthopaed & Hand Surg, Uppsala, Sweden.
    Eklund, Martin
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.
    Wiig, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery. Uppsala Univ Hosp, Dept Orthopaed & Hand Surg, Uppsala, Sweden.
    Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair: Long-term follow-up on 273 patients treated with active extension-passive flexion with rubber bands.2019In: Journal of Hand Therapy, ISSN 0894-1130, E-ISSN 1545-004X, Vol. 32, no 3, p. 328-333, article id S0894-1130(17)30093-5Article in journal (Refereed)
    Abstract [en]

    Study Design: Observational cohort study.

    Introduction: Investigating prognostic factors using population-based data may be used to improve functional outcome after flexor tendon injury and repair.

    Purpose of the Study: The aim of this study is to investigate the effect of concomitant nerve transection, combined flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendon transection and the age of the patient, on digital range of motion (ROM) more than 1 year after FDP tendon transection and repair in zone I and II.

    Methods: Two hundred seventy-three patients with a total of 311 fingers admitted for FDP injury in zone I and II were treated with active extension-passive flexion with rubber bands and followed for at least 1 year. We compared outcome by evaluating digital mobility using Strickland's evaluation system.

    Results: At 12 months 72% of patients aged > 50 had fair or poor ROM compared to 17% of patients aged 0-25 years. At 24 months the results for patients aged > 50 had improved to 33% with fair or poor ROM, whereas no improvement had occurred for patients aged 0-25 (17% with fair or poor ROM). Concomitant nerve transection and FDS tendon transection had no negative effects on digital mobility.

    Discussion: Age above 50 was significantly associated with impaired digital ROM during the first year after flexor tendon injury and repair but not at 2 years follow-up. Concomitant nerve transection and combined transection of FDP and FDS do not affect digital mobility.

    Conclusions: Older patients are likely to have a slower healing process and impaired digital ROM during the first year after surgery.

     

  • 271.
    Edsfeldt, Sara
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Eklund, Martin
    Wiig, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Risk factors for rupture of repaired flexor tendons in zone I and IIArticle in journal (Other academic)
  • 272.
    Edsfeldt, Sara
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Holm, Björn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Mahlapuu, Margit
    Pergamum AB, Stockholm, Sweden.
    Reno, Carol
    Univ Calgary, McCaig Inst Bone & Joint Hlth, Dept Surg, Calgary, AB, Canada.
    Hart, David A
    Univ Calgary, McCaig Inst Bone & Joint Hlth, Dept Surg, Calgary, AB, Canada.
    Wiig, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    PXL01 in sodium hyaluronate results in increased PRG4 expression: a potential mechanism for anti-adhesion2017In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 122, no 1, p. 28-34Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To investigate the anti-adhesive mechanisms of PXL01 in sodium hyaluronate (HA) by using the rabbit lactoferrin peptide, rabPXL01 in HA, in a rabbit model of healing tendons and tendon sheaths. The mechanism of action for PXL01 in HA is interesting since a recent clinical study of the human lactoferrin peptide PXL01 in HA administered around repaired tendons in the hand showed improved digit mobility.

    MATERIALS AND METHODS: On days 1, 3, and 6 after tendon injury and surgical repair, reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) was used to assess mRNA expression levels for genes encoding the mucinous glycoprotein PRG4 (also called lubricin) and a subset of matrix proteins, cytokines, and growth factors involved in flexor tendon repair. RabPXL01 in HA was administered locally around the repaired tendons, and mRNA expression was compared with untreated repaired tendons and tendon sheaths.

    RESULTS: We observed, at all time points, increased expression of PRG4 mRNA in tendons treated with rabPXL01 in HA, but not in tendon sheaths. In addition, treatment with rabPXL01 in HA led to repression of the mRNA levels for the pro-inflammatory mediators interleukin (IL)-1β, IL-6, and IL-8 in tendon sheaths.

    CONCLUSIONS: RabPXL01 in HA increased lubricin mRNA production while diminishing mRNA levels of inflammatory mediators, which in turn reduced the gliding resistance and inhibited the adhesion formation after flexor tendon repair.

  • 273.
    Edsfeldt, Sara
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hand Surgery.
    Rempel, D
    Kursa, K
    Diao, E
    Lattanza, L
    In vivo flexor tendon forces generated during different rehabilitation exercises2015In: Journal of Hand Surgery, European Volume, ISSN 1753-1934, E-ISSN 2043-6289, Vol. 40, no 7, p. 705-710Article in journal (Refereed)
    Abstract [en]

    We measured in vivo forces in the flexor digitorum profundus and the flexor digitorum superficialis tendons during commonly used rehabilitation manoeuvres after flexor tendon repair by placing a buckle force transducer on the tendons of the index finger in the carpal canal during open carpal tunnel release of 12 patients. We compared peak forces for each manoeuvre with the reported strength of a flexor tendon repair. Median flexor digitorum profundus force (24 N) during isolated flexor digitorum profundus flexion and median flexor digitorum superficialis force (13 N) during isolated flexor digitorum superficialis flexion were significantly higher than during the other manoeuvres. Significantly higher median forces were observed in the flexor digitorum superficialis with the wrist at 30° flexion (6 N) compared with the neutral wrist position (5 N). Median flexor digitorum profundus forces were significantly higher during active finger flexion (6 N) compared with place and hold (3 N). Place and hold and active finger flexion with the wrist in the neutral position or tenodesis generated the lowest forces; isolated flexion of these tendons generated higher forces along the flexor tendons.

  • 274. Egenvall, M.
    et al.
    Morner, M.
    Påhlman, Lars
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Gunnarsson, U.
    Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 9, p. 696-702Article in journal (Refereed)
    Abstract [en]

    Aim The hypothesis tested in this study was that major blood loss during surgery for rectal cancer increases the risk for surgical complications and for small bowel obstruction (SBO) as a result of adhesions or tumour recurrence, and reduces overall survival. Method Data were retrieved from the Uppsala/Orebro Regional Rectal Cancer Registry for all patients undergoing radical resection for rectal cancer during 1997-2003 (n = 1843) and were matched against the Swedish National Patient Registry regarding surgery and admission for SBO. These patient records were scrutinized to determine the etiology of surgery for SBO. The registry was scrutinized for blood loss and other surgical complications associated with surgery. Uni- and multivariate Cox analysis and logistic regression were used. Results Ninety-four (5.1%) patients underwent surgery for SBO > 30 days after the index operation: 82 for adhesions and 12 for tumour recurrence. The volume of blood lost did not influence the risk of surgery for SBO as a result of adhesions, but blood loss above the median (>= 800 ml) increased the risk for surgery for SBO caused by tumour recurrence (hazard ratio = 10.52; 95% CI: 1.36-81.51). Increased blood loss increased the risk of surgical complications (OR = 1.78; 95% CI: 1.35-2.35 with blood loss of >= 450 ml) but did not reduce overall survival. Irradiation before surgery increased blood loss, complications and admission for SBO. Conclusion Major blood loss during surgery for rectal cancer increases the risk of later surgery for SBO caused by tumour recurrence and surgical complications, but overall survival is not affected.

  • 275.
    Eich, Torsten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical Immunology.
    Ståhle, Magnus U.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical Immunology.
    Gustafsson, Bengt
    Sahlgrens Univ Hosp, Dept Transplantat, Gothenburg, Sweden.
    Horneland, Rune
    Oslo Univ Hosp, Rikshosp, Dept Transplantat, Oslo, Norway.
    Lempinen, Marko
    Helsinki Univ Hosp, Dept Transplantat & Liver Surg, Helsinki, Finland.
    Lundgren, Torbjorn
    Karolinska Univ Hosp, Div Transplantat Surg, CLINTEC, Stockholm, Sweden.
    Rafael, Ehab
    Skåne Univ Hosp, Dept Surg, Transplantat Unit, Malmö, Sweden.
    Tufveson, Gunnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Transplantation Surgery.
    von Zur-Mühlen, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Transplantation Surgery.
    Olerud, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical Immunology.
    Scholz, Hanne
    Oslo Univ Hosp, Rikshosp, Dept Transplantat, Oslo, Norway.
    Korsgren, Olle
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical Immunology. Univ Gothenburg, Dept Biomed, Gothenburg, Sweden.
    Calcium: A Crucial Potentiator for Efficient Enzyme Digestion of the Human Pancreas2018In: Cell Transplantation, ISSN 0963-6897, E-ISSN 1555-3892, Vol. 27, no 7, p. 1031-1038Article in journal (Refereed)
    Abstract [en]

    Background: Effective digestive enzymes are crucial for successful islet isolation. Supplemental proteases are essential because they synergize with collagenase for effective pancreatic digestion. The activity of these enzymes is critically dependent on the presence of Ca2+ ions at a concentration of 5–10 mM. The present study aimed to determine the Ca2+ concentration during human islet isolation and to ascertain whether the addition of supplementary Ca2+ is required to maintain an optimal Ca2+ concentration during the various phases of the islet isolation process.

    Methods: Human islets were isolated according to standard methods and isolation parameters. Islet quality control and the number of isolations fulfilling standard transplantation criteria were evaluated. Ca2+ was determined by using standard clinical chemistry routines. Islet isolation was performed with or without addition of supplementary Ca2+ to reach a Ca2+ of 5 mM.

    Results: Ca2+ concentration was markedly reduced in bicarbonate-based buffers, especially if additional bicarbonate was used to adjust the pH as recommended by the Clinical Islet Transplantation Consortium. A major reduction in Ca2+ concentration was also observed during pancreatic enzyme perfusion, digestion, and harvest. Additional Ca2+ supplementation of media used for dissolving the enzymes and during digestion, perfusion, and harvest was necessary in order to obtain the concentration recommended for optimal enzyme activity and efficient liberation of a large number of islets from the human pancreas.

    Conclusions: Ca2+ is to a large extent consumed during clinical islet isolation, and in the absence of supplementation, the concentration fell below that recommended for optimal enzyme activity. Ca2+ supplementation of the media used during human pancreas digestion is necessary to maintain the concentration recommended for optimal enzyme activity. Addition of Ca2+ to the enzyme blend has been implemented in the standard isolation protocols in the Nordic Network for Clinical Islet Transplantation.

  • 276.
    Eiriksson, Kristinn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Technical Aspects of Laparoscopic Liver Resection. An Experimental Study2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Various techniques are used to transect the liver. With increase in laparoscopic liver resections (LLR), it is of even more interest to develop surgical techniques to minimize bleeding and the risk for gas embolism during transection. Instrument like argon enhanced coagulator provides good hemostasis but increases the danger of gas embolism. The CO2 pneumoperitoneum that is routinely used in most types of laparoscopic surgery can be modified by the use of different gas pressure. It can be assumed that different pressure influences bleeding but also the risk for gas embolism.

    In presented porcine studies, three instrumental combinations have been studied. In study I sixteen piglets were randomized to LLR with either the cavitron ultrasonic aspirator (CUSA™) in combination with vessels sealing system (Ligasure™) or with CUSA™ and ultrascision scissors (Autosonix™), with the endpoints of intra-operative bleeding and gas embolism.  In study IV sixteen piglets were randomized to LLR either with staple device (Endo-GIA™) or the Ligasure™ - CUSA™ combination with same primary endpoints and additionally secondary endpoints of effect on gas-exchange, systemic- and pulmonary hemodynamic.

    Focusing on intra-abdominal pressure (IAP) in study II, sixteen piglets were randomized to LLR with an IAP of either 8 or 16 mmHg.  Primary endpoints were bleeding and gas embolism and secondary endpoints, effect on gas-exchange, systemic- and pulmonary hemodynamic.

    In study III effect of argon gas was tested during LLR. Sixteen piglets were randomized to either argon pneumoperitoneum or CO2 pneumoperitoneum. Primary endpoints were effect on gas-exchange, systemic- and pulmonary hemodynamic.

    In presented studies, we tested efficacy and safety of different techniques for LLR. CUSA™ can be used in combination with either Ligasure™ or Autosonix™. However, Ligasure™ reduces the amount of bleeding. The recent introduction of staplers seems promising with a further reduction in bleeding, gas embolism, and operating time. The IAP influences both the amount of bleeding as well as gas embolism. It seems reasonable to use a higher IAP to decrease bleeding with caution and with close monitoring for gas embolism. Argon gas embolism gives more extensive effect on gas-exchange and hemodynamic and should probably be avoided in this type of surgery.

    List of papers
    1. Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques
    Open this publication in new window or tab >>Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques
    2009 (English)In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 23, no 5, p. 1038-1042Article in journal (Refereed) Published
    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.

    Keywords
    Laparoscopic liver surgery, Liver resection, Carbon dioxide embolism, Bleeding
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-109411 (URN)10.1007/s00464-008-0115-6 (DOI)000265442900017 ()18814003 (PubMedID)
    Available from: 2009-10-15 Created: 2009-10-15 Last updated: 2017-12-12Bibliographically approved
    2. High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism
    Open this publication in new window or tab >>High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism
    2011 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 6, p. 845-852Article in journal (Refereed) Published
    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.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-154346 (URN)10.1002/bjs.7457 (DOI)000290519300077 ()21523699 (PubMedID)
    Available from: 2011-05-31 Created: 2011-05-31 Last updated: 2017-12-11Bibliographically approved
    3. Is there a difference between carbon dioxide and argon gas embolisms in laparoscopic liver resection?
    Open this publication in new window or tab >>Is there a difference between carbon dioxide and argon gas embolisms in laparoscopic liver resection?
    2012 (English)Article in journal (Other academic) Submitted
    Abstract [en]

    Background:

    Several methods are available to control bleeding during laparoscopic liver resection (LLR).  One of these techniques, argon enhanced coagulation (AEC), could be hazardous because of the argon gas.  Argon gas has poorer solubility in blood than CO2.  Previous animal studies have shown the danger of gas embolism during LLR.  The aim of this study was to compare the effects of Argon gas embolism and CO2 embolism, with special emphasis on pulmonary circulation and gas exchange, during laparoscopic liver surgery.

    Method:

    Sixteen piglets underwent laparoscopic left lateral liver resection and were randomised to either CO2 or argon pneumoperitoneum, at 16 mmHg.  The pulmonary circulation of the animals was monitored with a pulmonary arterial catheter.  Paratrend® was used to continuously measure PaCO2, PaO2, and pH, and transoesophageal ultrasound was used to detect embolisms on the right side of the heart.

    Results:

    Equal amount of embolism were seen in both groups.  The mean pulmonary arterial pressure (MPAP) increased in the Argon-group (P=0.050) as did the pulmonary vascular resistance (PVR) (P=0.015) compared with the CO2-group, correlating with the amount of embolism.  The gas exchange was then affected with an decrease in PaO2 and increase in PaCO2 , resulting  in acidosis.

    Conclusion:

    Argon gas embolism has more effects on pulmonary circulation and gas exchange than CO2.  If used, great care should be taken with argon gas and the patient should be carefully monitored during LLR.

    Keywords
    gas embolism, laparoscopy, liver surgery, pneumoperitoneum, argon.
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-171729 (URN)
    Available from: 2012-03-26 Created: 2012-03-26 Last updated: 2018-06-18Bibliographically approved
    4. Faster and safer resection with a stapler device: randomised, controlled trial of laparoscopic liver resection in a porcine model
    Open this publication in new window or tab >>Faster and safer resection with a stapler device: randomised, controlled trial of laparoscopic liver resection in a porcine model
    Show others...
    (English)Article in journal (Other academic) Submitted
    Abstract [en]

    Introduction. Many surgeons use stapling during liver resection. The stapler has the potential to close all luminal structures in the liver tissue and thus result in minimal bleeding, reduced danger of gas embolism, and a faster surgery.

    Material. Sixteen piglets where randomised into two groups receiving either laparoscopic liver resection with a vessel sealing system and an ultrasonic dissector (group-L) or with stapling (group-S). Pneumoperitoneum at 16 mmHg pressure was used. Gas embolism was detected with transesophageal ultrasound and intra-operative bleeding estimated. Monitoring of gas exchange with continuous recording of PaCO2, PaO2, end-tidal CO2, and pH was used. Invasive monitoring of systemic and pulmonary circulation was performed.

    Results. Stapling resulted in less bleeding (P = 0.026), less gas embolism (P = 0.001), and a shorter operating time (P = 0.004).

    Conclusion. In this animal model, stapling of the liver parenchyma led to a faster and safer resection compared to the use of a vessel sealing system and an ultrasonic dissector.

    Keywords
    Pneumoperitoneum, laparoscopy, liver surgery, stapling device, gas embolism, bleeding
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-171731 (URN)
    Available from: 2012-03-27 Created: 2012-03-26 Last updated: 2012-08-01Bibliographically approved
  • 277.
    Eiriksson, Kristinn
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    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.
    Is there a difference between carbon dioxide and argon gas embolisms in laparoscopic liver resection?2012Article in journal (Other academic)
    Abstract [en]

    Background:

    Several methods are available to control bleeding during laparoscopic liver resection (LLR).  One of these techniques, argon enhanced coagulation (AEC), could be hazardous because of the argon gas.  Argon gas has poorer solubility in blood than CO2.  Previous animal studies have shown the danger of gas embolism during LLR.  The aim of this study was to compare the effects of Argon gas embolism and CO2 embolism, with special emphasis on pulmonary circulation and gas exchange, during laparoscopic liver surgery.

    Method:

    Sixteen piglets underwent laparoscopic left lateral liver resection and were randomised to either CO2 or argon pneumoperitoneum, at 16 mmHg.  The pulmonary circulation of the animals was monitored with a pulmonary arterial catheter.  Paratrend® was used to continuously measure PaCO2, PaO2, and pH, and transoesophageal ultrasound was used to detect embolisms on the right side of the heart.

    Results:

    Equal amount of embolism were seen in both groups.  The mean pulmonary arterial pressure (MPAP) increased in the Argon-group (P=0.050) as did the pulmonary vascular resistance (PVR) (P=0.015) compared with the CO2-group, correlating with the amount of embolism.  The gas exchange was then affected with an decrease in PaO2 and increase in PaCO2 , resulting  in acidosis.

    Conclusion:

    Argon gas embolism has more effects on pulmonary circulation and gas exchange than CO2.  If used, great care should be taken with argon gas and the patient should be carefully monitored during LLR.

  • 278.
    Eiriksson, Kristinn
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Fors, Diddi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Waage, Anne
    University of Oslo, Norway.
    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.
    Faster and safer resection with a stapler device: randomised, controlled trial of laparoscopic liver resection in a porcine modelArticle in journal (Other academic)
    Abstract [en]

    Introduction. Many surgeons use stapling during liver resection. The stapler has the potential to close all luminal structures in the liver tissue and thus result in minimal bleeding, reduced danger of gas embolism, and a faster surgery.

    Material. Sixteen piglets where randomised into two groups receiving either laparoscopic liver resection with a vessel sealing system and an ultrasonic dissector (group-L) or with stapling (group-S). Pneumoperitoneum at 16 mmHg pressure was used. Gas embolism was detected with transesophageal ultrasound and intra-operative bleeding estimated. Monitoring of gas exchange with continuous recording of PaCO2, PaO2, end-tidal CO2, and pH was used. Invasive monitoring of systemic and pulmonary circulation was performed.

    Results. Stapling resulted in less bleeding (P = 0.026), less gas embolism (P = 0.001), and a shorter operating time (P = 0.004).

    Conclusion. In this animal model, stapling of the liver parenchyma led to a faster and safer resection compared to the use of a vessel sealing system and an ultrasonic dissector.

  • 279.
    Ekelund, Anders
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences.
    The effects of cyclosporin A on bone turnover and repair1998Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The effects of cyclosporin A on bone metabolism are unclear and controversial. The aims of this thesis were to study the effects of cyclosporin A on bone turnover and on different repair processes such as fracture healing, osteoinduction and osteoconduction.

    Osteoinduction was studied by implanting inductive demineralized bone matrix in the abdominal muscles of rats. Matrix from different species (rat and rabbit) was used, and the amount of bone formation, the degree of matrix resorption, the occurrence of neuropeptide containing nerve endings, and calcium incorporation were studied. Cyclosporin A was found to enhance bone induction in allogeneic and xenogeneic bone matrix, while resorption of the demineralized bone matrix was unaffected. The mineral turnover in the induced ossicles was not affected by cyclosporin A treatment. Cyclosporin A treatmentresulted in the normal occurrence of neuropeptide containing nerve endings in xenografts.

    Bone ingrowth into allografts and xenografts was studied in the rat using bone chambers. At 6 weeks there was less bone ingrowth into the xenografts than into the allografts. This difference was unaffected by cyclosporin A treatment.

    In the intact skeleton in growing rats, cyclosporin A treatment induced an early transient increase in mineral and matrix turnover, but the total mineral content was unaffected. Tibia fractures were created in rabbits. Cyclosporin A treatment increased callus volume and bone mineral content in the fractured tibia as compared to controls. Disuse osteopenia in the femora was unaffected by cyclosporin A.

    In conclusion, cyclosporin A enhanced osteoinduction in rats, but it did not affect osteoconduction. Furthermore, cyclosporin A induced increased bone turnover in intact bone without affecting the total mineral content Bone mineral content and callus volume in rabbit tibia fractures were increased by cyclosporin A. The mechanism for the stimulation of bone formation is unclear, but a direct or cytokine mediated effect on bone forming cells is possible.

  • 280.
    Eklund, Arne
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
    Laparoscopic or Open Inguinal Hernia Repair - Which is Best for the Patient?2009Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Inguinal hernia repair is the most common operation in general surgery. Its main challenge is to achieve low recurrence rates. With the introduction of mesh implants, first in open and later in laparoscopic repair, recurrence rates have decreased substantially. Therefore, the focus has been shifted from clinical outcome, such as recurrence, towards patient-experienced endpoints, such as chronic pain. In order to compare the results of open and laparoscopic hernia repair, a randomised multicentre trial - the Swedish Multicentre trial of Inguinal hernia repair by Laparoscopy (SMIL) - was designed by a study group from 11 hospitals.

    Between November 1996 and August 2000, 1512 men aged 30-70 years with a primary inguinal hernia were randomised to either laparoscopic (TEP, Totally ExtraPeritoneal) or open (Lichtenstein) repair. The primary endpoint was recurrence at five years. Secondary endpoints were short-term results, frequency of chronic pain and a cost analysis including complications and recurrences up to five years after surgery.

    In total, 1370 patients, 665 in the TEP and 705 in the Lichtenstein group, underwent operation.

    With 94% of operated patients available for follow-up after 5.1 years, the recurrence rate was 3.5% in the TEP and 1.2% in the Lichtenstein group.

    Postoperative pain was lower in the TEP group up to 12 weeks after operation, resulting in five days less sick leave and 11 days shorter time to full recovery. Patients in the TEP group had a slightly increased risk of major complications.

    Chronic pain was reported by 9-11% of patients in the TEP and 19-25% in the Lichtenstein group at the different follow-up points.

    Hospital costs for TEP were higher than for Lichtenstein, while community costs were lower due to shorter sick leave. By avoiding disposable laparoscopic equipment, the cost for TEP would be almost equal compared with Lichtenstein.

    In conclusion, both TEP and Lichtenstein repair have advantages and disadvantages for the patient. Depending on local resources and expertise both methods can be used and recommended for primary inguinal hernia repair.

    List of papers
    1. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair
    Open this publication in new window or tab >>Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair
    Show others...
    2006 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 9, p. 1060-1068Article in journal (Refereed) Published
    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.

    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-107553 (URN)10.1002/bjs.5405 (DOI)000240394200006 ()16862612 (PubMedID)
    Available from: 2009-09-02 Created: 2009-08-17 Last updated: 2017-12-13Bibliographically approved
    2. Low Recurrence Rate After Laparoscopic (TEP) and Open(Lichtenstein) Inguinal Hernia RepairA Randomized, Multicenter Trial With 5-Year Follow-Up
    Open this publication in new window or tab >>Low Recurrence Rate After Laparoscopic (TEP) and Open(Lichtenstein) Inguinal Hernia RepairA Randomized, Multicenter Trial With 5-Year Follow-Up
    Show others...
    2009 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 249, no 1, p. 33-38Article in journal (Refereed) Published
    Abstract [en]

    Objectives: To compare a laparoscopic (totally extraperitoneal patch (TEP)) and an open technique (Lichtenstein) for inguinal hernia repair regarding recurrence rate and possible risk factors for recurrence.

    Summary Background Data: Laparoscopic hernia repair has been introduced as an alternative to open repair. Short-term follow-up suggests benefits for those patients operated with a laparoscopic approach compared with open techniques; ie, less postoperative pain and a shorter convalescence period. Long-term results, however, are less well known.

    Methods: The study was conducted as a multicenter randomized trial with a 5-year follow-up. A total of 1512 men aged 30 to 70 years, with a primary unilateral inguinal hernia, were randomized to either TEP or Lichtenstein repair.

    Results: Overall, 665 patients in the TEP group and 705 patients in the Lichtenstein group were evaluable. The cumulative recurrence rate was 3.5% in the TEP group and 1.2% in the Lichtenstein group (P = 0.008). Test for heterogeneity revealed significant differences between individual surgeons. The exclusion of 1 surgeon, who was responsible for 33% (7 of 21) of all recurrences in the TEP group, lowered the cumulative recurrence rate to 2.4% in this group, which was not statistically different from that of the Lichtenstein group.

    Conclusions: The recurrence rate for both TEP and Lichtenstein repair was low. A higher cumulative recurrence rate in the TEP group was seen at 5 years. Further analysis revealed that this could be attributable to incorrect surgical technique.

    Place, publisher, year, edition, pages
    Lippincott Williams & Wilkins, 2009
    Keywords
    Adult, Aged, Follow-Up Studies, Hernia, Inguinal, Humans, Laparoscopy, Middle Aged, Recurrence, Time Factors, methods
    National Category
    Medical and Health Sciences
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-107556 (URN)10.1097/SLA.0b013e31819255d0 (DOI)000262219300007 ()
    Available from: 2009-08-17 Created: 2009-08-17 Last updated: 2019-10-12Bibliographically approved
    3. Chronic pan 5 years after randomised comparison of laparoscopic and Lichtenstein inguinal hernia repair
    Open this publication in new window or tab >>Chronic pan 5 years after randomised comparison of laparoscopic and Lichtenstein inguinal hernia repair
    2010 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 4, p. 600-608Article in journal (Other academic) Published
    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.

    Keywords
    Chronic pain, inguinal hernia, laparoscopy
    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-107628 (URN)10.1002/bjs.6904 (DOI)000276375400022 ()20186889 (PubMedID)
    Available from: 2009-08-20 Created: 2009-08-20 Last updated: 2017-12-13Bibliographically approved
    4. A cost-minimisation analysis comparing TEP with Lichtenstein for treatment of inguinal hernia in Sweden
    Open this publication in new window or tab >>A cost-minimisation analysis comparing TEP with Lichtenstein for treatment of inguinal hernia in Sweden
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background: Laparoscopic surgery has emerged as a new treatment modality for inguinal hernia. It is important to analyse its long-term costs in relation to other methods.

    Methods: A randomized multicenter study comparing totally extraperitoneal laparoscopic repair (TEP) with open repair according to Lichtenstein was performed on men with a primary inguinal hernia. Long-term follow-up collecting data on recurrences and complications up to five years after operation was carried out. Taking treatment costs into consideration, a cost-minimisation analysis was conducted.

    Results: Altogether 1370 patients were operated, 665 in the TEP and 705 in the Lichtenstein group. The total hospital cost for the index operation was €710.6 higher for TEP (P<0.001). Including costs for recurrences and complications, this difference increased to €795.1 (P<0.001). Taking community costs into account, the difference decreased with €503.1 to €292.0 (P=0.024).

    Conclusion: With five-year follow-up including complication, reoperation and community costs, there was a small but significant difference in total costs between the two methods.

    Keywords
    cost-minimisation, inguinal hernia, laproscopy
    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-107629 (URN)
    Available from: 2009-08-20 Created: 2009-08-20 Last updated: 2013-06-20
  • 281.
    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.
    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.
    Montgomery, Agneta
    Rasmussen, Ib
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sandbu, Rune
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Low Recurrence Rate After Laparoscopic (TEP) and Open (Lichtenstein) Inguinal Hernia Repair A Randomized, Multicenter Trial With 5-year Follow-up Reply2009In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 250, no 2, p. 355-355Article in journal (Refereed)
    Abstract
  • 282.
    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. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    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.
    Rudberg, Claes
    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.
    Montgomery, Agneta
    Rasmussen, Ib
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Sandbue, Rune
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Laparoscopic Versus Open Mesh Repair for Inguinal Hernia Reply2009In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 250, no 2, p. 354-354Article in journal (Refereed)
    Abstract
  • 283.
    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.
    Carlsson, Per
    Linköpings universitet.
    Rosenblad, Andreas
    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.
    A cost-minimisation analysis comparing TEP with Lichtenstein for treatment of inguinal hernia in SwedenManuscript (preprint) (Other academic)
    Abstract [en]

    Background: Laparoscopic surgery has emerged as a new treatment modality for inguinal hernia. It is important to analyse its long-term costs in relation to other methods.

    Methods: A randomized multicenter study comparing totally extraperitoneal laparoscopic repair (TEP) with open repair according to Lichtenstein was performed on men with a primary inguinal hernia. Long-term follow-up collecting data on recurrences and complications up to five years after operation was carried out. Taking treatment costs into consideration, a cost-minimisation analysis was conducted.

    Results: Altogether 1370 patients were operated, 665 in the TEP and 705 in the Lichtenstein group. The total hospital cost for the index operation was €710.6 higher for TEP (P<0.001). Including costs for recurrences and complications, this difference increased to €795.1 (P<0.001). Taking community costs into account, the difference decreased with €503.1 to €292.0 (P=0.024).

    Conclusion: With five-year follow-up including complication, reoperation and community costs, there was a small but significant difference in total costs between the two methods.

  • 284.
    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.

  • 285.
    Ekman, Anna
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences.
    Hips at risk osteoporosis and prevention of hip fractures2001Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Hip fractures are the most serious consequence of osteoporosis, and are one important cause of morbidity and mortality among the elderly. Prophylactic treatment for hip fractures are now available. Early detection of individuals with increased risk for hip fractures is therefor of great interest. A subset of non-institutionalised patients with a first hip fracture (cases;n=l18) and controls (n=263), aged 65-85 years, underwent dual X-ray absorptiometry (DXA) of the femoral neck, quantitative ultrasound (QUS) of the heel and phalanges and radiographic absorptiometry (RA) of the phalanges. The entire cohort was followed for approximately four years or to death. In women, DXA of the proximal femur and QUS of the heel showed a high predictive value for an incident first hip fracture, adjusted odds ratio (OR) 3.6 (95% confidence interval (CI) 2.4-5.5) and 3.4 (95%CI 2.2-5.0) respectively. The association was even stronger in men, but only for DXA of the proximal femu,r with an adjusted OR of4.8 (95%CI 2.3-9.9). Bone densitometry at non-weight-bearing sites, QUS and RA of the phalanges did not discriminate female cases from controls, but proved capable of separating male cases from controls. The risk of death was higher in cases than in controls, with a multivariate rate ratio (RR) of 3.4 (95%CI 1.7-7.0). There was no significant association between bone density and mortality.

    Nursing home residents underwent QUS of the heel and phalanges. Almost all of the female residents and 51% of the male residents were, if the WHO-criterion for osteoporosis was applied, osteoporotic as assessed by heel and finger QUS. The QUS values were approximately 1.5 SD lower than expected for age and gender.

    In this randomised controlled intervention study we evaluated the effect of external hip protectors in nursing home residents; 302 residents were allocated to wear such protectors and 442 were controls. External hip protectors were found to be effective in preventing hip fractures in nursing home residents, with an adjusted relative risk for hip fracture of 0.33 (CI 0.11 - 1.00).

  • 286.
    Elf, Kristin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rostedt Punga: Clinical Neurophysiology.
    Ronne-Engström, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Enblad: Neurosurgery.
    Semnic, Robert
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Rostami-Berglund, Elham
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Enblad: Neurosurgery.
    Sundblom, Jimmy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Enblad: Neurosurgery.
    Zetterling, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Enblad: Neurosurgery.
    Continuous EEG monitoring after brain tumor surgery2019In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 161, no 9, p. 1835-1843Article in journal (Refereed)
    Abstract [en]

    Background

    Prolonged seizures generate cerebral hypoxia and increased intracranial pressure, resulting in an increased risk of neurological deterioration, increased long-term morbidity, and shorter survival. Seizures should be recognized early and treated promptly.

    The aim of the study was to investigate the occurrence of postoperative seizures in patients undergoing craniotomy for primary brain tumors and to determine if non-convulsive seizures could explain some of the postoperative neurological deterioration that may occur after surgery.

    Methods

    A single-center prospective study of 100 patients with suspected glioma. Participants were studied with EEG and video recording for at least 24 h after surgery.

    Results

    Seven patients (7%) displayed seizure activity on EEG recording within 24 h after surgery and another two patients (2%) developed late seizures. One of the patients with early seizures also developed late seizures. In five patients (5%), there were non-convulsive seizures. Four of these patients had a combination of clinically overt and non-convulsive seizures and in one patient, all seizures were non-convulsive. The non-convulsive seizures accounted for the majority of total seizure time in those patients. Non-convulsive seizures could not explain six cases of unexpected postoperative neurological deterioration. Postoperative ischemic lesions were more common in patients with early postoperative seizures.

    Conclusions

    Early seizures, including non-convulsive, occurred in 7% of our patients. Within this group, non-convulsive seizure activity had longer durations than clinically overt seizures, but only 1% of patients had exclusively non-convulsive seizures. Seizures were not associated with unexpected neurological deterioration.

  • 287.
    Elias, Khalid
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
    Bekhali, Zakaria
    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.
    Graf, Wilhelm
    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.
    Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch2018In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 14, no 2, p. 144-149Article in journal (Refereed)
    Abstract [en]

    Background: Bariatric procedures are increasingly being used, but data on bowel habits are scarce.

    Objectives: To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).

    Setting: University hospital in Sweden.

    Methods: We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation.

    Results: Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P<.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P<.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P<.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected.

    Conclusion: RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling.

  • 288. Eliasson, Alf
    et al.
    Narby, Birger
    Ekstrand, Karl
    Hirsch, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Oral and Maxillofacial Surgery.
    Johansson, Anders
    Wennerberg, Ann
    A 5-Year Prospective Clinical Study of Submerged and Nonsubmerged Paragon System Implants in the Edentulous Mandible2010In: International Journal of Prosthodontics, ISSN 0893-2174, E-ISSN 1139-9791, Vol. 23, no 3, p. 231-238Article in journal (Refereed)
    Abstract [en]

    Purpose: The aim of this investigation was to evaluate the clinical outcome of two different surgical protocols in the edentulous mandible: submerged and nonsubmerged. Further, the Paragon dental implant with a titanium plasma-sprayed surface was evaluated. Materials and Methods: Twenty-nine consecutively treated patients with 168 implants supporting fixed prostheses were included. All but 3 patients were provided 6 implants, placed via nonsubmerged healing on one side and submerged healing on the other. Data were collected from patient records and radiographs. Twenty-four patients participated in the 5-year clinical follow-up examination, Results: After 5 years, all patients still had their mandibular fixed prostheses in function. Cumulative survival rates were 100% for prostheses and 99.4% for implants. However, 3 implants fractured in 1 patient. One submerged implant was lost before loading but no further implants were lost during follow-up. The radiographic bone loss was small for all implants with a mean of 0.14 mm (standard deviation [SD]: 0.37) at 1 year and 0.42 mm (SD: 0.48) at 5 years for nonsubmerged implants and 0.17 mm (SD: 0.32) at 1 year and 0,51 mm (SD: 0.33) at 5 years for submerged implants. Nineteen implants (including the 3 that fractured) presented annual bone loss exceeding 0.2 mm after the first year, yielding a cumulative success rate of 86.2% after 5 years. Conclusion: Single-stage surgery was shown to have the same predictability as two-stage surgery in the anterior edentulous mandible. Paragon implants with a titanium plasma-sprayed surface showed a fracture rate of 2.2% and a success rate of 86.2% after 5 years. Int J Prosthodont 2010;23:231-238.

  • 289. Elliot, A. H.
    et al.
    Martling, A.
    Glimelius, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Oncology.
    Nordenvall, C.
    Johansson, H.
    Nilsson, P. J.
    Preoperative treatment selection in rectal cancer: A population-based cohort study2014In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 40, no 12, p. 1782-1788Article in journal (Refereed)
    Abstract [en]

    Background: Preoperative radiotherapy and chemoradiotherapy for rectal cancer reduce local recurrence rates but is also associated with side effects. Thus, it is important to identify patients in whom the benefits exceed the risks. This study assessed the pretherapeutic parameters influencing the selection to preoperative treatment. Methods: Data on all patients in the Stockholm-Gotland area, Sweden, who underwent elective trans-abdominal surgery for rectal cancer in 2000-2010, was retrieved from the Regional Cancer Registry and the Swedish National Patient Register. Clinical variables were analysed in relation to selected preoperative therapy. Odds Ratios were derived from univariable and multivariable logistic regression models. Results: In total 2619 patients were included. Of these 1789 (68.3%) received preoperative radiotherapy or chemoradiotherapy. Over time, use of preoperative therapy increased (p < 0.001). In a multivariable model, age (>= 80 years) and comorbidity (Charlson Comorbidity Index score >= 2) were strongly correlated to omittance of preoperative treatment (OR: 0.05; 95% CI: 0.04-0.07 and 0.29; 95% CI: 0.21-0.39) but there was no difference between genders. Pre-treatment tumour stage was a strong predictor for selection to preoperative (chemo-) radiotherapy. However, 8.2% of patients with intermediate or advanced tumours were selected to no preoperative treatment while 55.0% of patients with early tumours were selected to preoperative therapy. Conclusions: The use of preoperative (chemo-) radiotherapy increased over time. Suboptimal adherence to guidelines appears to exist leading to a risk of overtreatment and to a small extent also undertreatment. More robust selection criteria, also including age and comorbidity should be developed.

  • 290.
    Elowsson, Per
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences.
    Effects on cardiac output distribution of propranolol, verapamil and epidural blockade during continuous positive-pressure ventilation: An experimental study in the pig2000Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The blood perfusion of all body regions is governed by local vasoregulation, and systemic humoral and neural impulses provide additional tuning of vascular tone. Is the regulation of circulation centralised or, in other words, is the sympathetic nervous system (SNS) superior to local autoregulation of the perfusion of vital organs? Using the microsphere method and acquired data on the body composition of the pig, it was possible to interpret the absolute distribution of cardiac output (CO) and flux changes between organs and tissues. Also, two indirect methods for estimating body composition, dual-energy x-ray absorptiometry (DXA) and underwater weighing (UWW), were validated against carcass analysis. The circulation was challenged by continuous positive-pressure ventilation (CPPV), which reduces venous return and hence CO. The SNS was interfered with in the periphery by the β-receptor blocker propranolol, which acts as a peripheral vasoconstrictor, and at the proximal level by an epidural blockade defined in the pig. We also investigated how the calcium channel blocker verapamil, a peripheral vasodilator, interfered with vasoregulation.

    The body composition of the 12-week-old pig (20-25-kg) is described. Body components obtained by DXA correlated closely to carcass analysis. DXA overestimated bone mineral mass, lean mass and total weight and underestimated fat mass. The fat estimations by DXA and UWW were significantly affected by the amount of water in lean mass and fat-free mass.

    The combination of β-blockade and CPPV severely reduced CO. Local vasoregulation seems to outweigh the influence of SNS. The adrenal blood flow increased during CPPV, but this was obviated by epidural blockade.

  • 291.
    Emami, Abbas
    Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences.
    Tibial shaft fractures: An epidemiological and clinical study1998Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The epidemiological features of tibial shaft fractures were studied in Uppsala during two 5-year periods. The incidence decreased in men below 20 years of age in the late 1980's compared with the early 1970's (mostly due to a reduction of fractures sustained in traffic accidents), while the incidence increased in women over 80.

    67 patients with closed tibial shaft fractures treated with a unilateral external fixation were examined after 1-5 years. The major drawbacks were prolonged healing time and recurrent need for unplanned secondary operations. The majority of the complications were either related to the pin tracts or to insufficient mechanical stability.

    37 infected tibial shaft nonunions treated by debridement and open autogenous cancellouos bone grafting in a 2-stage procedure were followed for 2 years. In 12 cases additional debridement was necessary before bone grafting. All fractures healed. Open cancellous bone grafting is considered to be a simple and reliable technique.

    In 32 patients the effect of low-intensity ultrasound in fracture healing in closed or open grade I fresh tibial fractures treated with an intramedullary nail was studied. Contrary to previous reports the ultrasound treatment did not shorten the healing time.

    In 30 patients from the previous study the serum bone markers (pyridinoline cross-linked telopeptide of type I collagen, bone-specific alkaline phosphatase and osteocalcin) were measured ten times during one year. Ultrasound treatment seemed to reduce the early bone resorption, while it did not seem to have any effect on bone formation. Patients with delayed healing had a much slower rise in bone-specific alkaline phosphatase compared with the profile in patients with normal healing time.

    31 patients with closed or open grade I fresh tibial fractures were treated with an intramedullary nail, followed by immediate mobilisation and early weight-bearing. Very limited bone loss was found in the proximal part of ipsilateral femur and calcaneus during the first postoperative year.

  • 292.
    Enajat, Morteza
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.
    Rozen, Warren M.
    Audolfsson, Thorir
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.
    Acosta, Rafael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.
    Thermal injuries in the insensate deep inferior epigastric artery perforator flap: case series and literature review on mechanisms of injury2009In: Microsurgery, ISSN 0738-1085, E-ISSN 1098-2752, Vol. 29, no 3, p. 214-217Article, review/survey (Refereed)
    Abstract [en]

    With the increasing use of the deep inferior epigastric artery perforator (DIEP) flap, complications that are particularly rare (less than 1%) may start to become clinically relevant. During DIEP flap harvest, cutaneous nerves innervating the flap are necessarily sacrificed, resulting in reduced sensibility This impaired sensibility prevents adequate thermoregulatory reflexes, like vasodilatation, sweating, and protective behaviors, leaving the reconstructed breast considerably more susceptible to thermal insult. We present four DIEP flap cases who sustained postoperative thermal injury to the reconstructed breast. All four cases were operated on between 2001 and 2008, over the course of 600 DIEP flaps in our unit (an incidence of 0.7%). The injuries occurred between 2 and 18 months after reconstruction. Two patients sustained thermal injury while sunbathing, one while staying in a warm environment, and one sustained the injury while taking a shower. No flap losses ensued, but these were not without morbidity. A literature review discusses other similar cases in the literature and describes the mechanisms for these findings. As a majority of patients will regain both fine-touch and heat sensation by 3 years postoperatively, it is pertinent that prophylactic measures be instituted during this period, such as the avoidance of sunbathing and the use of cooler shower temperatures for the first 3 years postoperatively. While performing sensory nerve coaptation is the gold standard for maximizing the success of sensory regeneration, this is not always sought and the 0.7% incidence of thermal injury we have encountered suggest the role for greater consideration of such injury.

  • 293.
    Enblad, Malin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Colorectal and appendiceal peritoneal metastases: From population studies to genetics2018Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Peritoneal dissemination of colorectal and appendiceal origin was previously considered the end-stage of malignant disease. Today, treatment with cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) has prolonged survival and cured some patients with peritoneal metastases (PM). Unfortunately, a majority of patients still have fatal outcomes. In this thesis, colorectal and appendiceal PM were studied from a wide population-based perspective down to the detailed perspectives of histopathology and genetics, with the aim of further contributing to prolonged survival.

    In Paper I, the heterogeneous histopathology of PM was investigated and a substantial proportion of patients undergoing CRS and HIPEC were found to have surgical specimens lacking neoplastic epithelium. These patients had a favourable prognosis and the results illustrate the importance of thorough analysing and reporting of histopathology for understanding differences in survival outcomes and for improving patient selection. In Paper II, the role of inflammation in colorectal and appendiceal carcinogenesis was investigated at a population-based level. Patients with non-surgical treatment of appendicitis had an increased incidence of cancer (especially of appendiceal and right-sided colon cancer) compared to the general population. This should be taken into consideration in the discussion of optimal management of patients with appendicitis. In Paper III, risk factors for PM were studied with the aim of aiding in the detection of PM at earlier stages. Appendiceal and right-sided colon cancer, advanced tumour and node stages, mucinous histopathology and vascular invasion were identified as high risk features for developing PM, and should increase awareness of potential PM. In Paper IV, genome-wide chromosomal copy number alterations of PM were explored and associated with prognosis after CRS and HIPEC. Colorectal PM exhibited a wide range of alterations of which copy number gain on parts of chromosome 1p and 15q were significantly associated with poor prognosis and have the potential to be used as prognostic molecular markers in the future.

    In conclusion, this thesis provides new insights into the field of colorectal and appendiceal cancer and PM to be used for improved patient selection, early detection and prevention, ultimately contributing to improved survival.

    List of papers
    1. Importance of Absent Neoplastic Epithelium in Patients Treated With Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
    Open this publication in new window or tab >>Importance of Absent Neoplastic Epithelium in Patients Treated With Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
    Show others...
    2016 (English)In: Annals of Surgical Oncology, ISSN 1068-9265, E-ISSN 1534-4681, Vol. 23, no 4, p. 1149-1156Article in journal (Refereed) Published
    Abstract [en]

    The importance of absent neoplastic epithelium in specimens from cytoreductive surgery (CRS) is unknown. This study aimed to investigate the prevalence and prognostic value of histopathology without neoplastic epithelium in patients treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). Data were extracted from medical records and histopathology reports for patients treated with initial CRS and HIPEC at Uppsala University Hospital, Sweden, between 2004 and 2012. Patients with inoperable disease and patients undergoing palliative non-CRS surgery were excluded from the study. Patients lacking neoplastic epithelium in surgical specimens from CRS, with or without mucin, were classified as "neoplastic epithelium absent" (NEA), and patients with neoplastic epithelium were classified as "neoplastic epithelium present" (NEP). The study observed NEA in 78 of 353 patients (22 %). Mucin was found in 28 of the patients with NEA. For low-grade appendiceal mucinous neoplasms and adenomas, the 5-year overall survival rate was 100 % for NEA and 84 % for NEP, and the 5-year recurrence-free survival rate was 100 % for NEA and 59 % for NEP. For appendiceal/colorectal adenocarcinomas (including tumors of the small intestine), the 5-year overall survival rate was 61 % for NEA and 38 % for NEP, and the 5-year recurrence-free survival rate was 60 % for NEA and 14 % for NEP. Carcinoembryonic antigen level, peritoneal cancer index, and completeness of the cytoreduction score were lower in patients with NEA. A substantial proportion of patients undergoing CRS and HIPEC have NEA. These patients have a favorable prognosis and a decreased risk of recurrence. Differences in patient selection can affect the proportion of NEA and hence explain differences in survival rates between reported series.

    National Category
    Cancer and Oncology Surgery
    Identifiers
    urn:nbn:se:uu:diva-282455 (URN)10.1245/s10434-015-4989-y (DOI)000371333200015 ()26577120 (PubMedID)
    Available from: 2016-04-05 Created: 2016-04-05 Last updated: 2018-03-09Bibliographically approved
    2. Increased incidence of bowel cancer after non-surgical treatment of appendicitis
    Open this publication in new window or tab >>Increased incidence of bowel cancer after non-surgical treatment of appendicitis
    Show others...
    2017 (English)In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 43, no 11, p. 2067-2075Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: There is an ongoing debate on the use of antibiotics instead of appendectomy for treating appendicitis but diagnostic difficulties and longstanding inflammation might lead to increased incidence of bowel cancer in these patients. The aim of this population-based study was to investigate the incidence of bowel cancer after non-surgical treatment of appendicitis.

    PATIENTS AND METHODS: Patients diagnosed with appendicitis but lacking the surgical procedure code for appendix removal were retrieved from the Swedish National Inpatient Register 1987-2013. The cohort was matched with the Swedish Cancer Registry and the standardised incidence ratios (SIR) with 95% confidence interval (95% CI) for appendiceal, colorectal and small bowel cancers were calculated.

    RESULTS: Of 13 595 patients with non-surgical treatment of appendicitis, 352 (2.6%) were diagnosed with appendiceal, colorectal or small bowel cancer (SIR 4.1, 95% CI 3.7-4.6). The largest incidence increase was found for appendiceal (SIR 35, 95% CI 26-46) and right-sided colon cancer (SIR 7.5, 95% CI 6.6-8.6). SIR was still elevated when excluding patients with less than 12 months since appendicitis and the incidence of right-sided colon cancer was elevated five years after appendicitis (SIR 3.5, 95% CI 2.1-5.4). An increased incidence of bowel cancer was found after appendicitis with abscess (SIR 4.6, 95% CI 4.0-5.2), and without abscess (SIR 3.5, 95% CI 2.9-4.1).

    CONCLUSION: Patients with non-surgical treatment of appendicitis have an increased short and long-term incidence of bowel cancer. This should be considered in the discussion about optimal management of patients with appendicitis.

    Place, publisher, year, edition, pages
    Elsevier, 2017
    Keywords
    Appendiceal cancer, Appendicitis, Colorectal cancer, Non-surgical treatment
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-333277 (URN)10.1016/j.ejso.2017.08.016 (DOI)000418107200012 ()28942236 (PubMedID)
    Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2018-03-09Bibliographically approved
    3. Risk factors for appendiceal and colorectal peritoneal metastases
    Open this publication in new window or tab >>Risk factors for appendiceal and colorectal peritoneal metastases
    2018 (English)In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 44, no 7, p. 997-1005Article in journal (Refereed) Published
    Abstract [en]

    Background

    Early diagnosis to target minimal volume disease has received increased attention in the management of appendiceal and colorectal peritoneal metastases (PM). This study aimed to identify risk factors for appendiceal, colon and rectal PM.

    Methods

    Data were retrieved from the Swedish Colorectal Cancer Registry for all patients undergoing bowel resection of appendiceal and colorectal tumours, in Sweden, 2007–2015. Risk factors for synchronous and metachronous PM were analysed with multivariate logistic and Cox proportional hazard regression models.

    Results

    Synchronous PM was most common in appendiceal cancer (23.5%), followed by colon (3.1%) and rectal (0.6%) cancer. The 5-year cumulative incidence was 9.0% for appendiceal, 2.5% for right colon, 1.8% for left colon and 1.2% for rectal cancer. In appendiceal cancer (n = 327), T4, N2, mucinous tumour, and non-radical surgery were associated with PM. In colon cancer (n = 24,399), synchronous PM were primarily associated with T4 (OR 18.37, 95% CI 8.12–41.53), T3 and N2 but also with N1, right-sided tumour, mucinous tumour, vascular and perineural invasion, female gender, age <60 and emergency surgery. These factors were also associated with metachronous PM. In rectal cancer (n = 10,394), T4 (OR 19.12, 95% CI 5.52–66.24), proximal tumour and mucinous tumour were associated with synchronous PM and T4 and mucinous tumour with metachronous PM.

    Conclusions

    This study shows that appendiceal cancer, right-sided colon cancer, advanced tumour and node stages and mucinous histopathology are the main high-risk features for PM and should increase the awareness of current or future PM.

    Keywords
    Peritoneal metastases, Appendiceal cancer, Colorectal cancer, Risk factors
    National Category
    Surgery Cancer and Oncology
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-340054 (URN)10.1016/j.ejso.2018.02.245 (DOI)000437391100012000437391100012 ()29576463 (PubMedID)
    Funder
    Swedish Cancer Society, 160411
    Available from: 2018-01-25 Created: 2018-01-25 Last updated: 2019-07-02Bibliographically approved
    4. Prognostic importance of genetic alterations in colorectal peritoneal metastases
    Open this publication in new window or tab >>Prognostic importance of genetic alterations in colorectal peritoneal metastases
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Surgery
    Identifiers
    urn:nbn:se:uu:diva-340055 (URN)
    Available from: 2018-01-25 Created: 2018-01-25 Last updated: 2018-03-09
  • 294.
    Enblad, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Birgisson, Helgi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Wanders, Alkwin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology.
    Sköldberg, Filip
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Ghanipour, Lana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Importance of Absent Neoplastic Epithelium in Patients Treated With Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy2016In: Annals of Surgical Oncology, ISSN 1068-9265, E-ISSN 1534-4681, Vol. 23, no 4, p. 1149-1156Article in journal (Refereed)
    Abstract [en]

    The importance of absent neoplastic epithelium in specimens from cytoreductive surgery (CRS) is unknown. This study aimed to investigate the prevalence and prognostic value of histopathology without neoplastic epithelium in patients treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC). Data were extracted from medical records and histopathology reports for patients treated with initial CRS and HIPEC at Uppsala University Hospital, Sweden, between 2004 and 2012. Patients with inoperable disease and patients undergoing palliative non-CRS surgery were excluded from the study. Patients lacking neoplastic epithelium in surgical specimens from CRS, with or without mucin, were classified as "neoplastic epithelium absent" (NEA), and patients with neoplastic epithelium were classified as "neoplastic epithelium present" (NEP). The study observed NEA in 78 of 353 patients (22 %). Mucin was found in 28 of the patients with NEA. For low-grade appendiceal mucinous neoplasms and adenomas, the 5-year overall survival rate was 100 % for NEA and 84 % for NEP, and the 5-year recurrence-free survival rate was 100 % for NEA and 59 % for NEP. For appendiceal/colorectal adenocarcinomas (including tumors of the small intestine), the 5-year overall survival rate was 61 % for NEA and 38 % for NEP, and the 5-year recurrence-free survival rate was 60 % for NEA and 14 % for NEP. Carcinoembryonic antigen level, peritoneal cancer index, and completeness of the cytoreduction score were lower in patients with NEA. A substantial proportion of patients undergoing CRS and HIPEC have NEA. These patients have a favorable prognosis and a decreased risk of recurrence. Differences in patient selection can affect the proportion of NEA and hence explain differences in survival rates between reported series.

  • 295.
    Enblad, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Ghanipour, Lana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Cashin, Peter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Prognostic scores for colorectal cancer with peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy2018In: International Journal of Hyperthermia, ISSN 0265-6736, E-ISSN 1464-5157, Vol. 34, no 8, p. 1390-1395Article in journal (Refereed)
    Abstract [en]

    Background: Selecting colorectal patients for HIPEC-surgery needs improvement. The study aim was to improve the colorectal peritoneal score (COREP) and to compare it with three other scores: peritoneal-surface disease-severity score (PSDS), colorectal-peritoneal metastases prognostic-surgical-score (COMPASS), and the CEA/PCI ratio.

    Method: Twelve preoperative factors were chosen to evaluate for COREP score modification. Criteria from logistical analyses were set to qualify for the modified COREP score (mCOREP). Odds ratios were used to assign score points for the eligible factors with open/close laparotomy prediction as endpoint. mCOREP was applied internally and compared with the original COREP, PSDS, COMPASS, and CEA/PCI ratio. Odds ratios, hazard ratios, and Kaplan-Meier curves were used for comparison.

    Results: Seven factors qualified for mCOREP: CEA, CA 19-9, CA-125, C-reactive protein, albumin, platelet count and signet-cell histology. mCOREP was superior to the original COREP. mCOREP and COMPASS scores were the only scores with independent prognostic value. The mCOREP had the best discriminatory ability between its prognostic groupings. mCOREP 11+had 9months survival with half of patients being open/close surgery.

    Conclusion: The mCOREP has successfully been simplified while still improving its prognostic ability. The mCOREP and COMPASS scores have independent prognostic value. Patients with mCOREP 11+may not benefit from treatment.

  • 296.
    Enblad, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Birgisson, Helgi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Risk factors for appendiceal and colorectal peritoneal metastases2018In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 44, no 7, p. 997-1005Article in journal (Refereed)
    Abstract [en]

    Background

    Early diagnosis to target minimal volume disease has received increased attention in the management of appendiceal and colorectal peritoneal metastases (PM). This study aimed to identify risk factors for appendiceal, colon and rectal PM.

    Methods

    Data were retrieved from the Swedish Colorectal Cancer Registry for all patients undergoing bowel resection of appendiceal and colorectal tumours, in Sweden, 2007–2015. Risk factors for synchronous and metachronous PM were analysed with multivariate logistic and Cox proportional hazard regression models.

    Results

    Synchronous PM was most common in appendiceal cancer (23.5%), followed by colon (3.1%) and rectal (0.6%) cancer. The 5-year cumulative incidence was 9.0% for appendiceal, 2.5% for right colon, 1.8% for left colon and 1.2% for rectal cancer. In appendiceal cancer (n = 327), T4, N2, mucinous tumour, and non-radical surgery were associated with PM. In colon cancer (n = 24,399), synchronous PM were primarily associated with T4 (OR 18.37, 95% CI 8.12–41.53), T3 and N2 but also with N1, right-sided tumour, mucinous tumour, vascular and perineural invasion, female gender, age <60 and emergency surgery. These factors were also associated with metachronous PM. In rectal cancer (n = 10,394), T4 (OR 19.12, 95% CI 5.52–66.24), proximal tumour and mucinous tumour were associated with synchronous PM and T4 and mucinous tumour with metachronous PM.

    Conclusions

    This study shows that appendiceal cancer, right-sided colon cancer, advanced tumour and node stages and mucinous histopathology are the main high-risk features for PM and should increase the awareness of current or future PM.

  • 297.
    Enblad, Malin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Graf, Wilhelm
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Terman, Alexei
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Immunology, Genetics and Pathology, Clinical and experimental pathology.
    Pucholt, Pascal
    Uppsala University, Science for Life Laboratory, SciLifeLab.
    Viklund, Björn
    Uppsala University, Science for Life Laboratory, SciLifeLab.
    Isaksson, Anders
    Uppsala University, Science for Life Laboratory, SciLifeLab.
    Birgisson, Helgi
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
    Prognostic importance of genetic alterations in colorectal peritoneal metastasesManuscript (preprint) (Other academic)
  • 298.
    Enblad, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Continuous monitoring of intracranial compliance in neurointensive care (Editorial by invitation)2018In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 160, no 12, p. 2289-2290Article in journal (Other academic)
  • 299.
    Enell, Jacob
    et al.
    Umea Univ, Dept Surg & Perioperat Sci, S-90185 Umea, Sweden.
    Bayadsi, Haytham
    Umea Univ, Dept Surg & Perioperat Sci, S-90185 Umea, Sweden.
    Lundgren, Ewa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Endocrine Surgery.
    Hennings, Joakim
    Umea Univ, Dept Surg & Perioperat Sci, S-90185 Umea, Sweden.
    Primary Hyperparathyroidism is Underdiagnosed and Suboptimally Treated in the Clinical Setting2018In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 42, no 9, p. 2825-2834Article in journal (Refereed)
    Abstract [en]

    To evaluate whether patients presenting with laboratory results consistent with primary hyperparathyroidism (pHPT) are managed in accordance with guidelines. The laboratory database at a hospital in Sweden, serving 127,000 inhabitants, was searched for patients with biochemically determined pHPT. During 2014, a total of 365 patients with biochemical laboratory tests consistent with pHPT were identified. Patients with possible differential diagnoses or other reasons for not being investigated according to international guidelines were excluded after scrutinizing records, after new blood tests, and clinical assessments by endocrine surgeons. Altogether, 92 patients had been referred to specialists and 82 had not. The latter group had lower serum calcium (median 2.54 mmol/L) and PTH (5.7 pmol/L). Out of these 82 cases, 9 patients were diagnosed with pHPT or had some sort of long-term follow-up planned as outpatients. Primary hyperparathyroidism is overlooked and underdiagnosed in a number of patients in the clinical setting. It is important to provide local guidelines for the management of patients presenting with mild pHPT to ensure that these patients receive proper evaluation and follow-up according to current research.

  • 300.
    Engquist, Markus
    et al.
    Ryhov Hosp, Dept Orthopaed, S-55185 Jonkoping, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Orthopaed, Gothenburg, Sweden..
    Löfgren, Håkan
    Ryhov Hosp, Neuroorthoped Ctr, S-55185 Jonkoping, Sweden..
    Öberg, Birgitta
    Linkoping Univ, Fac Hlth Sci, Dept Med & Hlth Sci, Div Physiotherapy, Linkoping, Sweden..
    Holtz, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
    Pålsson, Anneli
    Linkoping Univ, Fac Hlth Sci, Dept Med & Hlth Sci, Div Physiotherapy, Linkoping, Sweden..
    Söderlund, Anne
    Malardalen Univ, Sch Hlth Care & Social Welf, Dept Physiotherapy, Vasteras, Sweden..
    Vavruch, Ludek
    Ryhov Hosp, Neuroorthoped Ctr, S-55185 Jonkoping, Sweden..
    Lind, Bengt
    Univ Gothenburg, Sahlgrenska Acad, Dept Orthopaed, Inst Clin Sci, Gothenburg, Sweden.;Spine Ctr Goteborg, Gothenburg, Sweden..
    Factors Affecting the Outcome of Surgical Versus Nonsurgical Treatment of Cervical Radiculopathy2015In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 40, no 20, p. 1553-1563Article in journal (Refereed)
    Abstract [en]

    Study Design. Prospective randomized controlled trial. Objective. To analyze factors that may influence the outcome of anterior cervical decompression and fusion (ACDF) followed by physiotherapy versus physiotherapy alone for treatment of patients with cervical radiculopathy. Summary of Background Data. An understanding of patient-related factors affecting the outcome of ACDF is important for preoperative patient selection. No previous prospective, randomized study of treatment effect modifiers relating to outcome of ACDF compared with physiotherapy has been carried out. Methods. 60 patients with cervical radiculopathy were randomized to ACDF followed by physiotherapy or physiotherapy alone. Data for possible modifiers of treatment outcome at 1 year, such as sex, age, duration of pain, pain intensity, disability (Neck Disability Index, NDI), patient expectations of treatment, anxiety due to neck/arm pain, distress (Distress and Risk Assessment Method), self-efficacy (Self-Efficacy Scale) health status (EQ-5D), and magnetic resonance imaging findings were collected. A multivariate analysis was performed to find treatment effect modifiers affecting the outcome regarding arm/neck pain intensity and NDI. Results. Factors that significantly altered the treatment effect between treatment groups in favor of surgery were: duration of neck pain less than 12 months (P = 0.007), duration of arm pain less than 12 months (P = 0.01) and female sex (P = 0.007) (outcome: arm pain), low EQ-5D index (outcome: neck pain, P = 0.02), high levels of anxiety due to neck/arm pain (outcome: neck pain, P = 0.02 and NDI, P = 0.02), low Self-Efficacy Scale score (P = 0.05), and high Distress and Risk Assessment Method score (P = 0.04) (outcome: NDI). No factors were found to be associated with better outcome with physiotherapy alone. Conclusion. In this prospective, randomized study of patients with cervical radiculopathy, short duration of pain, female sex, low health quality, high levels of anxiety due to neck/arm pain, low self-efficacy, and a high level of distress before treatment were associated with better outcome from surgery. No factors were found to be associated with better outcome from physiotherapy alone.

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