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31.
  • ERAS, Compliance Group (författare)
  • The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection : Results From an International Registry
  • 2015
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 261:6, s. 1153-1159
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>BACKGROUND:</strong> The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood.</p><p><strong>OBJECTIVE:</strong> This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection.</p><p><strong>METHODS:</strong> The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication.</p><p><strong>FINDINGS:</strong> A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P &lt; 0.001] and length of stay (OR = 0.83, P &lt; 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P &lt; 0.001) and shorter primary hospital admission (OR = 0.88, P &lt; 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR = 0.86, P &lt; 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P &lt; 0.001).</p><p><strong>CONCLUSIONS:</strong> This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.</p>
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32.
  • Essén, Pia, et al. (författare)
  • Laparoscopic cholecystectomy does not prevent the postoperative protein catabolic response in muscle
  • 1995
  • Ingår i: Annals of Surgery. - Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 222:1, s. 36-42
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>OBJECTIVE:</p><p>The authors determined the effect of laparoscopic cholecystectomy on protein synthesis in skeletal muscle. In addition to a decrease in muscle protein synthesis, after open cholecystectomy, the authors previously demonstrated a decrease in insulin sensitivity. This study on patients undergoing laparoscopic and open surgery, therefore, included simultaneous measurements of protein synthesis and insulin sensitivity.</p><p>SUMMARY BACKGROUND DATA:</p><p>Laparoscopy has become a routine technique for several operations because of postoperative benefits that allow rapid recovery. However, its effect on postoperative protein catabolism has not been characterized. Conventional laparotomy induces a drop in muscle protein synthesis, whereas degradation is unaffected.</p><p>METHODS:</p><p>Patients were randomized to laparoscopic or open cholecystectomy, and the rate of protein synthesis in skeletal muscle was determined 24 hours postoperatively by the flooding technique using L-(2H5)phenylalanine, during a hyperinsulinemic normoglycemic clamp to assess insulin sensitivity.</p><p>RESULTS:</p><p>The protein synthesis rate decreased by 28% (1.77 +/- 0.11%/day vs. 1.26 +/- 0.08%/day, p &lt; 0.01) in the laparoscopic group and by 20% (1.97 +/- 0.15%/day vs. 1.57 +/- 0.15%/day, p &lt; 0.01) in the open cholecystectomy group. In contrast, the fall in insulin sensitivity after surgery was lower with laparoscopic (22 +/- 2%) compared with open surgery (49 +/- 5%).</p><p>CONCLUSIONS:</p><p>Laparoscopic cholecystectomy did not avoid a substantial decline in muscle protein synthesis, despite improved insulin sensitivity. The change in the two parameters occurred independently, indicating different mechanisms controlling insulin sensitivity and muscle protein synthesis.</p>
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33.
  • Franklin, Oskar, et al. (författare)
  • Plasma micro-RNA alterations appear late in pancreatic cancer
  • 2018
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 267:4, s. 775-781
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objectives: The aim of this research was to study whether plasma microRNAs (miRNA) can be used for early detection of pancreatic cancer (PC) by analyzing prediagnostic plasma samples collected before a PC diagnosis. Background: PC has a poor prognosis due to late presenting symptoms and early metastasis. Circulating miRNAs are altered in PC at diagnosis but have not been evaluated in a prediagnostic setting. Methods: We first performed an initial screen using a panel of 372 miRNAs in a retrospective case-control cohort that included early-stage PC patients and healthy controls. Significantly altered miRNAs at diagnosis were then measured in an early detection case-control cohort wherein plasma samples in the cases are collected before a PC diagnosis. Carbohydrate antigen 19–9 (Ca 19–9) levels were measured in all samples for comparison. Results: Our initial screen, including 23 stage I-II PC cases and 22 controls, revealed 15 candidate miRNAs that were differentially expressed in plasma samples at PC diagnosis. We combined all 15 miRNAs into a multivariate statistical model, which outperformed Ca 19–9 in receiver-operating characteristics analysis. However, none of the candidate miRNAs, individually or in combination, were significantly altered in prediagnostic plasma samples from 67 future PC patients compared with 132 matched controls. In comparison, Ca 19–9 levels were significantly higher in the cases at &lt;5 years before diagnosis. Conclusion: Plasma miRNAs are altered in PC patients at diagnosis, but the candidate miRNAs found in this study appear late in the course of the disease and cannot be used for early detection of the disease.</p>
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34.
  • Fränneby, Ulf, et al. (författare)
  • Risk factors for long-term pain after hernia surgery
  • 2006
  • Ingår i: Annals of Surgery. - Wolters Kluwer. - 0003-4932 .- 1528-1140. ; 244:2, s. 212-219
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>OBJECTIVE:</strong> To estimate the prevalence of residual pain 2 to 3 years after hernia surgery, to identify factors associated with its occurrence, and to assess the consequences for the patient.</p><p><strong>SUMMARY BACKGROUND DATA:</strong> Iatrogenic chronic pain is a neglected problem that may totally annul the benefits from hernia repair.</p><p><strong>METHODS:</strong> From the population-based Swedish Hernia Register 3000 patients aged 15 to 85 years were sampled from the 9280 patients registered as having undergone a primary groin hernia operation in the year 2000. Of these, the 2853 patients still alive in 2003 were requested to fill in a postal questionnaire.</p><p><strong>RESULTS:</strong> After 2 reminders, 2456 patients (86%), 2299 men and 157 women responded. In response to a question about "worst perceived pain last week," 758 patients (31%) reported pain to some extent. In 144 cases (6%), the pain interfered with daily activities. Age below median, a high level of pain before the operation, and occurrence of any postoperative complication were found to significantly and independently predict long-term pain in multivariate logistic analysis when "worst pain last week" was used as outcome variable. The same variables, along with a repair technique using anterior approach, were found to predict long-term pain with "pain right now" as outcome variable.</p><p><strong>CONCLUSION:</strong> Pain that is at least partly disabling appears to occur more often than recurrences. The prevalence of long-term pain can be reduced by preventing postoperative complications. The impact of repair technique on the risk of long-term pain shown in our study should be further assessed in randomized controlled trials.</p>
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35.
  • Gero, Daniel, et al. (författare)
  • Defining Global Benchmarks in Bariatric Surgery A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy
  • 2019
  • Ingår i: Annals of Surgery. - Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 270:5, s. 859-867
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective: To define “best possible” outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]).</p><p>Background: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix.</p><p>Methods: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI&gt;50 kg/m<sup>2</sup> and age&gt;65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers’ median values for respective quality indicators.</p><p>Results: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ± 5.8 kg/m<sup>2</sup>. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication.</p><p>Conclusion: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.</p><p>ClinicalTrials.gov Identifier NCT03440138</p>
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36.
  • Ghaneh, Paula, et al. (författare)
  • The Impact of Positive Resection Margins on Survival and Recurrence Following Resection and Adjuvant Chemotherapy for Pancreatic Ductal Adenocarcinoma
  • 2019
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 269:3, s. 520-529
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective and Background: Local and distant disease recurrence are frequently observed following pancreatic cancer resection, but an improved understanding of resection margin assessment is required to aid tailored therapies</p><p>Methods: Analyses were carried out to assess the association between clinical characteristics and margin involvement as well as the effects of individual margin involvement on site of recurrence and overall and recurrence-free survival using individual patient data from the European Study Group for Pancreatic Cancer (ESPAC)-3 randomized controlled trial.</p><p>Results: There were 1151 patients, of whom 505 (43.9%) had an RI resection. The median and 95% confidence interval (CI) overall survival was 24.9 (22.9-27.2) months for 646 (56.1%) patients with resection margin negative R0 &gt;1 mm) tumors, 25.4 (21.6 30.4) months for 146 (12.7%) patients with RI &lt;1 mm positive resection margins, and 18.7 (17.2-21.1) months for 359 (31.2%) patients with R1-direct positive margins (P &lt; 0.001). In multivariable analysis, overall R 1-direct tumor margins, poor tumor differentiation, positive lymph node status, WHO performance status ≥ 1, maximum tumor size, and RI-direct posterior resection margin were all independently significantly associated with reduced overall and recurrence-free survival. Competing risks analysis showed that overall R1-direct positive resection margin status, positive lymph node status. WHO performance status 1, and R1-direct positive superior mesenteric/medial margin resection status were all significantly associated with local recurrence.</p><p>Conclusions: RI-direct resections were associated with significantly reduced overall and recurrence-free survival following pancreatic cancer resection. Resection margin involvement was also associated with an increased risk for local recurrence.</p>
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37.
  • Gutlic, Nihad, et al. (författare)
  • Impact of mesh fixation on chronic pain in total extraperitoneal inguinal hernia repair (TEP) : a nationwide register-based study
  • 2016
  • Ingår i: Annals of Surgery. - Philadelphia : Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 263:6, s. 1199-1206
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>BACKGROUND:</strong> Mesh fixation is used to prevent recurrence at the potential risk for chronic pain in TEP. The aim was to compare the impact of permanent fixation (PF) with no fixation (NF)/nonpermanent fixation (NPF) of mesh on chronic pain after TEP repair for primary inguinal hernia.</p><p><strong>METHODS:</strong> Men, 30 to 75 years old, consecutively registered in the Swedish Hernia Register for a TEP primary repair in 2005 to 2009, were included in a mail survey using SF-36 and the Inguinal Pain Questionnaire (IPQ). Primary endpoint was IPQ question "Did you have pain during past week that could not be ignored." Risk factors for chronic pain and recurrent operations were analyzed.</p><p><strong>RESULTS:</strong> A total of 1110 patients were included (325 PF, 785 NF/NPF) with 7.7% reporting pain at median 33 months follow-up. No difference regarding primary endpoint pain (P &lt; 0.462), IPQ and SF-36 subscales were seen. Recurrent operation was carried out in 1.4% during 7.5 years follow-up with no difference between PF- and NF-groups including subgroups of medial hernias. All SF-36 subscale-scores were equal to or better than the Swedish norm. A postoperative complication was a risk factor for chronic pain (OR 2.44, 95% CI 1.23-5.25, P &lt; 0.023).</p><p><strong>CONCLUSIONS:</strong> The TEP procedure for primary inguinal hernia repair in men is associated with a low frequency of chronic pain and recurrent operations, with no difference between permanent fixation and no/nonpermanent fixation of mesh in a nationwide population-based study. TEP without fixation reduces costs and is safe for all patients.</p>
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38.
  • Haapaniemi, S, et al. (författare)
  • Reoperation after recurrent groin hernia repair.
  • 2001
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 234:1, s. 122-6
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>OBJECTIVE:</strong> To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.</p><p><strong>METHODS:</strong> Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.</p><p><strong>RESULTS:</strong> From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.</p><p><strong>CONCLUSIONS:</strong> Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.</p>
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39.
  • Haapaniemi, Staffan, et al. (författare)
  • Reoperation after recurrent groin hernia repair
  • 2001
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 234:1, s. 122-126
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective: To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.</p><p>Methods: Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.</p><p>Results: From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.</p><p>Conclusions: Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.</p>
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40.
  • Hansson, Johan, 1964-, et al. (författare)
  • Single-photon emission computed tomography for prediction of treatment results in sequential intraperitoneal chemotherapy at peritoneal carcinomatosis
  • 2012
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140.
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>Background: </strong></p><p>Cytoreductive surgery and intraperitoneal chemotherapy (IPC) treatment can improve survival in peritoneal carcinomatosis. One of the reasons for failure of sequential postoperative intraperitoneal chemotherapy (SPIC) is lack of distribution of the chemotherapy in the peritoneal cavity. The primary aim of this study was to evaluate single-photon emission computed tomography (SPECT) as a predictor of successful SPIC treatment and prognosis. A secondary aim was to assess the relationship between SPECT, feasibility of SPIC, and clinical variables.</p><p><strong>Methods: </strong></p><p>Fifty-one patients (mean age 52 years, range 14-74, 20 women) were treated with Cytoreductive surgery and SPIC. SPECT studies with intraperitoneal (i.p.) Technetium-99 via a Port-a-Cath (PaC) were performed before the second course of treatment. The i.p. distribution was registered as a detected volume (DV) at four different threshold settings (1, 2, 5, and 10%) of the global maximum intensity of the SPECT examination. A calculation model for SPECT and clinical variables was tested.</p><p><strong>Results: </strong></p><p>The DV measured in the SPECT examination predicted the number of subsequent SPIC courses. The highest correlation (R=0.45) for DV was in the 2% threshold setting. Patients with a DV<sub>2%</sub> lower than mean reached two SPIC courses and patients with a DV<sub>2%</sub> higher than mean reached six SPIC course. Height correlated to higher DV and a higher number of SPIC courses. Patients with a height lower than mean reached a DV<sub>2%</sub> at 3930 ml and patients higher than mean reached a DV<sub>2%</sub> at 5507 ml. A taller person could tolerate more SPIC courses (R=0.28) and patients with a height higher than mean reached six SPIC courses; patients with a height lower than mean reached four courses. There was no correlation between DV and survival.</p><p><strong>Conclusion: </strong></p><p>The feasibility of performing SPIC without further surgical intervention can be predicted by SPECT, and it might therefore be an instrument to select which patients should preferably be treated with alternative therapy.<strong></strong></p>
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