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  • Lagerros, Ylva Trolle, et al. (författare)
  • Suicide, Self-harm, and Depression After Gastric Bypass Surgery : A Nationwide Cohort Study
  • 2017
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 265:2, s. 235-243
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>OBJECTIVE:</strong> The aim of this study was to examine risk of self-harm, hospitalization for depression and death by suicide after gastric bypass surgery (GBP).</p><p><strong>SUMMARY OF BACKGROUND DATA:</strong> Concerns regarding severe adverse psychiatric outcomes after GBP have been raised.</p><p><strong>METHODS:</strong> This nationwide, longitudinal, self-matched cohort encompassed 22,539 patients who underwent GBP during 2008 to 2012. They were identified through the Swedish National Patient Register, the Prescribed Drug Register, and the Causes of Death Register. Follow-up time was up to 2 years. Main outcome measures were hazard ratios (HRs) for post-surgery self-harm or hospitalization for depression in patients with presurgery self-harm and/or depression compared to patients without this exposure; and standardized mortality ratio (SMR) for suicide post-surgery.</p><p><strong>RESULTS:</strong> A diagnosis of self-harm in the 2 years preceding surgery was associated with an HR of 36.6 (95% confidence interval [CI] 25.5-52.4) for self-harm during the 2 years of follow up, compared to GBP patients who had no self-harm diagnosis before surgery. Patients with a diagnosis of depression preceding GBP surgery had an HR of 52.3 (95% CI 30.6-89.2) for hospitalization owing to depression after GBP, compared to GBP patients without a previous diagnosis of depression. The SMR for suicide after GBP was increased among females (n = 13), 4.50 (95% CI 2.50-7.50). The SMR among males (n = 4), was 1.71 (95% CI 0.54-4.12).</p><p><strong>CONCLUSIONS:</strong> The increased risk of post-surgery self-harm and hospitalization for depression is mainly attributable to patients who have a diagnosis of self-harm or depression before surgery. Raised awareness is needed to identify vulnerable patients with history of self-harm or depression, which may be in need of psychiatric support after GBP.</p>
  • Lang, Hauke, et al. (författare)
  • 10th Anniversary of ALPPS-Lessons Learned and quo Vadis
  • 2019
  • Ingår i: Annals of Surgery. - LIPPINCOTT WILLIAMS & WILKINS. - 0003-4932 .- 1528-1140. ; 269:1, s. 114-119
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective: Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been tested in various indications and clinical scenarios, leading to steady improvements in safety. This report presents the current status of ALPPS. Summary Background Data: ALPPS offers improved resectability, but drawbacks are regularly pointed out regarding safety and oncologic benefits. Methods: During the 12th biennial congress of the European African-Hepato-Pancreato-Biliary Association (Mainz, Germany, May 23-26, 2017) an expert meeting "10th anniversary of ALPP" was held to discuss indications, management, mechanisms of regeneration, as well as pitfalls of this novel technique. The aim of the meeting was to make an inventory of what has been achieved and what remains unclear in ALPPS. Results: Precise knowledge of liver anatomy and its variations is paramount for success in ALPPS. Technical modifications, mainly less invasive approaches like partial, mini- or laparoscopic ALPPS, mostly aiming at minimizing the extensiveness of the first-stage procedure, are associated with improved safety. In fibrotic/cirrhotic livers the degree of future liver remnant hypertrophy after ALPPS appears some less than that in noncirrhotic. Recent data from the only prospective randomized controlled trial confirmed significant higher resection rates in ALPPS with similar peri-operative morbidity and mortality rates compared with conventional 2-stage hepatectomy including portal vein embolization. ALPPS is effective reliably even after failure of portal vein embolization. Conclusions: Although ALPPS is now an established 2-stage hepatectomy additional data are warranted to further refine indication and technical aspects. Long-term oncological outcome results are needed to establish the place of ALPPS in patients with initially nonresectable liver tumors.</p>
  • Lindstedt, Sandra, et al. (författare)
  • Microvascular Blood Flow Changes in the Small Intestinal Wall During Conventional Negative Pressure Wound Therapy and Negative Pressure Wound Therapy Using a Protective Disc Over the Intestines in Laparostomy
  • 2011
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 255:1, s. 171-175
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objectives: Blood flow changes in the intestines during conventional negative pressure wound therapy (NPWT), and NPWT using a protective disc over the intestines in laparostomy.</p><p>Background: Higher closure rates of the open abdomen have been reported with NPWT compared with other kinds of wound management. However, the method has been associated with increased development of fistulae. We have compared the changes in blood flow in the intestinal wall using conventional NPWT and NWPT with a protective disc between the intestines and the vacuum source.</p><p>Methods: Midline incisions were made in 10 pigs and either conventional NPWT or NPWT with a disc over the intestines was applied. The microvascular blood flow was measured in the intestinal wall before and after the application of topical negative pressures of -50, -70, and -120 mmHg, using laser Doppler velocimetry.</p><p>Results: The blood flow was significantly decreased (by 24%) after the application of conventional NPWT at -50 mmHg, compared with a slight decrease (2%) after the application of NWPT with a protective disc (P &lt; 0.05). The blood flow was significantly decreased (by 54%) after the application of conventional NPWT at -120 mmHg, compared with a slight decrease (17%) after application of NPWT using a protective disc (P &lt; 0.001).</p><p>Conclusions: Inserting a disc between the intestines and the vacuum source in NPWT protects the intestines from ischemia. The decreased blood flow in the intestinal wall may induce ischemia, which could promote the development of intestinal fistulae.</p>
  • Linecker, Michael, et al. (författare)
  • Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity
  • 2017
  • Ingår i: Annals of Surgery. - LIPPINCOTT WILLIAMS & WILKINS. - 0003-4932 .- 1528-1140. ; 266:5, s. 779-786
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective: To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome. Background: ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome. Methods: ALPPS centers of the International ALPPS Registry having performed amp;gt;= 10 cases over a period of amp;gt;= 3 years were assessed for 90-day mortality and major interstage complications (amp;gt;= 3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies. Results: Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P amp;lt; 0.001; OR: 1.62; 95% CI: 1.36-1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18-0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers. Conclusions: Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.</p>
  • Lundström, Karl-Johan, et al. (författare)
  • Risk factors for complications in Groin Hernia surgery : A National register study
  • 2012
  • Ingår i: Annals of Surgery. - Philasdelphia, PA, USA : Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 255:4, s. 784-788
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objective: This study aims to analyze and identify risk factors for postoperative complications and analyze the relative risk of reoperation for recurrence for respective complication. Background: The outcome of groin hernia surgery is evaluated mostly by comparing recurrence rates and long-term pain. The aim of this observational population-based registry study was to identify risk factors for postoperative complications and analyze the relative risk of reoperation for recurrence for respective complication. Methods: Using data from the nationwide Swedish Hernia Register between 1998 and 2009, 150,514 herniorrhaphies were analyzed with respect to postoperative complications occurring within 30 days of surgery. Results: Risk factors significantly affecting the rate of postoperative complications were laparoscopic repair (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.24-1.47) and open preperitoneal techniques (OR: 1.31, 95% CI: 1.15-1.49), with open anterior mesh as reference category. Other significant risk factors were general (OR: 1.30, 95% CI: 1.23-1.37) and regional anesthesia (OR: 1.53, 95% CI: 1.43-1.63), with local anesthesia as reference category, emergency procedures (OR: 1.53, 95% CI: 1.43-1.63); recurrent hernia repair (OR: 1.39, 95% CI: 1.27-1.52); femoral hernia (OR: 1.30, 95% CI: 1.14-1.48); aged older than 65 years (OR: 1.26, 95% CI: 1.21-1.31); and duration of surgery exceeding 50 minutes (OR: 1.27, 95% CI: 1.22-1.33). Conclusions: Open anterior approach and surgery under local anesthesia are associated with less risk of postoperative complications.</p>
  • Machado, Mikael, et al. (författare)
  • Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer : a prospective randomized trial.
  • 2003
  • Ingår i: Annals of Surgery. - Philadelphia, USA : Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 238:2, s. 214-20
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Objectives: To compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome.</p><p>Summary beckground data: A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis.</p><p>Methods: One-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively.</p><p>Results: Fifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in &lt;15 minutes at 6 months reached a significant difference in favor of the pouch procedure.</p><p>Conclusions: The data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results.</p>
  • Marimuthu, Kanagaraj, et al. (författare)
  • A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery
  • 2012
  • Ingår i: Annals of Surgery. - Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 255:6, s. 1060-1068
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>Background: Immune modulating nutrition (IMN) has been shown to reduce complications after major surgery, but strong evidence to recommend its routine use is still lacking. Objective: The aim of this meta-analysis was to evaluate the impact of IMN combinations on postoperative infectious and noninfectious complications, length of hospital stay, and mortality in patients undergoing major open gastrointestinal surgery. Methods: Randomized controlled trials published between January 1980 and February 2011 comparing isocaloric and isonitrogenous enteral IMN combinations with standard diet in patients undergoing major open gastrointestinal surgery were included. The quality of evidence and strength of recommendation for each postoperative outcome were assessed using the GRADE approach and the outcome measures were analyzed with RevMan 5.1 software (Cochrane Collaboration, Copenhagen, Denmark). Results: Twenty-six randomized controlled trials enrolling 2496 patients (1252 IMN and 1244 control) were included. The meta-analysis suggests strong evidence in support of decrease in the incidence of postoperative infectious [risk ratio (RR) (95% confidence interval [CI]): 0.64 (0.55, 0.74)] and length of hospital stay [mean difference (95% CI): -1.88 (-2.91, -0.84 days)] in those receiving IMN. Even though significant benefit was observed for noninfectious complications [RR (95% CI): 0.82 (0.71, 0.95)], the quality of evidence was low. There was no statistically significant benefit on mortality [RR (95% CI): 0.83 (0.49, 1.41)]. Conclusions: IMN is beneficial in reducing postoperative infectious and noninfectious complications and shortening hospital stay in patients undergoing major open gastrointestinal surgery.</p>
  • Matthiessen, Peter, 1957-, et al. (författare)
  • Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer : A randomized multicenter trial
  • 2007
  • Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 246:2, s. 207-214
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>OBJECTIVE: The aim of this randomized multicenter trial was to assess the rate of symptomatic anastomotic leakage in patients operated on with low anterior resection for rectal cancer and who were intraoperatively randomized to a defunctioning stoma or not.</p> <p>SUMMARY BACKGROUND DATA: The introduction of total mesorectal excision surgery as the surgical technique of choice for carcinoma in the lower and mid rectum has led to decreased local recurrence and improved oncological results. Despite these advances, perioperative morbidity remains a major issue, and the most feared complication is symptomatic anastomotic leakage. The role of the defunctioning stoma in regard to anastomotic leakage is controversial and has not been assessed in any randomized trial of sufficient size.</p> <p>METHODS: From December 1999 to June 2005, a total of 234 patients were randomized to a defunctioning loop stoma or no loop stoma. Loop ileostomy or loop transverse colostomy was at the choice of the surgeon. Inclusion criteria for randomization were expected survival &gt;6 months, informed consent, anastomosis ≤7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events.</p> <p>RESULTS: The overall rate of symptomatic leakage was 19.2% (45 of 234). Patients randomized to a defunctioning stoma (n = 116) had leakage in 10.3% (12 of 116) and those without stoma (n = 118) in 28.0% (33 of 118) (odds ratio = 3.4, 95% confidence interval, 1.6-6.9, P &lt; 0.001). The need for urgent abdominal reoperation was 8.6% (10 of 116) in those randomized to stoma and 25.4% (30 of 118) in those without (P &lt; 0.001). After a follow-up of median 42 months (range, 6-72 months), 13.8% (16 of 116) of the initially defunctioned patients still had a stoma of any kind, compared with 16.9% (20 of 118) those not defunctioned (not significant). The 30-day mortality after anterior resection was 0.4% (1 of 234) and after elective reversal a defunctioning stoma 0.9% (1 of 111). Median age was 68 years (range, 32-86 years), 45.3% (106 of 234) were females, 79.1% (185 of 234) had preoperative radiotherapy, the level of anastomosis was median 5 cm, and intraoperative blood loss 550 mL, without differences between the groups.</p> <p>CONCLUSION: Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.</p>
  • Mayer, D., et al. (författare)
  • Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair : a two-center 14-year experience
  • 2012
  • Ingår i: Annals of Surgery. - Philadelphia, USA : Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 256:5, s. 688-696
  • Tidskriftsartikel (refereegranskat)abstract
    • <p><strong>Objective:</strong> To present the combined 14-year experience of 2 university centers performing endovascular aneurysm repair (EVAR) on 100% of noninfected ruptured abdominal aortic aneurysms (RAAA) over the last 32 months.</p><p><strong>Background:</strong> : Endovascular aneurysm repair for RAAA feasibility is reported to be 20% to 50%, and EVAR for RAAA has been reported to have better outcomes than open repair.</p><p><strong>Methods: </strong>We retrospectively analyzed prospectively gathered data on 473 consecutive RAAA patients (Zurich, 295; Örebro, 178) from January 1, 1998, to December 31, 2011, treated by an "EVAR-whenever-possible" approach until April 2009 (EVAR/OPEN period) and thereafter according to a "100% EVAR" approach (EVAR-ONLY period).Straightforward cases were treated by standard EVAR. More complex RAAA were managed during EVAR-ONLY with adjunctive procedures in 17 of 70 patients (24%): chimney, 3; open iliac debranching, 1; coiling, 8; onyx, 3; and chimney plus onyx, 2.</p><p><strong>Results:</strong> Since May 2009, all RAAA but one have been treated by EVAR (Zurich, 31; Örebro, 39); 30-day mortality for EVAR-ONLY was 24% (17 of 70). Total cohort mortality (including medically treated patients) for EVAR/OPEN was 32.8% (131 of 400) compared with 27.4% (20 of 73) for EVAR-ONLY (P = 0.376). During EVAR/OPEN, 10% (39 of 400) of patients were treated medically compared with 4% (3 of 73) of patients during EVAR-ONLY. In EVAR/OPEN, open repair showed a statistically significant association with 30-day mortality (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI], 1.4-7.5; P = 0.004). For patients with no abdominal decompression, there was a higher mortality with open repair than EVAR (adjusted OR = 5.6; 95% CI, 1.9-16.7). In patients with abdominal decompression by laparotomy, there was no difference in mortality (adjusted OR = 1.1; 95% CI, 0.3-3.7).</p><p><strong>Conclusions: </strong>The "EVAR-ONLY" approach has allowed EVAR treatment of nearly all incoming RAAA with low mortality and turndown rates. Although the observed association of a higher EVAR mortality with abdominal decompression needs further study, our results support superiority and more widespread adoption of EVAR for the treatment of RAAA.</p>
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