| 1. |
- Afshari, Kevin, et al.
(författare)
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Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction
- 2021
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Ingår i: Scandinavian Journal of Gastroenterology. - : Taylor & Francis Group. - 0036-5521 .- 1502-7708. ; 56:9, s. 1126-1130
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: This study aimed to determine whether day-case closure of loop ileostomy with discharge within 23 h was both feasible and accepted by patients.Materials and methods: We conducted a prospective pilot study where selected rectal cancer patients with diverting loop ileostomy underwent stoma closure in a 23-h stay setting. Patients were followed up on the third, seventh, and 30th postoperative day and phoned daily during the first week. A comparable group of 30 patients who underwent standard in-hospital stoma closure prior to the start of the study were selected retrospectively as historical controls.Results: In total, 30 patients (median age, 67 years; range, 41-79 years) were included. All patients met discharge criteria and were discharged within 23 h of surgery, except one. In total, seven patients (23%) were admitted. Two of these patients underwent laparotomy because of anastomotic leakage and small bowel obstruction, respectively. The mean total length of stay was 1.7 days. Most patients (87%) were satisfied with the treatment without feeling neglected or anxious and preferred the 23-h stay setting. In the control group, the mean length of stay was 5 days. Seven patients (23%) were readmitted. Two of these patients underwent laparotomy because of small bowel obstruction and abscess, respectively.Conclusion: Ileostomy closure in a 23-h stay setting in selected patients with meticulous follow up is feasible and safe with high patient satisfaction.
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| 2. |
- Afshari, Kevin, et al.
(författare)
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Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case–control study
- 2019
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Ingår i: Surgical Oncology. - : Elsevier BV. - 0960-7404 .- 1879-3320. ; 29, s. 102-106
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: The aim was to identify patient-, tumor- and treatment-related prognostic factors for five-year survival in rectal cancer patients with synchronous stage IV disease. Material and methods: This nationwide case-control study was based on the Swedish Colorectal Cancer Registry with supplementary information from medical records and the Swedish Inpatient Registry during the period 2000–2008. All resected rectal cancer patients with synchronous metastases that survived more than five years were included as cases. The control group consisted of corresponding patients who lived less than five years, matched in a 1:2 based on gender, age, resection of the rectal tumor, and the study period. Results: A total of 405 patients were identified; 99 long-term survivors (LTS) and 182 short-term survivors (STS). Patient-related factors of symptoms and comorbidity did not differ between LTS and STS. Among the treatment-related factors, multiple site metastases (p = 0.007), bilobar liver metastasis (p = 0.002), and increasing number of liver metastasis (p < 0.001) were associated with STS. Prognostic treatment-related factors were preoperative radiotherapy (p = 0.001), metastasectomy (p < 0.001), and radical resection of the primary tumor (p = 0.014). In the multivariable analysis, the single most important factor for becoming a LTS was a metastasectomy (hazard ratio: 8.474, 95% confidence interval: 4.098–17.543). Conclusions: The most important prognostic factor for long-term survival in patients with stage IV rectal cancer was metastasectomy, especially liver surgery. With thorough selection of patients for metastasectomy more patients with metastasized rectal cancer may survive beyond five years. © 2019 Elsevier Ltd
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| 3. |
- Afshari, Kevin, et al.
(författare)
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Risk factors for small bowel obstruction after open rectal cancer resection
- 2021
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Ingår i: BMC Surgery. - : BioMed Central (BMC). - 1471-2482. ; 21:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery.Methods: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed.Results: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO.Conclusions: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.
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| 4. |
- Afshari, Kevin
(författare)
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Surgical Aspects and Prognostic Factors in the Management of Rectal Cancer
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Survival among patients with stage IV rectal cancer is poor and surgical treatment for this disease is associated with morbidities such as small bowel obstruction, complications with a diverting loop ileostomy, and functional bowel disturbances. The overall aim of this thesis was to assess risk factors and morbidity after surgery for rectal cancer and to evaluate factors affecting survival in patients with stage IV rectal cancer.Paper I a prospective study on patients with rectal cancer with loop ileostomy who underwent stoma closure in a 23-hour hospital stay setting. Results were compared with a group who underwent standard in-hospital stoma closure prior to the start of the study, selected retrospectively as controls. No differences were found in the number of complications or the frequency of re-hospitalization or re-operation, indicating that ileostomy closure in a 23-hour hospital stay setting in these selected patients was feasible and safe with high patient satisfaction.Paper II a population-based study with data gathered prospectively. In total, 11% of the patients developed small bowel obstruction (SBO), mostly during the first year after rectal cancer surgery. Surgical treatment for SBO was performed in 4.2% of the patients, and the mechanism was stoma-related in one-fourth. Rectal resection without anastomoses, age, morbidity, and previous radiotherapy (RT) was not associated with admission to the hospital or surgery for SBO. Re-laparotomy due to complications after rectal cancer surgery was an independent risk factor for admission for treating SBO.Paper III a population-based study with data gathered prospectively on bowel function at 1 year after anterior resection or stoma reversal. No associations were found between any defecatory dysfunction and the part of the colon used for anastomosis, the level of the vascular tie, or gender. An association was observed between higher anastomotic level and a lower risk of incontinence and clustering. At 1 year after loop ileostomy closure, the risks of incontinence, clustering, and urgency increased by up to fourfold.Paper IV a case-control study aiming to identify patient-, tumor-, and treatment-related prognostic factors for 5-year survival in patients with rectal cancer with synchronous stage IV disease. Patient-related factors did not differ between groups. Among the tumor-related factors, multiple site metastases, bilobar liver metastases, and increasing numbers of liver metastases were associated with poor survival. Prognostic treatment-related factors were preoperative RT, metastasectomy, and radical resection of the primary tumor. The most important prognostic factor for long-term survival was metastasectomy.
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| 5. |
- Almer, Sven, 1953-, et al.
(författare)
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Leukocyte scintigraphy compared to intraoperative small bowel enteroscopy and laparotomy findings in Crohn's disease
- 2007
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Ingår i: Inflammatory Bowel Diseases. - : Oxford University Press (OUP). - 1078-0998 .- 1536-4844. ; 13:2, s. 164-174
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Tidskriftsartikel (refereegranskat)abstract
- Background: Leukocyte scintigraphy is a noninvasive investigation to assess inflammation. We evaluated the utility of labeled leukocytes to detect small bowel inflammation and disease complications in Crohn's disease and compared it to whole small bowel enteroscopy and laparotomy findings.Methods: Scintigraphy with technetium-99m exametazime-labeled leukocytes was prospectively performed in 48 patients with Crohn's disease a few days before laparotomy; 41 also had an intraoperative small bowel enteroscopy. The same procedures were performed in 8 control patients. Independent grading of scans was compared with the results of enteroscopy and with surgical, histopathologic, and clinical data.Results: In the 8 control patients leukocyte scan, endoscopy, and histopathology were all negative for the small bowel. In patients with Crohn's disease and small bowel inflammation seen at enteroscopy and/or laparotomy (n = 39) the scan was positive in 33. In 8 patients without macroscopic small bowel inflammation, the scan was positive for the small bowel in 3 patients; at histology, 2 of 3 had inflammation. When combining results for patients and controls, the sensitivity of leukocyte scan for macroscopically evident small bowel inflammation was 0.85, specificity 0.81, accuracy 0.84, positive predictive value 0.92, and negative predictive value 0.68. Scintigraphy detected inflammatory lesions not known before laparotomy in 16 of 47 (34%) Crohn's disease patients and showed uptake in 25 of 35 (71%) bowel strictures. It was diagnostic regarding 4 of 8 abscesses and 9 of 15 fistulas. In 6 patients (13%) lesions first demonstrated by leukocyte scintigraphy were treated during the surgery performed.Conclusions: Leukocyte scintigraphy reliably detects small bowel inflammation in Crohn's disease. It gives additional information on the presence of inflammatory lesions in a fraction of patients planned for surgery.
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| 6. |
- Birgisson, Helgi, et al.
(författare)
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Effects of Centralization of Colorectal Surgery on the Outcome of Patients with Distal Sigmoid Colonic Cancer
- 2009
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Ingår i: Digestive Surgery. - : S. Karger AG. - 0253-4886 .- 1421-9883. ; 26:2, s. 169-175
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Tidskriftsartikel (refereegranskat)abstract
- Background: In 1996, all colorectal surgery in the county of Västmanland, Sweden, was centralized to the central District Hospital in Västerås. A Colorectal Unit was established and modern surgical procedures were introduced. The aim of this study was to analyze the outcome for patients treated surgically for distal sigmoid colonic cancer before and after the centralization. Methods: Hospital records of all patients with distal sigmoid colonic cancer, treated between 1991-1995, group 1 (n = 64), and 1996-2000, group 2 (n = 82), were studied retrospectively. Results: In group 2, there were fewer reoperations (n = 0) than in group 1 (n = 6; p = 0.005) and the postoperative mortality was lower; one in group 2 compared with five in group 1 (p = 0.047). The amount of lymph nodes examined were higher and the length of distal surgical margin longer in group 2. Curatively treated patients in group 2 had better overall survival compared to group 1 (RR 0.56; 95% CI 0.34-0.93). Conclusion: Centralization of colorectal surgery resulted in an improvement of pathologic specimens and a decrease in postoperative reoperations and mortality in patients treated surgically for distal sigmoid colonic cancer. Moreover, the overall survival of curatively treated patients was improved.
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| 7. |
- Birgisson, Helgi, et al.
(författare)
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The correlation between a family history of colorectal cancer and survival of patients with colorectal cancer
- 2009
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Ingår i: Familial Cancer. - : Springer Science and Business Media LLC. - 1389-9600 .- 1573-7292. ; 8:4, s. 555-561
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Tidskriftsartikel (refereegranskat)abstract
- The purpose was to analyze survival of patients with colorectal cancer and a positive family history for colorectal cancer in first degree relatives compared with those with no such family history and to determine whether differences in survival could be explained by known clinico-pathological factors. During 2000-2003, 318 consecutive patients with colorectal cancer answered a written questionnaire about their family history for colorectal cancer. During a 6-year follow-up, recurrences and survival were registered. Thirty-one (10%) patients had a first-degree relative with colorectal cancer, moreover two patients fulfilled the criteria of hereditary non-polyposis colorectal cancer and were excluded. Patients with a first-degree relative with colorectal cancer had better survival and lower risk for recurrences compared to those with no relatives with colorectal cancer. In a multivariate analysis including age, gender, stage of disease, tumor differentiation, vascular invasion and family history, patients with first-degree relatives with colorectal cancer had lower risks for death (RR 0.37; 95% CI 0.17-0.78) and death from cancer (RR 0.25; 95% CI 0.08-0.80), compared to those with a no relative with colorectal cancer. The differences were seen in patients with colon cancer but not rectal cancer. Family history for colorectal cancer in a first-degree relative is an individual prognostic factor in patients with colon cancer and could not be explained by known clinico-pathological factors. The value of family history taking in patients with colon cancer is therefore not only to identify families with hereditary colorectal cancer, but also to add information to the prognosis of the patients.
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| 8. |
- Buunen, Mark, et al.
(författare)
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Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial.
- 2009
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Ingår i: The lancet oncology. - 1474-5488 .- 1470-2045. ; 10:1, s. 44-52
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Laparoscopic surgery for colon cancer has been proven safe, but debate continues over whether the available long-term survival data justify implementation of laparoscopic techniques in surgery for colon cancer. The aim of the COlon cancer Laparoscopic or Open Resection (COLOR) trial was to compare 3-year disease-free survival and overall survival after laparoscopic and open resection of solitary colon cancer. METHODS: Between March 7, 1997, and March 6, 2003, patients recruited from 29 European hospitals with a solitary cancer of the right or left colon and a body-mass index up to 30 kg/m(2) were randomly assigned to either laparoscopic or open surgery as curative treatment in this non-inferiority randomised trial. Disease-free survival at 3 years after surgery was the primary outcome, with a prespecified non-inferiority boundary at 7% difference between groups. Secondary outcomes were short-term morbidity and mortality, number of positive resection margins, local recurrence, port-site or wound-site recurrence, and blood loss during surgery. Neither patients nor health-care providers were blinded to patient groupings. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00387842. FINDINGS: During the recruitment period, 1248 patients were randomly assigned to either open surgery (n=621) or laparoscopic surgery (n=627). 172 were excluded after randomisation, mainly because of the presence of distant metastases or benign disease, leaving 1076 patients eligible for analysis (542 assigned open surgery and 534 assigned laparoscopic surgery). Median follow-up was 53 months (range 0.03-60). Positive resection margins, number of lymph nodes removed, and morbidity and mortality were similar in both groups. The combined 3-year disease-free survival for all stages was 74.2% (95% CI 70.4-78.0) in the laparoscopic group and 76.2% (72.6-79.8) in the open-surgery group (p=0.70 by log-rank test); the difference in disease-free survival after 3 years was 2.0% (95% CI -3.2 to 7.2). The hazard ratio (HR) for disease-free survival (open vs laparoscopic surgery) was 0.92 (95% CI 0.74-1.15). The combined 3-year overall survival for all stages was 81.8% (78.4-85.1) in the laparoscopic group and 84.2% (81.1-87.3) in the open-surgery group (p=0.45 by log-rank test); the difference in overall survival after 3 years was 2.4% (95% CI -2.1 to 7.0; HR 0.95 [0.74-1.22]). INTERPRETATION: Our trial could not rule out a difference in disease-free survival at 3 years in favour of open colectomy because the upper limit of the 95% CI for the difference just exceeded the predetermined non-inferiority boundary of 7%. However, the difference in disease-free survival between groups was small and, we believe, clinically acceptable, justifying the implementation of laparoscopic surgery into daily practice. Further studies should address whether laparoscopic surgery is superior to open surgery in this setting.
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| 9. |
- Chabok, Abbas, et al.
(författare)
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Prevalence of fecal carriage of antibiotic-resistant bacteria in patients with acute surgical abdominal infections
- 2010
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Ingår i: SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. - : Informa Healthcare. - 0036-5521 .- 1502-7708. ; 45:10, s. 1203-1210
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Tidskriftsartikel (refereegranskat)abstract
- Objective. Antibiotic resistance is increasing worldwide. The aims of the current study were to determine the fecal carriage of antibiotic-resistant bacteria and antibiotic treatment in surgical patients admitted to hospital due to acute intra-abdominal infections. Materials and methods. Eight Swedish surgical units participated in this prospective multicenter investigation. Rectal swabs were obtained on admission to hospital. Cultures were performed on chromogenic agar and antibiotic susceptibility testing was performed using the disk diffusion method. Extended-spectrum beta-lactamase (ESBL)phenotype was confirmed by Etest. Results. Rectal samples were obtained and analyzed from 208 patients with intra-abdominal surgical infections. Surgery was performed in 134 patients (65%). Cephalosporins were the most frequently used empirical antibiotic therapy. The highest rates of resistance among Enterobacteriaceae were detected for ampicillin (54%), tetracycline (26%), cefuroxime (26%) and trimethoprim-sulfamethoxazole (20%). The prevalence of decreased susceptibility (I + R) for the other antibiotics tested was for ciprofloxacin 20%, piperacillin-tazobactam 17%, cefotaxime 14%, ertapenem 12%, gentamicin 3% and imipenem 0%. ESBL-producing Enterobacteriaceae were found in samples from 10 patients (5%). Three patients had five E. coli isolates producing AmpC enzymes. Conclusions. This study shows a high rate of resistance among Enterobacteriaceae against antibiotics which are commonly used in Sweden and should have implications for the future choice of antibiotics for surgical patients.
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| 10. |
- Chabok, Abbas, et al.
(författare)
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Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis
- 2012
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 99:4, s. 532-539
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Tidskriftsartikel (refereegranskat)abstract
- Background: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up. Methods: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. Results: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1.9 per cent) who received no antibiotics and in three (1.0 per cent) who were treated with antibiotics (P = 0.302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0.881). Conclusion: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.
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| 11. |
- Djureinovic, Tatjana, et al.
(författare)
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The CHEK2 1100delC variant in Swedish colorectal cancer
- 2006
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Ingår i: Anticancer Research. - 0250-7005 .- 1791-7530. ; 26:6C, s. 4885-4888
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The cell cycle checkpoint kinase 2 (CHEK2) 1100delC variant has recently been identified at high frequency in families with both breast and colorectal cancer, suggesting the possible role of this variant in colorectal cancer predisposition. PATIENTS AND METHODS: To evaluate the role of CHEK2 ll00delC among Swedish colorectal cancer patients, the variant frequency was determined in 174 selected familial cases, 644 unselected cases and 760 controls, as well as in l8 families used in the genome-wide linkage analysis, where weak linkage was seen for the region harboring the CHEK2 gene. RESULTS: CHEK2 l100delC was found in 1.15% of familial and in 0.93% of unselected cases, compared to 0.66% of controls, showing no significant difference between groups. One out of 45 familial cases with a family history of breast cancer was shown to be a carrier. The variant was not identified in the 18 families included in the linkage analysis. CONCLUSION: The CHEK2 1100delC was not significantly increased in Swedish colorectal cancer patients, however, in order to determine the role of the variant in colorectal cancer families with the history of breast cancer a larger sample size is needed.
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| 12. |
- Hosseinali Khani, Maziar, 1975-, et al.
(författare)
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Treatment strategies for patients with stage IV rectal cancer : a report from the Swedish Rectal Cancer Registry
- 2012
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Ingår i: European Journal of Cancer. - : Elsevier BV. - 0959-8049 .- 1879-0852. ; 48:11, s. 1616-1623
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Tidskriftsartikel (refereegranskat)abstract
- Background: The optimal treatment strategy for patients with stage IV rectal cancer is unclear. The aim of the present study was to describe trends and compare the different treatment strategies for this group of patients at a national level and over time.Methods: Data from 2758 rectal cancer patients with (stage IV group) and 13 420 without metastases (stage I-III group) were available from the Swedish Rectal Cancer Registry between January 1995 and December 2006.Results: Patients with stage IV disease increased from 15 to 19 per cent between 1995 and 2006 (p<0.001) and the frequency of patients not operated increased from 13 to 26 per cent (p<0.001). Postoperative 30 day mortality after bowel resection was 2 per cent and after exploratory laparotomy 9 per cent. Median survival for stage IV patients operated with bowel resection was 16.3 months, an exploratory laparotomy 6.1 months, and for patients having no surgery 4.6 months. Patients aged 60-69 years increased their survival over time, irrespective of the treatment given. In the multivariate analysis, an increased risk of death was associated with: age > 80 years, operation at a local hospital, treatment in earlier time periods, not receiving preoperative radio- or chemotherapy, and not having a bowel resection.Conclusion: Survival for stage IV rectal cancer patients improved in the latest time period despite the great increase in non-operated patients. Patients aged > 80 years should be carefully assessed and staged before surgery. The survival advantage for stage IV rectal cancer patients who underwent primary tumour resection is probably due to selection bias.
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| 13. |
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| 14. |
- Isacson, Daniel, et al.
(författare)
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Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis
- 2019
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Ingår i: British Journal of Surgery. - : WILEY. - 0007-1323 .- 1365-2168. ; 106:11, s. 1542-1548
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Tidskriftsartikel (refereegranskat)abstract
- Background: The aim of this study was to assess the long-term results in patients with uncomplicated diverticulitis who had participated in the Antibiotics in Acute Uncomplicated Diverticulitis (AVOD) RCT, which randomized patients with CT-verified left-sided acute uncomplicated diverticulitis to management without or with antibiotics.Methods: The medical records of patients who had participated in the AVOD trial were reviewed for long-term results such as recurrences, complications and surgery. Quality-of-life questionnaires (EQ-5D (TM)) were sent to patients, who were also contacted by telephone. Descriptive statistics were used for the analysis of clinical outcomes.Results: A total of 556 of the 623 patients (89 center dot 2 per cent) were followed up for a median of 11 years. There were no differences between the no-antibiotic and antibiotic group in recurrences (both 31 center dot 3 per cent; P = 0 center dot 986), complications (4 center dot 4 versus 5 center dot 0 per cent; P = 0 center dot 737), surgery for diverticulitis (6 center dot 2 versus 7 center dot 1 per cent; P = 0 center dot 719) or colorectal cancer (0 center dot 4 versus 2 center dot 1 per cent; P = 0 center dot 061). The response rate for the EQ-5D (TM) was 52 center dot 8 versus 45 center dot 2 per cent respectively (P = 0 center dot 030), and no differences were found between the two groups in any of the measured dimensions.Conclusion: Antibiotic avoidance for uncomplicated diverticulitis is safe in the long term.
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| 15. |
- Isacson, Daniel, et al.
(författare)
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Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings
- 2018
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Ingår i: Scandinavian Journal of Gastroenterology. - : Informa UK Limited. - 0036-5521 .- 1502-7708. ; 53:4, s. 449-452
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Tidskriftsartikel (refereegranskat)abstract
- Purpose:Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.Methods:The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Vastmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.Results:In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p<.001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p<.001). The total health-care cost was Euro558,679 in 2011 compared with Euro370,370 in 2014 (p<.001). Three patients developed complications in 2011 and four in 2014 (p=.469).Conclusions:The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.
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| 16. |
- Isacson, Daniel, et al.
(författare)
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Outpatient, non-antibiotic management in acute uncomplicated diverticulitis : a prospective study
- 2015
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Ingår i: International Journal of Colorectal Disease. - : Springer Science and Business Media LLC. - 0179-1958 .- 1432-1262. ; 30:9, s. 1229-1234
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period. A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months. In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 x 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4 %) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6 %) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients. Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.
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| 17. |
- Isacson, Daniel
(författare)
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Treatment of Acute Uncomplicated Colonic Diverticulitis
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to evaluate the clinical management of AUD with regard to the no-antibiotic policy and its long-term effect, treatment on an outpatient basis and the potential health-care cost savingsStudy I: a retrospective study at Västmanlands Hospital that evaluated and confirmed the adherence to the no-antibiotic policy in patients with AUD and its safety regarding complications and recurrences. A total of 246 patients with acute diverticulitis were identified, of which 195 had computed tomography (CT) confirmed AUD. In total, 91.3% of these patients did not receive any antibiotics and only two developed complications.Study II: a retrospective study with the aim to conduct a long-term follow-up of all Swedish patients who participated in the AVOD trial in terms of recurrences, complications, surgery and quality of life. The medical records of 96% of the patients were reviewed with a mean follow up of 11 years. Quality of life questionnaires were sent out to all patients. There were no differences regarding the rates of recurrence, complications or surgery for diverticulitis. There were no differences in the quality of life between groups according to the EQ-5D questionnaire.Study III: a prospective study where 155 patients with CT-verified AUD as were treated as outpatients without antibiotics. On day 3, patients reported an average pain score of 1.8 of 10 on the VAS scale and only 30% of patients were using analgesia. Four patients returned to hospital because of treatment failure.Study IV: a retrospective cohort study at Västmanland’s Hospital evaluated the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. Medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics were reviewed. Overall 494 episodes of AUD were identified: 254 in 2011 and 240 in 2014. Three patients developed complications in 2011 and four in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 61% in 2014. The hospital admissions, total length of stay of and total health-care costs were almost halved.In conclusion, these studies confirm the low complication and recurrence rates of AUD and strengthens findings that antibiotics have no benefit in the treatment of this disease. The no-antibiotic policy had no impact on short- or long-term outcomes regarding the rates of recurrence, complications, surgery or quality of life. Outpatient management was found to be feasible and safe, and significantly reduced admissions, which led to large health-care cost savings.
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| 18. |
- Khani, M. Hosseinali, et al.
(författare)
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Centralization of rectal cancer surgery improves long-term survival
- 2010
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Ingår i: Colorectal Disease. - : Wiley. - 1462-8910 .- 1463-1318. ; 12:9, s. 874-879
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Tidskriftsartikel (refereegranskat)abstract
- Aim In 1996, rectal cancer surgery in the Swedish county of Vastmanland was centralized to a single colorectal unit. At the same time, total mesorectal excision and multidisciplinary team meetings were introduced. The aim of this audit was to determine the long-term results before and after centralization. Method All consecutive rectal cancer patients who underwent curative or palliative surgery at one of the county's four hospitals between 1993 and 1996 (n = 133, group 1) were compared with patients operated at the new centralized colorectal unit between 1996 and 1999 (n = 144, group 2). Results Preoperative radiotherapy was common in both groups, but in group 2, it was planned using MRI. Local recurrences were detected in 8% of all patients operated in group 1 vs 3.5% in group 2 (P = 0.043). The overall 5-year survival for all patients in group 1 was 38 vs 62% in group 2 (P = 0.003). According to multivariate analysis, the new colorectal unit was an independent predictor for improved long-term survival. Conclusion This population-based audit shows reduced local recurrence rate and prolonged overall survival for rectal cancer patients after centralization to a single colorectal unit with multidisciplinary management and increased subspecialization.
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| 19. |
- Kindler, Csaba, et al.
(författare)
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Detection of Free Cancer Cells in Pelvic Lavage with Double Immunocytochemistry at Rectal Cancer Surgery
- 2017
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Ingår i: Anticancer Research. - : International Institute of Anticancer Research. - 0250-7005 .- 1791-7530. ; 37:4, s. 1563-1568
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Tidskriftsartikel (refereegranskat)abstract
- Background/Aim: The aim of the present study was to describe a double immunocytochemical staining method for detecting free cancer cells after rectal cancer surgery and to evaluate their extent and prognostic role. Materials and Methods: Immunocytochemistry was performed using antibodies against cytokeratin 20/caudal-typehomeobox transcription factor 2 (CDX2) and mucin glycoprotein-2 (MUC2)/p53 protein. The study included 29 patients with infraperitoneal rectal cancer who underwent bowel resection and four controls. The pelvic lavage was retrieved at the start of laparotomy, after total mesorectal excision and after abdominal lavage with sterile water. Results: Free cancer cells were detected with the double immunocytochemical method in the two controls with carcinomatosis and one control with sigmoidal cancer. None of the patients with rectal tumours had presence of free cancer cells. Conclusion: Immunocytochemical analysis of peritoneal lavage was feasible and negative in patients with infraperitoneal rectal cancer. Further studies are encouraged to investigate the clinical relevance in cases with free cancer cells after incomplete total mesorectal excision.
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| 20. |
- Liljegren, G, et al.
(författare)
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Acute colonic diverticulitis : a systematic review of diagnostic accuracy
- 2007
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Ingår i: Colorectal Disease. - Oxford : Wiley. - 1462-8910 .- 1463-1318. ; 9:6, s. 480-488
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Forskningsöversikt (refereegranskat)abstract
- Objective To appraise the literature on the diagnosis of acute colonic diverticulitis by ultrasound (US), computed tomography (CT), barium enema (BE) and magnetic resonance imaging (MRI).Method The databases of Pub Med, the Cochrane Library and EMBASE were searched for articles on the diagnosis of diverticulitis published up to November 2005. Studies where US, CT, BE, or MRI were compared with a reference standard on consecutive or randomly selected patients were included. Three examiners independently read the articles according to a prespecified protocol. In case of disagreement consensus was sought. The level of evidence of each article was classified according to the criteria of the Centre for Evidence-Based Medicine (CEBM), Oxford, UK.Results Forty-nine articles relevant to the subject were found and read in full. Twenty-nine of these were excluded. Among the remaining 20 articles, only one study, evaluating both US and CT reached level of evidence 1b according to the CEBM criteria. Two US studies and one MRI study reached level 2b. The remaining studies were level 4.Conclusion The best evidence for diagnosis of diverticulitis in the literature is on US. Only one small study of good quality was found for CT and for MRI-colonoscopy.
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| 21. |
- Nikberg, Maziar, et al.
(författare)
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Lymphovascular and perineural invasion in stage II rectal cancer : a report from the Swedish colorectal cancer registry
- 2016
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Ingår i: Acta Oncologica. - 0284-186X .- 1651-226X. ; 55:12, s. 1418-1424
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Tidskriftsartikel (refereegranskat)abstract
- Background: Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level. Materials and methods: Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012. Results: Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09-1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34-2.43, p < .001) had significantly increased risks of recurrence. Conclusions: Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.
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| 22. |
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| 23. |
- Picelli, Simone, et al.
(författare)
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Common variants in human CRC genes as low-risk alleles
- 2010
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Ingår i: European Journal of Cancer. - : Elsevier BV. - 0959-8049 .- 1879-0852. ; 46:6, s. 1041-1048
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Tidskriftsartikel (refereegranskat)abstract
- The genetic susceptibility to colorectal cancer (CRC) has been estimated to be around 35% and yet high-penetrance germline mutations found so far explain less than 5% of all cases. Much of the remaining variations could be due to the co-inheritance of multiple low penetrant variants. The identification of all the susceptibility alleles could have public health relevance in the near future. To test the hypothesis that what are considered polymorphisms in human CRC genes could constitute low-risk alleles, we selected eight common SNPs for a pilot association study in 1785 cases and 1722 controls. One SNP, rs3219489:G>C (MUTYH Q324H) seemed to confer an increased risk of rectal cancer in homozygous status (OR = 1.52; CI = 1.06-2.17). When the analysis was restricted to our 'super-controls', healthy individuals with no family history for cancer, also rs1799977:A>G (MLH1 I219V) was associated with an increased risk in both colon and rectum patients with an odds ratio of 1.28 (CI = 1.02-1.60) and 1.34 (CI = 1.05-1.72), respectively (under the dominant model); while 2 SNPs, rs1800932:A>G (MSH6 P92P) and rs459552:T>A (APC D1822V) seemed to confer a protective effect. The latter, in particular showed an odds ratio of 0.76 (CI = 0.60-0.97) among colon patients and 0.73 (CI = 0.56-0.95) among rectal patients. In conclusion, our study suggests that common variants in human CRC genes could constitute low-risk alleles. (C) 2010 Elsevier Ltd. All rights reserved.
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| 24. |
- Sigurdardottir, Johanna, et al.
(författare)
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Elective surgery should be considered after successful conservative treatment of recurrent diverticular abscesses
- 2020
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Ingår i: Scandinavian Journal of Gastroenterology. - : TAYLOR & FRANCIS LTD. - 0036-5521 .- 1502-7708. ; 55:4, s. 454-459
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: The purpose of this study was to evaluate the disease pattern and treatment of diverticular abscesses. Methods: Patients treated for diverticulitis (K57) in Vastmanland, Sweden were identified for this retrospective population-based study between January 2010 and December 2014. Patients with diverticular abscesses were included. The clinical and radiological data were extracted, and the computed tomography scans were reevaluated. Results: Of the 75 patients (45 women) with a median age of 62 years (range: 23-88 years), abscesses were localized pericolic in 42 patients (59%) and in the pelvis in 33 patients (41%). The median abscess size was 4.8 cm (range: 1.1-11.0 cm). Six patients (8%) required urgent surgical intervention during the index admission. The median follow-up time was 58 months (range: 0-95 months). During follow-up, 40 patients (58%) had disease recurrence and 35 of these patients (88%) presented with complicated diverticulitis. The median time until re-admission was 2 months (range: 3 days-94 months). Patients with pelvic abscesses developed fistulas more frequently, 3 versus 11 patients (p = .003). Twenty-three percent of patients with pericolic abscesses required surgery compared with 40% of patients with pelvic abscesses (p = .09). No patients had a recurrence of abscesses after a colonic resection. Conclusion: The majority of patients with diverticular abscesses had recurrences with repeated admissions regardless of abscess location. An unexpectedly high proportion of patients required surgical intervention during the follow-up period. A liberal approach regarding elective surgery for patients with recurrent diverticulitis abscesses who tolerate surgery seems justified.
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| 25. |
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