| 1. |
- Abdalla, Maie, et al.
(författare)
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Anorectal Function After Ileo-Rectal Anastomosis Is Better than Pelvic Pouch in Selected Ulcerative Colitis Patients
- 2020
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Ingår i: Digestive Diseases and Sciences. - : Springer-Verlag New York. - 0163-2116 .- 1573-2568. ; , s. 250-259
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: With a lifelong perspective, 12% of ulcerative colitis patients will need a colectomy. Further reconstruction via ileo-rectal anastomosis or pouch can be affected by patients' perspective of their quality of life after surgery.AIM: To assess the function and quality of life after restorative procedures with either ileo-rectal anastomosis or ileal pouch-anal anastomosis in relation to the inflammatory activity on endoscopy and in biopsies.METHOD: A total of 143 UC patients operated with subtotal colectomy and ileo-rectal anastomosis or pouches between 1992 and 2006 at Linköping University Hospital were invited to participate. Those who completed the validated questionnaires (Öresland score, SF-36, Short Health Scale) were offered an endoscopic evaluation including multiple biopsies. Associations between anorectal function and quality of life with type of restorative procedure and severity of endoscopic and histopathologic grading of inflammation were evaluated.RESULTS: Some 77 (53.9%) eligible patients completed questionnaires, of these 68 (88.3%) underwent endoscopic evaluation after a median follow-up of 12.5 (range 3.5-19.4) years after restorative procedure. Patients with ileo-rectal anastomosis reported better overall Öresland score: median = 3 (IQR 2-5) for ileo-rectal anastomosis (n = 38) and 10 (IQR 5-15) for pouch patients (n = 39) (p < 0.001). Anorectal function (Öresland score) and endoscopic findings (Baron-Ginsberg score) were positively correlated in pouch patients (tau: 0.28, p = 0.006).CONCLUSION: Patients operated with ileo-rectal anastomosis reported better continence compared to pouches. Minor differences were noted regarding the quality of life. Ileo-rectal anastomosis is a valid option for properly selected ulcerative colitis patients if strict postoperative endoscopic surveillance is carried out.
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| 2. |
- Abdalla, Maie
(författare)
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Cancer and reconstructive surgery in Inflammatory bowel disease
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Ulcerative colitis (UC) is a chronic inflammatory disease that affects the colon. According to the literature, some thirty percent of UC patients may require a subtotal colectomy and ileostomy due to failure of medical treatment, acute toxic colitis or dysplasia/cancer diagnosis. Some patients choose to get continence restored with either an ileorectal anastomosis (IRA) or an ileal pouch-anal anastomosis (IPAA). Worldwide most surgeons prefer an IPAA to an IRA, despite reports of pouchitis, impaired fertility and fecundity. Fear of recurring proctitis and fear of rectal cancer in the remaining rectum is contributing to the choice of an IPAA. Little is known regarding the outcomes of IRA compared with IPAA in UC patients. We aimed to investigate the anorectal function, quality of life (QoL), risk of failure and rectal cancer in patients with UC restored with IRA and IPAA respectively. Methods: Data about all Inflammatory bowel disease (IBD) patients was obtained from the Swedish National Patient Register (NPR) between 1964-2014 and in one study from the Linköping University Hospital medical records 2006-2012. Patients who developed cancer were identified from the Swedish National Cancer Register. We investigated the risk of cancer and inflammation, functional outcome and failure as well as the quality of life for IRA and IPAA patients. Investigation of risk for cancer in IRA and IPAA compared with the background population was performed using survival analytic techniques: uni-and multivariate regression, Kaplan Meier curves and standardized incidence ratio. Results: Twelve percent (7,889 /63,795) of UC patients required colectomy according to the NPR. The relative risk for rectal cancer among patients with an IRA was increased (SIR 8.7). However, the absolute risk was 1.8% after a mean follow up of 8.6 years and the cumulative risk 10- and 20-years after IRA was 1.6% and 5.6%, respectively. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio 6.12), and severe dysplasia or cancer of the colon prior to subtotal colectomy in patients with a diverted rectum in place (hazard ratio 3.67). Regarding IPAA, the relative risk to develop rectal cancer was (SIR 0.4) compared with the background population and the absolute risk was only 0.06% after a mean of 12.2 years of follow up. Among patients operated at the Linköping University Hospital: IRA patients reported better overall continence according to the Öresland score with in median3 (IQR 2–5) for IRA (n=38) and 10 (IQR 5–15) for IPAA (n=39, p<0.001). There were no major differences regarding the QoL. According to the NPR, after a median follow up of 12.4 years failure occurred in 265(32%) out of 1112 patients, of which 76 were secondarily reconstructed with an IPAA. Failure of the IPAA occurred in 103 (6%) patients with primary and in 6 (8%) patients after secondary IPAA (log-rank p=0.38). Conclusion: IRA is a safe restorative procedure for selected UC patients. Patients should be aware of the annual postoperative endoscopic evaluation with biopsies as well as the need to the use of local anti-inflammatory preparations. However, IRA should not be offered for UC patients with an associated primary sclerosing cholangitis diagnosis due to the increased risk to develop rectal cancer in their rectal mucosa. In such case, IPAA is probably the treatment of choice.
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| 3. |
- Ahle, Margareta, 1966-, et al.
(författare)
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Maternal, fetal and perinatal factors associated with necrotizing enterocolitis in Sweden. A national case-control study
- 2018
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Ingår i: Plos One. - San Francisco, United States : Public Library of Science (PLoS). - 1932-6203. ; 13:3
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Tidskriftsartikel (refereegranskat)abstract
- Objective To analyze associations of maternal, fetal, gestational, and perinatal factors with necrotizing enterocolitis in a matched case-control study based on routinely collected, nationwide register data. Study design All infants born in 1987 through 2009 with a diagnosis of necrotizing enterocolitis in any of the Swedish national health care registers were identified. For each case up to 6 controls, matched for birth year and gestational age, were selected. The resulting study population consisted of 720 cases and 3,567 controls. Information on socioeconomic data about the mother, maternal morbidity, pregnancy related diagnoses, perinatal diagnoses of the infant, and procedures in the perinatal period, was obtained for all cases and controls and analyzed with univariable and multivariable logistic regressions for the whole study population as well as for subgroups according to gestational age. Results In the study population as a whole, we found independent positive associations with necrotizing enterocolitis for isoimmunization, fetal distress, cesarean section, neonatal bacterial infection including sepsis, erythrocyte transfusion, persistent ductus arteriosus, cardiac malformation, gastrointestinal malformation, and chromosomal abnormality. Negative associations were found for maternal weight, preeclampsia, maternal urinary infection, premature rupture of the membranes, and birthweight. Different patterns of associations were seen in the subgroups of different gestational age. Conclusion With some interesting exceptions, especially in negative associations, the results of this large, population based study, are in keeping with earlier studies. Although restrained by the limitations of register data, the findings mirror conceivable pathophysiological processes and underline that NEC is a multifactorial disease. © 2018 Ahle et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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| 4. |
- Ahle, Margareta, 1966-
(författare)
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Necrotising Enterocolitis : epidemiology and imaging
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Necrotising enterocolitis (NEC) is a potentially devastating intestinal inflammation of multifactorial aetiology in premature or otherwise vulnerable neonates. Because of the broad spectrum of presentations, diagnosis and timing of surgical intervention may be challenging, and imaging needs to be an integrated part of management.The first four studies included in this thesis used routinely collected, nationwide register data to describe the incidence of NEC in Sweden 1987‒2009, its variation with time, seasonality, space-time clustering, and associations with maternal, gestational, and perinatal factors, and the risk of intestinal failure in the aftermath of the disease.Early infant survival increased dramatically during the study period. The incidence rate of NEC was 0.34 per 1,000 live births, rising from 0.26 per 1,000 live births in the first six years of the study period to 0.57 in the last five. The incidence rates in the lowest birth weights were 100‒160 times those of the entire birth cohort. Seasonal variation was found, as well as space-time clustering in association with delivery hospitals but not with maternal residential municipalities.Comparing NEC cases with matched controls, some factors, positively associated with NEC, were isoimmunisation, fetal distress, caesarean section, persistent ductus arteriosus, cardiac and gastrointestinal malformations, and chromosomal abnormalities. Negative associations included maternal pre-eclampsia, maternal urinary infection, and premature rupture of the membranes. Intestinal failure occurred in 6% of NEC cases and 0.4% of controls, with the highest incidence towards the end of the study period.The last study investigated current practices and perceptions of imaging in the management of NEC, as reported by involved specialists. There was great consensus on most issues. Areas in need of further study seem mainly related to imaging routines, the use of ultrasound, and indications for surgery.Developing alongside the progress of neonatal care, NEC is a complex, multifactorial disease, with shifting patterns of predisposing and precipitating causes, and potentially serious long-term complications. The findings of seasonal variation, spacetime clustering, and negative associations with antenatal exposure to infectious agents, fit into the growing understanding of the central role of bacteria and immunological processes in normal maturation of the intestinal canal as well as in the pathogenesis of NEC. Imaging in the management of NEC may be developed through future studies combining multiple diagnostic parameters in relation to clinical outcome.
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| 5. |
- Andersson, Roland, 1950-
(författare)
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Appendicitis : Epidemiology and diagnosis
- 1998
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The study concerns appendicitis, its epidemiology and diagnosis, and the outcome of appendectomy. A population based cohort of 9,274 patients undergoing appendectomy in 1969 to 1990 in Jönköping County was retrospectively studied, and 502 patients admitted for suspected appendicitis to the hospitals in Jönköping and Eksjö between October 1992 and December 1993 were prospectively studied.Appendicitis was found to occur in outbreaks and space-time clusters, indicating an infectious etiology. The incidence of non-perforating appendicitis was strongly age-dependent, with a peak in adolescence, whereas the incidence of perforating appendicitis was stable at all ages. This suggests that perforating and non-perforating appendicitis are separate entities.There was a high rate of negative appendectomies, but during the study period an increasing diagnostic accuracy and decreasing incidence of negative appendectomies was observed, indicating a trend towards a more restrictive attitude to exploration in patients with suspected appendicitis. This was accompanied by a decreasing incidence of non-perforating appendicitis, whereas the incidence of perforating appendicitis was stable. An analysis of population based studies showed a strong relation between surgeons' attitude to exploration and the incidence of non-perforating ap9endicitis, whereas the incidence of perforating appendicitis was unrelated. This is consistent with a high proportion of potentially resolving appendicitis.A conservative management decreases the munber of negative explorations and saves a number of patients with resolving appendicitis from an unnecessary operation. This leads to a high proportion of perforations among the operated patients but the number of perforations is not increased. The perforation rate, therefore, should not be used as a quality measure of the management of patients with suspected appendicitis.The rate of negative explorations is higher in women. This gender difference is found at all ages and is not due to gynecological diseases alone. The explanation is the larger number of women attending for nonsurgical abdominal pain, whereas the rate of diagnostic errors among these patients is similar in men and women.Patients with a negative appendectomy are characterized by high intensity of pain and tenderness without signs of a systemic inflammatory response. Surgeons pay too much attention to pain and tenderness in their decision to operate, and underestimate the importance of temperature, laboratory variables and duration of symptoms.No single clinical or laboratory variable has sufficiently high discriminating power to be used as a true diagnostic test. The inflammatory variables are as important predictors as the clinical findings, and they are especially important in advanced appendicitis. Their diagnostic value is higher at a repeat examination after a few hours of observation.The study show for a need of an improved management of patients with suspected appendicitis, and the potential for improved clinical diagnosis. Inflammatory variables should be given more attention, and pain and tenderness should be interpreted more cautiously. An expectant management, with repeated clinical and laboratory examinations, is advisable once advanced appendicitis has been ruled out.
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| 6. |
- Andersson, Roland, 1950-, et al.
(författare)
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Interdisciplinary Dialogue Is Needed When Defining Perioperative Recommendations: Conflicting Guidelines for Anesthetizing Patients for Pilonidal Surgery
- 2018
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Ingår i: AandA practice. - : Wolters Kluwer. - 2575-3126. ; 11:8, s. 227-229
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Tidskriftsartikel (refereegranskat)abstract
- National or international guidelines can help surgeons and anesthesiologists make treatment decisions, but the existence of conflicting recommendations can hinder treatment rather than helping. A case in point is the treatment of pilonidal sinus disease, a chronic subcutaneous infection located in the sacrococcygeal area. Its incidence is rising, reaching almost 100/100,000 inhabitants. Three surgical societies have proposed guidelines for treating the disease, but these guidelines vary greatly in their approach to anesthesia. Who should provide input into guidelines? And how can medical disciplines successfully collaborate? Anesthesiologists must be involved in defining perioperative recommendations not only in patients with pilonidal sinus disease.
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| 7. |
- Andersson, Roland, 1950-
(författare)
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Less invasive pilonidal sinus surgical procedures
- 2019
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Ingår i: Colo-Proctology. - Heidelberg, Germany : Springer Medizin. - 0174-2442 .- 1615-6730. ; 41:2, s. 117-120
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Tidskriftsartikel (refereegranskat)abstract
- Pilonidal disease can be treated by less invasive methods such as simple mechanical cleansing of the sinus and cavity of hairs and granulation tissue eventually supplemented by filling the space with an antiseptic or sclerosing agent like phenol (forbidden in Germany due to its toxicity) or space-holding fibrin glue. Minimal excision or debridement of the sinus and/or cavity through amidline or aseparate paramedial excision can also be performed, leaving the wounds open or closed. These methods are simple and cost-efficient, and associated with low pain, rapid healing, and arapid return to normal activity. Adisadvantage is the higher recurrence rate; however, these methods can be used repeatedly for recurrences. Whereas the evidence for treatment with phenol or fibrine glue is weak, there are numerous reports supporting the safety and efficiency of the minimally invasive surgical methods. Because of the associated low risk for complications and morbidity, these procedures are suitable for first-line treatment in the majority of pilonidal disease patients.
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| 8. |
- Andersson, Roland, 1950-, et al.
(författare)
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Nonsurgical treatment of appendiceal abscess or phlegmon : A systematic review and meta-analysis
- 2007
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Ingår i: Annals of Surgery. - 0003-4932 .- 1528-1140. ; 246:5, s. 741-748
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence. SUMMARY BACKGROUND DATA: Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy. METHODS: A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed. RESULTS: Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3, CI: 1.9-5.6, P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1). CONCLUSIONS: The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon. © 2007 Lippincott Williams & Wilkins, Inc.
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| 9. |
- Andersson, Roland, 1950-
(författare)
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The natural history and traditional management of appendicitis revisited : spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis
- 2007
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 31:1, s. 86-92
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Tidskriftsartikel (refereegranskat)abstract
- Background The principle of early exploration on wide indications in order to prevent perforation has been the guiding star for the management of patients with suspected appendicitis for over 100 years, dating back to a time when appendicitis was a significant cause of mortality. Since then there has been a dramatic decrease in mortality due to appendicitis. Emerging evidence calls for a new understanding of the natural history of untreated appendicitis. This motivates a reappraisal of the fundamental principles for the management of patients with suspected appendicitis. Methods Analysis of epidemiologic and clinical studies that elucidate the natural history of appendicitis, i.e. the possibility of spontaneous resolution or the risk of progression to perforation, the determinants of the proportion of perforations and mortality, and the consequence of in-hospital delay. Results The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that perforation can seldom be prevented, that the risk of perforation has been exaggerated and that in-hospital delay is safe. An alternative understanding of the inverse relationship between the proportion of negative explorations and perforation and the increasing proportion of perforation with length of time is presented, mainly explaining these findings by selection due to spontaneous resolution. Conclusion Evidence suggests that spontaneous resolution of untreated, non-perforated appendicitis is common and that perforation can rarely be prevented and is associated with a lower increase in mortality than was previously thought. This motivates a shift in focus from the prevention of perforation to the early detection and treatment of advanced appendicitis. In order to minimize mortality, morbidity and costs avoidance of negative appendectomies is more important then preventing perforation. In patients with an equivocal diagnosis where advanced appendicitis is deemed less likely a correct diagnosis is more important than a rapid diagnosis. These patients can safely be managed by active observation with an improved diagnostic work-up under observation, which has consistently shown a low proportion of negative appendectomies without an increase in the proportion of perforations or morbidity. A high proportion of perforations can be explained by selection due to undiagnosed resolving appendicitis. The proportion of perforation is therefore a questionable measure of the quality of the management of patients with suspected appendicitis and should be used with caution.
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| 10. |
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