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  • 1.
    Giesecke, Peter
    et al.
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden.
    Frykman, Viveka
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden.
    Wallin, Göran K.
    Örebro University, School of Medical Sciences. Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Lönn, Stefan
    Department of Research and Development, Region Halland, Halmstad, Sweden.
    Discacciati, Andrea
    Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
    Törring, Ove
    Department of Clinical Research and Education, Karolinska Institute, Stockholm, Sweden.
    Rosenqvist, Mårten
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden.
    All-cause and cardiovascular mortality risk after surgery versus radioiodine treatment for hyperthyroidism2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 3, p. 279-286Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Little is known about the long-term side-effects of different treatments for hyperthyroidism. The few studies previously published on the subject either included only women or focused mainly on cancer outcomes. This register study compared the impact of surgery versus radioiodine on all-cause and cause-specific mortality in a cohort of men and women.

    METHODS: Healthcare registers were used to find hyperthyroid patients over 35 years of age who were treated with radioiodine or surgery between 1976 and 2000. Comparisons between treatments were made to assess all-cause and cause-specific deaths to 2013. Three different statistical methods were applied: Cox regression, propensity score matching and inverse probability weighting.

    RESULTS: Of the 10 992 patients included, 10 250 had been treated with radioiodine (mean age 65·1 years; 8668 women, 84·6 per cent) and 742 had been treated surgically (mean age 44·1 years; 633 women, 85·3 per cent). Mean duration of follow-up varied between 16·3 and 22·3 years, depending on the statistical method used. All-cause mortality was significantly lower among surgically treated patients, with a hazard ratio of 0·82 in the regression analysis, 0·80 in propensity score matching and 0·85 in inverse probability weighting. This was due mainly to lower cardiovascular mortality in the surgical group. Men in particular seemed to benefit from surgery compared with radioiodine treatment.

    CONCLUSION: Compared with treatment with radioiodine, surgery for hyperthyroidism is associated with a lower risk of all-cause and cardiovascular mortality in the long term. This finding was more evident among men.

  • 2. Gustafsson, U. O.
    et al.
    Thorell, A.
    Soop, M.
    Ljungqvist, Olle
    Örebro University, School of Health and Medical Sciences.
    Nygren, J.
    Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 11, p. 1358-1364Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Hyperglycaemia following major surgery increases morbidity, but may be improved by use of enhanced-recovery protocols. It is not known whether preoperative haemoglobin (Hb) A1c could predict hyperglycaemia and/or adverse outcome after colorectal surgery. METHODS: Some 120 patients without known diabetes underwent major colorectal surgery within an enhanced-recovery protocol. HbA1c was measured at admission and 4 weeks after surgery. All patients received an oral diet beginning 4 h after operation. Plasma glucose was monitored five times daily. Patients were stratified according to preoperative levels of HbA1c (within normal range of 4.5-6.0 per cent, or higher). RESULTS: Thirty-one patients (25.8 per cent) had a preoperative HbA1c level over 6.0 per cent. These had higher mean(s.d.) postoperative glucose (9.3(1.5) versus 8.0(1.5) mmol/l; P < 0.001) and C-reactive protein (137(65) versus 101(52) mg/l; P = 0.008) levels than patients with a normal HbA1c level. Postoperative complications were more common in patients with a high HbA1c level (odds ratio 2.9 (95 per cent confidence interval 1.1 to 7.9)). CONCLUSION: Postoperative hyperglycaemia is common among patients with no history of diabetes, even within an enhanced-recovery protocol. Preoperative measurement of HbA1c may identify patients at higher risk of poor glycaemic control and postoperative complications.

  • 3.
    Hausel, J
    et al.
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet and Centre for Surgical Sciences, Karolinska University Hospital Huddinge, Stockholm.
    Nygren, J
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet and Centre for Surgical Sciences, Karolinska University Hospital Huddinge, Stockholm.
    Thorell, A
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet and Centre for Surgical Sciences, Karolinska University Hospital Huddinge, Stockholm.
    Lagerkranser, M
    Department of Anaesthesiology and Intensive Care, Karolinska University Hospital Solna, Stockholm.
    Ljungqvist, Olle
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm; Karolinska Institutet and Centre for Surgical Sciences, Karolinska University Hospital, Stockholm.
    Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy.2005In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 92, no 4, p. 415-21Article in journal (Refereed)
    Abstract [en]

    Background: A carbohydrate-rich drink (CHO) has been shown to reduce preoperative discomfort. It was hypothesized that it may also reduce postoperative nausea and vomiting (PONV).

    Methods: Patients undergoing elective laparoscopic cholecystectomy under inhalational anaesthesia (127 women and 45 men; mean(s.d.) 48(15) years) were randomized to either preoperative fasting, intake of CHO (50 kcal/100 ml, 290 mOsm/kg) or placebo. The non-fasting groups were double-blinded; patients ingested 800 ml of liquid on the evening before surgery and 400 ml 2 h before anaesthesia. Nausea and pain scores on a visual analogue scale (VAS) and episodes of PONV were recorded up to 24 h after surgery.

    Results: The incidence of PONV was lower in the CHO than in the fasted group between 12 and 24 h after surgery (P = 0.039). Nausea scores in the fasted and placebo groups were higher after operation than before admission to hospital (P = 0.018 and P < 0.001 respectively), whereas there was no significant change in the CHO group. No intergroup differences in VAS scores were seen. The use of anaesthetics, opioids, antiemetics and intravenous fluids was similar in all groups.

    Conclusion: CHO may have a beneficial effect on PONV 12-24 h after laparoscopic cholecystectomy.

  • 4. Hendry, P. O.
    et al.
    Hausel, J.
    Nygren, J.
    Lassen, K.
    Dejong, C. H. C.
    Ljungqvist, Olle
    Örebro University, School of Health and Medical Sciences.
    Fearon, K. C. H.
    Determinants of outcome after colorectal resection within an enhanced recovery programme2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 2, p. 197-205Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Postoperative outcomes were studied in relation to adverse nutritional risk (body mass index (BMI) below 20 kg/m(2)), advanced age (80 years or more) and co-morbidity (American Society of Anesthesiologists (ASA) grade III-IV) in patients undergoing colorectal resection within an enhanced recovery after surgery programme. METHODS: Outcomes were audited prospectively in 1035 patients. Morbidity and mortality were compared with those predicted using the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and a multivariable model was used to determine independent predictors of outcome. RESULTS: Postoperative morbidity was lower than predicted (observed to expected 0.68; P < 0.001). Independent predictors of delayed mobilization were ASA III-IV (P < 0.001) and advanced age (P = 0.025). Prolonged hospital stay was related to advanced age (P = 0.002), ASA III-IV (P < 0.001), male sex (P = 0.037) and rectal surgery (P < 0.001). Morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002). None of the factors predicted 30-day mortality. CONCLUSION: Age and nutritional status were not independent determinants of morbidity or mortality. Pre-existing co-morbidity was an independent predictor of several outcomes.

  • 5.
    Humes, D. J.
    et al.
    Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Biomedical Research Unit, Queens Medical Centre Campus, University of Nottingham Nottingham, UK; Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.
    Walker, A. J.
    Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK .
    Hunt, B. J.
    Thrombosis and Haemophilia Centre Guy's Hospital, London, UK; St Thomas' NHS Foundation Trust, London, UK.
    Sultan, A. A.
    Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
    Ludvigsson, Jonas F.
    Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.
    West, J.
    Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
    Risk of symptomatic venous thromboembolism following emergency appendicectomy in adults2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 4, p. 443-450Article in journal (Refereed)
    Abstract [en]

    Background: Appendicectomy is the commonest intra-abdominal emergency surgical procedure, and little is known regarding the magnitude and timing of the risk of venous thromboembolism (VTE) after surgery. This study aimed to determine absolute and relative rates of symptomatic VTE following emergency appendicectomy.

    Methods: A cohort study was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data of patients who had undergone emergency appendicectomy from 2001 to 2011. Crude rates and adjusted incidence rate ratios (IRRs) for VTE were calculated using Poisson regression, compared with baseline risk in the year before appendicectomy.

    Results: A total of 13 441 patients were identified, of whom 56 (0·4 per cent) had a VTE in the first year after surgery. The absolute rate of VTE was highest during the in-hospital period, with a rate of 91·29 per 1000 person-years, which was greatest in those with a length of stay of 7 days or more (267·12 per 1000 person-years). This risk remained high after discharge, with a 19·1- and 6·6-fold increased risk of VTE in the first and second months respectively after discharge, compared with the year before appendicectomy (adjusted IRR: month 1, 19·09 (95 per cent c.i. 9·56 to 38·12); month 2, 6·56 (2·62 to 16·44)).

    Conclusion: The risk of symptomatic VTE following appendicectomy is relatively high during the in-hospital admission and remains increased after discharge. Trials of extended thromboprophylaxis are warranted in patients at particularly high risk.

  • 6.
    Järhult, Johannes
    et al.
    Ryhov Hospital, Jönköping, Sweden.
    Ander, S
    NÄL Trollhättan, Trollhättan, Sweden.
    Asking, B
    Ryhov Hospital, Jönköping, Sweden.
    Jansson, S
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Meehan, Adrian
    Örebro University, School of Medical Sciences. Sahlgrenska University Hospital, Göteborg, Sweden.
    Kristoffersson, A
    University Hospital, Umeå, Sweden.
    Nordenström, J
    Karolinska University Hospital, Stockholm, Sweden.
    Long-term results of surgery for lithium-associated hyperparathyroidism2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 11, p. 1680-1685Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Lithium therapy for affective bipolar disease is frequently associated with hyperparathyroidism (HPT), but the results of surgical treatment are virtually unknown. The aim of this retrospective review was to analyse the long-term outcome after surgery for lithium-induced HPT in a large series of patients.

    METHODS: Seventy-one patients on chronic lithium therapy who underwent surgery in three university and three district hospitals in Sweden were followed for a median of 6.3 years. Histopathology, complications of surgery and normocalcaemia at 6 months after surgery and last follow-up were analysed.

    RESULTS: The primary histopathological diagnoses were adenoma (45 per cent), double adenomas (3 per cent) and hyperplasia (52 per cent). No permanent paresis of the recurrent laryngeal nerve was recorded but 13 per cent of the patients suffered from permanent hypoparathyroidism. At follow-up, the rate of persistent and recurrent HPT was 42 per cent regardless of the histopathological diagnosis.

    CONCLUSION: The results of conventional surgery for lithium-associated HPT are poor. The surgical approach should be adjusted for the multiglandular disease that is usually the cause of HPT in patients on chronic lithium therapy.

  • 7.
    Ljungqvist, Olle
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Randomized clinical trial to compare the effects of preoperative oralcarbohydrate versus placebo on insulin resistance after colorectal surgery (Br J Surg 2010; 97: 317–327)2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 3, p. 327-327Article in journal (Refereed)
  • 8.
    Ljungqvist, Olle
    et al.
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm; Department of Surgery, Huddinge University Hospital, Karolinska Institute, Stockholm.
    Søreide, E
    Department of Anaesthesia and Intensive Care Medicine, Rogaland Central and University Hospital, Stavanger, Norway.
    Preoperative fasting2003In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 90, no 4, p. 400-6Article, review/survey (Refereed)
    Abstract [en]

    Background and methods: To avoid pulmonary aspiration, fasting after midnight has become standard in elective surgery, but recent studies have found no scientific support for this practice. Several anaesthesia societies now recommend a 2-h preoperative fast for clear fluids and a 6-h fast for solids in most elective patients. The literature supporting such fasting recommendations was reviewed.

    Results: The recommendations are safe and improve well-being before operation, mainly by reducing thirst. A carbohydrate-rich beverage given before anaesthesia and surgery alters metabolism from the overnight fasted to the fed state. This reduces the catabolic response (insulin resistance) after operation, which may have implications for postoperative recovery.

    Conclusion: Most patients having elective operations can be allowed a free intake of clear fluids up to 2 h before anaesthesia. Preoperative carbohydrates reduce postoperative insulin resistance.

  • 9.
    Maessen, J
    et al.
    Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
    Dejong, C H C
    Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
    Hausel, J
    Karolinska Institute, Clintec, Division of Surgery, Karolinska University Hospital, Huddinge, Stockholm; Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Nygren, J
    Karolinska Institute, Clintec, Division of Surgery, Karolinska University Hospital, Huddinge, Stockholm; Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Lassen, K
    University Hospital Northern Norway, Tromsø, Norway.
    Andersen, J
    Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark.
    Kessels, A G H
    Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, Maastricht, The Netherlands.
    Revhaug, A
    University Hospital Northern Norway, Tromsø, Norway.
    Kehlet, H
    Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark.
    Ljungqvist, Olle
    Karolinska Institute, Clintec, Division of Surgery, Karolinska University Hospital, Huddinge, Stockholm; Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Fearon, K C H
    Clinical and Surgical Sciences (Surgery), Royal Infirmary, Edinburgh, UK.
    von Meyenfeldt, M F
    Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
    A protocol is not enough to implement an enhanced recovery programme for colorectal resection2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 2, p. 224-31Article in journal (Refereed)
    Abstract [en]

    Background: Single-centre studies have suggested that enhanced recovery can be achieved with multimodal perioperative care protocols. This international observational study evaluated the implementation of an enhanced recovery programme in five European centres and examined the determinants affecting recovery and length of hospital stay.

    Methods: Four hundred and twenty-five consecutive patients undergoing elective open colorectal resection above the peritoneal reflection between January 2001 and January 2004 were enrolled in a protocol that defined multiple perioperative care elements. One centre had been developing multimodal perioperative care for 10 years, whereas the other four had previously undertaken traditional care.

    Results: The case mix was similar between centres. Protocol compliance before and during the surgical procedure was high, but it was low in the immediate postoperative phase. Patients fulfilled predetermined recovery criteria a median of 3 days after operation but were actually discharged a median of 5 days after surgery. Delay in discharge and the development of major complications prolonged length of stay. Previous experience with fast-track surgery was associated with a shorter hospital stay.

    Conclusion: Functional recovery in 3 days after colorectal resection could be achieved in daily practice. A protocol is not enough to enable discharge of patients on the day of functional recovery; more experience and better organization of care may be required.

  • 10. Matthiessen, Peter
    et al.
    Hallböök, Olof
    Rutegård, Jörgen
    Örebro University, Department of Clinical Medicine.
    Sjödahl, Rune
    Population-based study of risk factors for postoperative death after anterior resection of the rectum2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 4, p. 498-503Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this population-based study was to analyse risk factors for death within 30 days after anterior resection of the rectum. METHODS: Between 1987 and 1995 a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. One hundred and forty of these patients died within 30 days or during the initial hospital stay. These patients were compared with a randomly chosen cohort of 423 patients who underwent the same operation during the same interval, and were alive after 30 days and discharged from hospital. The association between death and 12 putative risk factors was studied. RESULTS: The mortality rate after elective anterior resection was 2.1 per cent (140 of 6833). The incidence of clinical anastomotic leakage was 42.1 per cent (59 of 140) among those who died and 10.9 per cent (46 of 423) in the cohort group. Multivariate regression analysis identified clinical leakage, increased age, male sex, Dukes' 'D' stage and intraoperative adverse events as independent risk factors for death within 30 days. CONCLUSION: Clinical anastomotic leakage was a major cause of postoperative death after anterior resection.

  • 11.
    Mortensen, K.
    et al.
    Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway.
    Nilsson, M.
    Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
    Slim, K.
    Department of Digestive Surgery, Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France.
    Schäfer, M.
    Department of Visceral Surgery, University Hospital of Lausanne (Centre Hospitalier Universitaire Vaudois), Lausanne, Switzerland.
    Mariette, C.
    Department of Digestive and Oncological Surgery, University Hospital C. Huriez, Lille, France.
    Braga, M.
    Department of Surgery, San Raffaele University, Milan, Italy.
    Carli, F.
    Department of Anesthesia, McGill University Health Centre, Montreal QC, Canada.
    Demartines, N.
    Department of Visceral Surgery, University Hospital of Lausanne (Centre Hospitalier Universitaire Vaudois), Lausanne, Switzerland.
    Griffin, S. M.
    Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
    Lassen, K.
    Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway.
    Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 10, p. 1209-1229Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.

    METHODS: An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.

    RESULTS: The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.

    CONCLUSION: The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

  • 12.
    Sackey, H.
    et al.
    Dept Mol Med & Surg, Karolinska Inst, Stockholm, Sweden; Karolinska Univ Hosp, Stockholm, Sweden.
    Magnuson, A.
    Sandelin, K.
    Dept Mol Med & Surg, Karolinska Inst, Stockholm, Sweden; Karolinska Univ Hosp, Stockholm, Sweden.
    Liljegren, Göran
    Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bergkvist, L.
    Dept Surg, Cent Hosp, Uppsala Univ, Västerås, Sweden; Clin Res Ctr, Cent Hosp, Uppsala Univ, Västerås, Sweden.
    Fulep, Z.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Celebioglu, F.
    Dept Clin Res & Educ, Karolinska Inst, Stockholm, Sweden; Södersjukhuset, Stockholm, Sweden.
    Frisell, J.
    Dept Mol Med & Surg, Karolinska Inst, Stockholm, Sweden; Karolinska Univ Hosp, Stockholm, Sweden.
    Arm lymphoedema after axillary surgery in women with invasive breast cancer2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 4, p. 390-397Article in journal (Refereed)
    Abstract [en]

    Background: The primary aim was to compare arm lymphoedema after sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) in women with node-negative and node-positive breast cancer. The secondary aim was to examine the potential association between self-reported and objectively measured arm lymphoedema.

    Methods: Women who had surgery during 1999-2004 for invasive breast cancer in four centres in Sweden were included. The study groups were defined by the axillary procedure performed and the presence of axillary metastases: SLNB alone, ALND without axillary metastases, and ALND with axillary metastases. Before surgery, and 1, 2 and 3years after operation, arm volume was measured and a questionnaire regarding symptoms of arm lymphoedema was completed. A mixed model was used to determine the adjusted mean difference in arm volume between the study groups, and generalized estimating equations were employed to determine differences in self-reported arm lymphoedema.

    Results: One hundred and forty women had SLNB alone, 125 had node-negative ALND and 155 node-positive ALND. Women who underwent SLNB had no increase in postoperative arm volume over time, whereas both ALND groups showed a significant increase. The risk of self-reported arm lymphoedema 1, 2 and 3years after surgery was significantly lower in the SLNB group compared with that in both ALND groups. Three years after surgery there was a significant association between increased arm volume and self-reported symptoms of arm lymphoedema.

    Conclusion: SLNB is associated with a minimal risk of increased arm volume and few symptoms of arm lymphoedema, significantly less than after ALND, regardless of lymph node status.

    Minimal after sentinel node biopsy

  • 13.
    Sadr Azodi, O.
    et al.
    Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Karolinska University, Solna, Sweden; Department of Surgery, Karolinska University Hospital, Huddinge, Sweden.
    Andrén-Sandberg, Å.
    Department of Surgery, Karolinska University Hospital, Huddinge, Sweden.
    Larsson, Henrik
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Genetic and environmental influences on the risk of acute appendicitis in twins2009In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 11, p. 1336-1340Article in journal (Refereed)
    Abstract [en]

    Background: Acute appendicitis is common but the aetiology is unclear. This study examined the heritability of acute appendicitis.

    Methods: The study included twin pairs with known zygosity born between 1959 and 1985. Individuals with acute appendicitis were found by record linkage with the Swedish Inpatient Register. Comparing monodizygotic and dizygotic twins, the similarity and relative proportions of phenotypic variance resulting from genetic and environmental factors were analysed. Risks of acute appendicitis explained by heritability and environmental effects were estimated.

    Results: Some 3441 monozygotic and 2429 dizygotic twins were identified. Almost no genetic effects were found in males (8 (95 per cent confidence interval 0 to 50) per cent), but shared (31 (0 to 49) per cent) and non-shared (61 (47 to 74) per cent) environmental factors accounted for this risk. In females, the heritability was estimated as 20 (0 to 36) per cent and the remaining variation was due to non-shared environmental factors (80 (64 to 98) per cent). For the sexes combined, genetic effects accounted for 30 (5 to 40) per cent and non-shared environmental effects for 70 (60 to 81) per cent of the risk.

    Conclusion: Acute appendicitis has a complex aetiology with sex differences in heritability and environmental factors.

  • 14.
    Soop, M
    et al.
    Centre for Surgical Sciences, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Carlson, G L
    Injury Research Group, University of Manchester, Hope Hospital, Salford, UK.
    Hopkinson, J
    Injury Research Group, University of Manchester, Hope Hospital, Salford, UK.
    Clarke, S
    Injury Research Group, University of Manchester, Hope Hospital, Salford, UK.
    Thorell, A
    Centre for Surgical Sciences, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Nygren, J
    Centre for Surgical Sciences, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Ljungqvist, Olle
    Centre for Surgical Sciences, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol2004In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 91, no 9, p. 1138-45Article in journal (Refereed)
    Abstract [en]

    Background: The effects of immediate postoperative enteral nutrition on postoperative nitrogen balance and insulin resistance were studied in patients subjected to an enhanced-recovery protocol.

    Methods: Eighteen patients undergoing major colorectal surgery in an enhanced-recovery protocol were randomized to immediate postoperative enteral feeding for 4 days with either complete or hypocaloric nutrition. Nitrogen balance and changes in glucose kinetics, substrate utilization (indirect calorimetry) and insulin sensitivity (hyperinsulinaemic-euglycaemic clamp) were measured. Values are mean(s.e.m.).

    Results: Mean postoperative urinary nitrogen losses were low (10.7(1.0) versus 10.5(0.7) g per day for complete versus hypocaloric nutrition) and insulin resistance was insignificant (-20(7) versus -27(11) per cent), with no difference between groups. Complete enteral feeding was given without hyperglycaemia (blood glucose concentration 5.8(0.4) versus 5.0(0.4) mmol/l) and resulted in nitrogen balance (+0.1(0.8) versus -12.6(0.6) g nitrogen per day; P < 0.001).

    Conclusion: This enhanced-recovery protocol was associated with minimal postoperative insulin resistance and nitrogen losses after surgery. Immediate postoperative enteral nutrition was provided without hyperglycaemia and resulted in nitrogen balance.

  • 15.
    Stenberg, Erik
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Näslund, Ingmar
    Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Outcomes of laparoscopic gastric bypass in a randomized clinical trial compared with a concurrent national database2017In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 104, no 5, p. 562-569Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: RCTs are the standard for assessing medical interventions, but they may not be feasible and their external validity is sometimes questioned. This study aimed to compare results from an RCT on mesenteric defect closure during laparoscopic gastric bypass with those from a national database containing data on the same procedure, to shed light on the external validity of the RCT.

    METHODS: Patients undergoing laparoscopic gastric bypass surgery within an RCT conducted between 1 May 2010 and 14 November 2011 were compared with those who underwent the same procedure in Sweden outside the RCT over the same time interval. Primary endpoints were severe complications within 30 days and surgery for small bowel obstruction within 4 years.

    RESULTS: Some 2507 patients in the RCT were compared with 8485 patients in the non-RCT group. There were no differences in severe complications within 30 days in the group without closure of the mesenteric defect (odds ratio (OR) for RCT versus non-RCT 0·94, 95 per cent c.i. 0·64 to 1·36; P = 0·728) or in the group with closure of the defect (OR 1·34, 0·96 to 1·86; P = 0·087). There were no differences between the RCT and non-RCT cohorts in reoperation rates for small bowel obstruction in the mesenteric defect non-closure (cumulative incidence 10·9 versus 9·4 per cent respectively; hazard ratio (HR) 1·20, 95 per cent c.i. 0·99 to 1·46; P = 0·065) and closure (cumulative incidence 5·7 versus 7·0 per cent; HR 0·82, 0·62 to 1·07; P = 0·137) groups. The relative risk for small bowel obstruction without mesenteric defect closure compared with closure was 1·91 in the RCT group and 1·39 in the non-RCT group.

    CONCLUSION: The efficacy of mesenteric defect closure was similar in the RCT and national registry, providing evidence for the external validity of the RCT.

  • 16.
    Svanfeldt, M
    et al.
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm.
    Thorell, A
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Hausel, J
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Soop, M
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Rooyackers, O
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm.
    Nygren, J
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Ljungqvist, Olle
    Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 11, p. 1342-50Article, review/survey (Refereed)
    Abstract [en]

    Background: Preoperative oral carbohydrate (CHO) reduces postoperative insulin resistance. In this randomized trial, the effect of CHO on postoperative whole-body protein turnover was studied.

    Methods: Glucose and protein kinetics ([6,6(2)H(2)]D-glucose, [(2)H(5)]phenylalanine, [(2)H(2)]tyrosine and [(2)H(4)]tyrosine) and substrate oxidation (indirect calorimetry) were studied at baseline and during hyperinsulinaemic normoglycaemic clamping before and on the first day after colorectal resection. Fifteen patients were randomized to receive a preoperative beverage with high (125 mg/ml) or low (25 mg/ml) CHO content.

    Results: Three patients were excluded after the intervention, leaving six patients in each group. After surgery whole-body protein balance did not change in the high oral CHO group, whereas it was more negative in the low oral CHO group after surgery at baseline (P = 0.003) and during insulin stimulation (P = 0.005). Insulin-stimulated endogenous glucose release was similar before and after surgery in the high oral CHO group, but was higher after surgery in the low oral CHO group (P = 0.013) and compared with the high oral CHO group (P = 0.044).

    Conclusion: Whole-body protein balance and the suppressive effect of insulin on endogenous glucose release are better maintained when patients receive a CHO-rich beverage before surgery.

  • 17.
    Syk, E
    et al.
    Department of Surgery, Ersta Hospital, Stockholm.
    Torkzad, M R
    Departments of Diagnostic Radiology, Karolinska Institute, Stockholm.
    Blomqvist, L
    Departments of Diagnostic Radiology, Karolinska Institute, Stockholm.
    Ljungqvist, Olle
    Department of Surgery, Ersta Hospital, Stockholm.
    Glimelius, B
    Departments of Oncology and Pathology, Karolinska Institute, Stockholm; Department of Oncology, Radiology and Clinical Immunology, University of Uppsala, Uppsala.
    Radiological findings do not support lateral residual tumour as a major cause of local recurrence of rectal cancer2006In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 93, no 1, p. 113-9Article in journal (Refereed)
    Abstract [en]

    Background: The aim of this study was to determine the sites of local recurrence following radical (R0) total mesorectal excision (TME) for rectal cancer in an effort to elucidate the reasons for recurrence.

    Methods: Thirty-seven patients with recurrence following curative resection for rectal cancer were identified from a population of 880 patients operated on by surgeons trained in the TME procedure. Two radiologists independently examined 33 available computed tomograms and magnetic resonance images taken when the recurrence was detected.

    Results: Twenty-nine of the 33 recurrences were found in the lower two-thirds of the pelvis. Two recurrent tumours appeared to originate from lateral pelvic lymph nodes. Evidence of residual mesorectal fat was identified in 15 patients. Fourteen of the recurrent tumours originated from primary tumours in the upper rectum; all of these tumours recurred at the anastomosis and 12 of the 14 patients had evidence of residual mesorectal fat.

    Conclusion: Lateral pelvic lymph node metastases are not a major cause of local recurrence after TME. Partial mesorectal excision may be associated with an increased risk of local recurrence from tumours in the upper rectum.

  • 18.
    Thorell, Anders
    et al.
    Departments of Surgery, Karolinska Hospital and Institute, Stockholm, Sweden.
    Efendic, S.
    Departments of Endocrinology, Karolinska Hospital and Institute, Stockholm, Sweden.
    Gutniak, M.
    Departments of Endocrinology, Karolinska Hospital and Institute, Stockholm, Sweden.
    Häggmark, T.
    Departments of Surgery, Karolinska Hospital and Institute, Stockholm, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Departments of Surgery, Karolinska Hospital and Institute, Stockholm, Sweden.
    Insulin resistance after abdominal surgery1994In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 81, no 1, p. 59-63Article in journal (Refereed)
    Abstract [en]

    A study was carried out to determine the time course and degree of postoperative insulin resistance in patients undergoing elective abdominal surgery. Mean(s.e.m.) insulin sensitivity was determined before and on the first (n = 10), fifth, ninth and 20th (n = 5) days after elective open cholecystectomy using the normoglycaemic (4.(0.1) mmol/l), hyperinsulinaemic (402(12) pmol/l) glucose clamp technique. Preoperative insulin sensitivity expressed as the M value varied from 2.3 to 8.2 mg per kg per min. The relative reduction in insulin sensitivity was most pronounced on the first day after surgery, at a mean(s.e.m) of 54(2) per cent. Thereafter, a large variation between individuals was found during the course of recovery, and insulin sensitivity returned to normal 20 days after operation. On the first day after surgery, plasma concentrations of glucose, C peptide, noradrenaline and glucagon were slightly but significantly higher than before operation (P<0.05), whereas insulin, growth hormone, cortisol and adrenaline levels were unaltered. Marked insulin resistance thus develops after elective upper abdominal surgery and persists for at least 5 days after operation. Factors other than simultaneous changes in levels of the hormones studied seem to regulate the maintenance of postoperative insulin resistance

  • 19.
    Wanjura, Viktor
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Szabo, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Österberg, Johanna
    Department of Surgery, Mora Hospital, Mora, Sweden.
    Ottosson, Johan
    Department of Surgery, Örebro University Hospital, Lindesberg, Sweden.
    Enochsson, Lars B.
    Department of Surgical and Perioperative Sciences, Division of Surgery, Sunderby Hospital, Umeå University, Umeå, Sweden.
    Sandblom, Gabriel
    Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Karolinska Institute, Sweden; Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Morbidity of cholecystectomy and gastric bypass in a national database2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 1, p. 121-127Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

    METHODS: Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

    RESULTS: There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P < 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P < 0·001) to the duration of surgery.

    CONCLUSION: Cholecystectomy should be performed before, not during or after, RYGB.

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