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  • 1.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. Sweden Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Sweden.
    The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study2021In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 111, no 1, article id 14574969211037588Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks.

    METHODS: A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index.

    RESULTS: A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 (p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 (p < 0.001).

    CONCLUSIONS: A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.

  • 2.
    Baban, Bayar
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, School of Medical Sciences, Faculty of Medicne and Health, Örebro University, Örebro, Sweden.
    Eklund, Daniel
    Örebro University, School of Medical Sciences.
    Tuerxun, Kedeye
    Örebro University, School of Medical Sciences.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, School of Medical Sciences, Faculty of Medicne and Health, Örebro University, Örebro, Sweden.
    Särndahl, Eva
    Örebro University, School of Medical Sciences.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery, School of Medical Sciences, Faculty of Medicne and Health, Örebro University, Örebro, Sweden.
    Dynamics of inflammation and inflammasome activation in open versus minimally invasive colorectal surgery for cancerManuscript (preprint) (Other academic)
  • 3.
    Back, E.
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Häggström, J.
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Holmgren, K.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Haapamäki, M. M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, J.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Rutegård, M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables2021In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 108, no 11, p. 1388-1395Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling.

    METHODS: Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk.

    RESULTS: Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive.

    CONCLUSION: Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.

  • 4.
    Back, Erik
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Brännström, Fredrik
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Surgery, Södertälje Hospital, Södertälje, Sweden.
    Svensson, Johan
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences.
    Haapamäki, Markku M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden .
    Mucosal blood flow in the remaining rectal stump is more affected by total than partial mesorectal excision in patients undergoing anterior resection: a key to understanding differing rates of anastomotic leakage?2021In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 406, no 6, p. 1971-1977Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Anterior resection is the procedure of choice for tumours in the mid and upper rectum. Depending on tumour height, a total mesorectal excision (TME) or partial mesorectal excision (PME) can be performed. Low anastomoses in particular have a high risk of developing anastomotic leakage, which might be explained by blood perfusion compromise. A pilot study indicated a worse blood flow in TME patients in an open setting. The aim of this study was to further evaluate perianastomotic blood perfusion changes in relation to TME and PME in a predominantly laparoscopic context.

    METHOD: In this prospective cohort study, laser Doppler flowmetry was used to evaluate the perianastomotic colonic and rectal perfusion before and after surgery. The two surgical techniques were compared in terms of mean differences of perfusion units using a repeated measures ANOVA design, which also enabled interaction analyses between type of mesorectal excision and location of measurement. Anastomotic leakage until 90 days after surgery was reported for descriptive purposes.

    RESULTS: Some 28 patients were available for analysis: 17 TME and 11 PME patients. TME patients had a reduced blood perfusion postoperatively compared to PME patients in the aboral posterior area (mean difference: -57 vs 18 perfusion units; p = 0.010). An interaction between mesorectal excision type and anterior/posterior location was detected at the aboral level (p = 0.007). Two patients developed a minor leakage, diagnosed after discharge.

    CONCLUSION: Patients operated on using TME have a decreased blood flow in the aboral posterior quadrant of the rectum postoperatively compared to patients operated on using PME. This might explain differing rates of anastomotic leakage.

    TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02401100.

  • 5.
    Back, Erik
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Holmgren, Klas
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Haapamäki, Markku M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Author response to: Permanent stoma prediction after anterior resection for rectal cancer: risk prediction scoring using preoperative variables2022In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 109, no 2, article id e40Article in journal (Other academic)
  • 6.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; 5 Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cardiac risk stratification in emergency resection for colonic tumours2021In: BJS Open, E-ISSN 2474-9842, Vol. 5, no 4, article id zrab057Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

    METHODS: Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

    RESULTS: Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

    CONCLUSION: This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

    Download full text (pdf)
    Cardiac risk stratification in emergency resection for colonic tumours
  • 7.
    Boström, Petrus
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Hultberg, Daniel Kverneng
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Haapamäki, Markku M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå, Sweden.
    Oncological Impact of High Vascular Tie After Surgery for Rectal Cancer: A Nationwide Cohort Study2021In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 274, no 3, p. e236-e244Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The purpose of this study was to investigate the impact of tie level on oncological outcomes in rectal cancer surgery.

    SUMMARY BACKGROUND DATA: Theoretically, a high tie of the inferior mesenteric artery could facilitate removal of apical node metastases and improve tumor staging accuracy. However, no appropriately sized randomized controlled trial exists and results from observational studies are not consistent.

    METHODS: All stage I-III rectal cancer patients who underwent abdominal surgery with curative intention in 2007 to 2014 were identified and followed, using the Swedish Colorectal Cancer Registry. Primary outcome was cancer-specific survival, whereas overall and relative survival, locoregional and distant recurrence, and lymph node harvest were secondary outcomes, with high tie as exposure. We used propensity score matching to emulate a randomized controlled trial, and then performed Cox regression analyses to estimate hazard ratios (HRs) with confidence intervals (CIs).

    RESULTS: Some 8287 patients remained for analysis, of which 37% had high tie surgery. After propensity score matching, the 5-year cancer-specific survival rate was overall 86% and we found no association between the level of tie and cancer-specific (HR 0.92, 95% CI 0.79-1.07) or overall (HR 0.98, 95% CI 0.89-1.08) survival, nor to locoregional (HR 0.85, 95% CI 0.59-1.23) or distant (HR 1.01, 95% CI 0.88-1.15) recurrence, nor to relative survival (HR 1.05, 95% CI 0.85-1.28). Stratification and sensitivity analyses were similarly insignificant, after adjustment for confounding. Total lymph node harvest was, however, increased after high tie surgery (P < 0.01), but no differences were seen regarding positive nodes (P = 0.72).

    CONCLUSION: In this nationwide cohort study, the level of tie did not influence any patient-oriented oncological outcome, neither overall nor in node-positive patients. This would allow the patient's anatomical configuration and the surgeon's preferences to determine the level of tie.

  • 8.
    Dehlaghi Jadid, Kaveh
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Petersson, Josefin
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Angenete, Eva
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Long term oncological outcomes for laparoscopic versus open surgery for rectal cancer: a population based nationwide non-inferiority study2022In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 24, no 11, p. 1308-1317Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to compare five-year overall survival in a national cohort of patients undergoing curative abdominal resection for rectal cancer by laparoscopic (LAP) or open (OPEN) technique.

    METHODS: All patients diagnosed with clinical stage I-III rectal cancer and who underwent LAP or OPEN abdominal curative surgery between 2010 and 2016 in Sweden were retrieved from the Swedish Colorectal Cancer Registry. A non-inferiority study design was employed with a statistical power of 90%, a one-side type I error of 2.5%, and a non-inferiority margin of 2%. The analyses were performed as intention-to-treat and the relationship between surgical technique and overall mortality within five years was analyzed. Multilevel regression models with the patients matched by propensity scores adjusted for patient and tumour related variables.

    RESULTS: A total of 8410 cancer stage I-III patients were included whereof 2094 LAP (24.9%) and 6316 underwent OPEN (74.9%) and were followed until December 31, 2020. Multivariable Cox regression demonstrated that five-year overall survival was higher in LAP; Hazard Ratio (HR): 0.877;(95% CI: 0.877-0.993). Outcome was similar when employing multiple imputation and propensity score matching. When excluding cT4 there was no difference; HR: 0.885;(95% CI: 0.790-1.033). At five years follow up, local recurrence was not different, 2.9% in LAP and 3.6% in OPEN (P=0.075), while metastatic disease was more frequent in OPEN, 19.6% compared with 15.6% in LAP (P<0.001).

    CONCLUSIONS: This study demonstrated that LAP was not inferior to OPEN with regard to overall five-year survival. These results support the use of laparoscopic surgery.

  • 9.
    Dehlaghi Jadid, Kaveh
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Petersson, Josefin
    SSORG - Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Sjövall, Annika
    Department of Pelvic Cancer, Gastrointestinal Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden.
    Angenete, Eva
    SSORG - Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Long term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer: A population-based nationwide study with a non-inferiority design2023In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 25, no 5, p. 954-963Article in journal (Refereed)
    Abstract [en]

    AIM: The study aimed to compare five-year overall survival in a national cohort of patients undergoing curative abdominal resection for colon cancer by minimally invasive surgery (MIS) or open (OPEN) technique.

    METHODS: All patients diagnosed between 2010 and 2016 in Sweden with pathological UICC stage I-III colon cancer localized in the cecum, ascending colon, hepatic flexure or sigmoid colon, and those who underwent curative right sided hemicolectomy, sigmoid resection or high anterior resection by MIS or OPEN were included. Patients were identified in the Swedish Colorectal Cancer Registry from which all data was retrieved. The analyses were performed as intention-to-treat and the relationship between surgical technique (MIS or OPEN) and overall mortality within five years was analysed. For the primary research question a non-inferiority hypothesis was assumed with a statistical power of 90%, a one-side type I error of 2.5%, and a non-inferiority margin of 2%. For the secondary analyses, multilevel survival regression models with the patients matched by propensity scores were employed, adjusted for patient- and tumuor-related variables.

    RESULTS: A total of 11605 pathological UICC cancer stage I-III patients were included with 3297 MIS (28.4%) and 8308 OPEN (71.6%) and were followed until December 31, 2020. The primary analysis demonstrated superiority for MIS compared to OPEN. The multilevel survival regression analyses confirmed that five-year overall survival was higher in MIS with a hazard ratio (HR) of 0.874 (95% confidence interval (CI): 0.791-0.965), and if excluding pT4, outcome was similar, with a HR of 0.847 (95% CI: 0.756-0.948).

    CONCLUSION: This observational study demonstrated that MIS was favourable to OPEN with regard to five-year overall survival. These results support the use of laparoscopic colon cancer surgery in routine practise.

  • 10.
    Dehlaghi Jadid, Kaveh
    et al.
    Örebro University, School of Medical Sciences.
    Gadan, Soran
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wallin, Göran
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences.
    Postoperative inflammatory response in patients undergoinglaparoscopic and robotic rectal cancer resectionManuscript (preprint) (Other academic)
  • 11.
    Dehlaghi Jadid, Kaveh
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Gadan, Soran
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Wallin, Göran
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Nordenwall, Caroline
    Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden .
    Boman, Sol Erika
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Hed Myrberg, Ida
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Does socio-economic status influence the choice of surgical techniquein abdominal rectal cancer surgery?Manuscript (preprint) (Other academic)
  • 12.
    Ekestubbe, Lovisa
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pharmacological differences between beta-blockers and postoperative mortality following colon cancer surgery2022In: Scientific Reports, E-ISSN 2045-2322, Vol. 12, no 1, article id 5279Article in journal (Refereed)
    Abstract [en]

    β-blocker therapy has been positively associated with improved survival in patients undergoing oncologic colorectal resection. This study investigates if the type of β-blocker used affects 90-day postoperative mortality following colon cancer surgery. The study was designed as a nationwide retrospective cohort study including all adult (≥ 18 years old) patients with ongoing β-blocker therapy who underwent elective and emergency colon cancer surgery in Sweden between January 1, 2007 and December 31, 2017. Patients were divided into four cohorts: metoprolol, atenolol, bisoprolol, and other beta-blockers. The primary outcome of interest was 90-day postoperative mortality. A Poisson regression model with robust standard errors was used, while adjusting for all clinically relevant variables, to determine the association between different β-blockers and 90-day postoperative mortality. A total of 9254 patients were included in the study. There was no clinically significant difference in crude 90-day postoperative mortality rate [n (%)] when comparing the four beta-blocker cohorts metoprolol, atenolol, bisoprolol and other beta-blockers. [97 (1.8%) vs. 28 (2.0%) vs. 29 (1.7%) vs. 11 (1.2%), p = 0.670]. This remained unchanged when adjusting for relevant covariates in the Poisson regression model. Compared to metoprolol, there was no statistically significant decrease in the risk of 90-day postoperative mortality with atenolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], bisoprolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], or other beta-blockers [adj. IRR (95% CI): 0.92 (0.46-1.85), p = 0.825]. In patients undergoing colon cancer surgery, the risk of 90-day postoperative mortality does not differ between the investigated types of β-adrenergic blocking agents.

  • 13.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Sweden.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Hjelmqvist, Hans
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden .
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden .
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden .
    Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study2021In: Annals of Medicine and Surgery, E-ISSN 2049-0801, Vol. 66, article id 102414Article in journal (Refereed)
    Abstract [en]

    Background: Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer.

    Methods: Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest.

    Results: Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts.

    Conclusions: In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer.

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    Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study
  • 14.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Hjelmqvist, Hans
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Allan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Epidural Analgesia and Mortality after Colorectal Cancer Surgery: A Retrospective Cohort StudyManuscript (preprint) (Other academic)
  • 15.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care.
    Magnuson, Anders
    School ofMedical Sciences, Örebro University, Örebro, Sweden.
    Eintrei, Christina
    Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden.
    Henningsson, Ragnar
    Department of Anaesthesiology and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden.
    Myrelid, Pär
    Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Comparison between epidural and intravenous analgesia effects on disease-free survival after colorectal cancer surgery: a randomised multicentre controlled trial2021In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 127, no 1, p. 65-74Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Thoracic epidural analgesia (TEA) has been suggested to improve survival after curative surgery for colorectal cancer compared with systemic opioid analgesia. The evidence, exclusively based on retrospective studies, is contradictory.

    METHODS: In this prospective, multicentre study, patients scheduled for elective colorectal cancer surgery between June 2011 and May 2017 were randomised to TEA or patient-controlled i.v. analgesia (PCA) with morphine. The primary endpoint was disease-free survival at 5 yr after surgery. Secondary outcomes were postoperative pain, complications, length of stay (LOS) at the hospital, and first return to intended oncologic therapy (RIOT).

    RESULTS: We enrolled 221 (110 TEA and 111 PCA) patients in the study, and 180 (89 TEA and 91 PCA) were included in the primary outcome. Disease-free survival at 5 yr was 76% in the TEA group and 69% in the PCA group; unadjusted hazard ratio (HR): 1.31 (95% confidence interval [CI]: 0.74-2.32), P=0.35; adjusted HR: 1.19 (95% CI: 0.61-2.31), P=0.61. Patients in the TEA group had significantly better pain relief during the first 24 h, but not thereafter, in open and minimally invasive procedures. There were no differences in postoperative complications, LOS, or RIOT between the groups.

    CONCLUSIONS: There was no significant difference between the TEA and PCA groups in disease-free survival at 5 yr in patients undergoing surgery for colorectal cancer. Other than a reduction in postoperative pain during the first 24 h after surgery, no other differences were found between TEA compared with i.v. PCA with morphine.

  • 16.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Örebro, Sweden .
    Eintrei, Christina
    Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden.
    Henningsson, Ragnar
    Department of Anaesthesiology and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden.
    Myrelid, Pär
    Department of Biomedical and Clinical Sciences, Linköping University and Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Comparison between epidural and intravenous analgesia on disease-free survival following colorectal cancer surgery: A randomised, controlled trialManuscript (preprint) (Other academic)
  • 17.
    Gadan, Soran
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden; Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Brand, Judith
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Rutegård, Martin
    Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer: a nationwide register-based cohort study2021In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 36, no 7, p. 1433-1442Article in journal (Refereed)
    Abstract [en]

    PURPOSE: A defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer.

    METHODS: Data from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects.

    RESULTS: During a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67-0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma.

    CONCLUSION: A defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.

  • 18.
    Gerdin, Anders
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Park, Jennifer
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Segelman, Josefin
    Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lydrup, Marie-Louise
    Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Preoperative beta blockers and other drugs in relation to anastomotic leakage after anterior resection for rectal cancer2024In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 26, no 5, p. 974-986Article in journal (Refereed)
    Abstract [en]

    AIM: Previous research has indicated that preoperative beta blocker therapy is associated with a decreased risk of complications after surgery for rectal cancer. This is thought to arise because of the anti-inflammatory activity of the drug. These results need to be reproduced and analyses extended to other drugs with such properties, as this information might be useful in clinical decision-making. The main aim of this work was to replicate previous findings of beta blocker use as a prognostic marker for postoperative leakage. We also investigated whether drug exposure might induce anastomotic leaks.

    METHOD: This is a retrospective multicentre cohort study, comprising 1126 patients who underwent anterior resection for rectal cancer between 2014 and 2018. The use of any preoperative beta blocker was treated as the primary exposure, while anastomotic leakage within 12 months of surgery was the outcome. Secondary exposures comprised angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins and metformin. Using multivariable regression, we performed a replication analysis with a predictive aim for beta blockers only, while adjustment for confounding was done in more causally oriented analyses for all drugs. We estimated incidence rate ratio (IRR) and relative risk (RR) with 95% confidence intervals (CIs).

    RESULTS: Anastomotic leakage occurred in 20.6% of patients. Preoperative beta blockers were used by 22.7% of the cohort, while the leak distribution was almost identical between exposure groups. In the main replication analysis, no association could be detected (IRR 0.95, 95% CI 0.68-1.33). In the causally oriented analyses, only metformin affected the risk of leakage (RR 1.59, 95% Cl 1.31-1.92).

    CONCLUSION: While previous research has suggested that preoperative beta blocker use could be prognostic of anastomotic leakage, this study could not detect any such association. On the contrary, our results indicate that preoperative beta blocker use neither predicts nor causes anastomotic leakage after anterior resection for rectal cancer.

  • 19.
    Golshani, Parisa
    et al.
    Department of Surgery, Regional Council of Gävleborg, Gävle, Sweden.
    Park, Jennifer
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Segelman, Josefin
    Department of Molecular Medicine and Surgery, Karolinska Institutet, and Ersta Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lydrup, Marie-Louise
    Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, SE-901 85, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    The modified Glasgow Prognostic Score indicates an increased risk of anastomotic leakage after anterior resection for rectal cancer2023In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 38, no 1, article id 200Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Preoperative inflammation might cause and also be a marker for anastomotic leakage after anterior resection for rectal cancer. Available biomarker indices such as the modified Glasgow Prognostic Score (mGPS) or the C-reactive protein-to-albumin ratio (CAR) may be clinically useful for leakage assessment.

    METHODS: Patients who underwent anterior resection for rectal cancer during 2014-2018 from a multicentre retrospective cohort were included. Data from the Swedish Colorectal Cancer registry and chart review at each hospital were collected. In a subset of patients, preoperative laboratory assessments were available, constituting the exposures mGPS and CAR. Anastomotic leakage within 12 months was the outcome. Causally oriented analyses were conducted with adjustment for confounding, as well as predictive models.

    RESULTS: A total of 418 patients were eligible for analysis. Most patients had mGPS = 0 (84.7%), while mGPS = 1 (10.8%) and mGPS = 2 (4.5%) were less common. mGPS = 2 (OR: 4.11; 95% CI: 1.69-10.03) seemed to confer anastomotic leakage, while this was not seen for mGPS = 1 (OR 1.09; 95% CI: 0.53-2.25). A cut off point of CAR > 0.36 might be indicative of leakage (OR 2.25; 95% CI: 1.21-4.19). Predictive modelling using mGPS rendered an area-under-the-curve of 0.73 (95% CI: 0.67-0.79) at most.

    DISCUSSION: Preoperative inflammation seems to be involved in the development of anastomotic leakage after anterior resection for cancer. Inclusion into prediction models did not result in accurate leakage prediction, but high degrees of systemic inflammation might still be important in clinical decision-making.

  • 20.
    Grahn, Oskar
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Lundin, Mathias
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business and Economics, Umeå University, Umeå, Sweden.
    Chapman, Stephen J.
    Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Concerning our paper on the possible relation of postoperative non-steroidal anti-inflammatory drugs to anastomotic leakage and cancer recurrence2022In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 24, no 10, p. 1245-1245Article in journal (Other academic)
  • 21.
    Grahn, Oskar
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Lundin, Mathias
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business and Economics, Umeå University, Umeå, Sweden.
    Chapman, Stephen J.
    Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Postoperative non-steroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer2022In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 24, no 8, p. 933-942Article in journal (Refereed)
    Abstract [en]

    AIM: To investigate whether non-steroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing.

    METHODS: This is a protocol-based retrospective cohort study on colorectal cancer patients operated between 2007 and 2012 at 21 hospitals in Sweden. The NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or non-radically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs).

    RESULTS: Some 6945 patients remained after exclusion, of which 3996 were treated at hospitals where an NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97; 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83; 95% 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68; 95% CI 0.48-0.97) and distant recurrences (HR 0.85; 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%; 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo- and ileo-rectal anastomoses (HR 0.47; 95% CI 0.33-0.68).

    CONCLUSION: There was no association between NSAID exposure and recurrence-free survival, but an association with improved cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.

  • 22.
    Hahn-Strömberg, Victoria
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Laboratory Medicine, Section for Pathology, Örebro University Hospital, Örebro, Sweden.
    Askari, Shlear
    Department of Laboratory Medicine, Section for Pathology, Örebro University Hospital, Örebro, Sweden.
    Befekadu, Rahel
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Laboratory Medicine, Section for Pathology, Örebro University Hospital, Örebro, Sweden.
    Matthiessen, Peter
    Örebro University Hospital. Department of Clinical Surgery, Örebro University Hospital, Örebro, Sweden.
    Karlsson, Sune
    Örebro University, Örebro University School of Business.
    Nilsson, Torbjorn K.
    Department of Medical Biosciences/Clinical Chemistry, Umeå University, Umeå, Sweden.
    Polymorphisms in the CLDN1 and CLDN7 genes are related to differentiation and tumor stage in colon carcinoma2014In: Acta Pathologica, Microbiologica et Immunologica Scandinavica (APMIS), ISSN 0903-4641, E-ISSN 1600-0463, Vol. 122, no 7, p. 636-642Article in journal (Refereed)
    Abstract [en]

    Tight junction is composed of transmembrane proteins important for maintaining cell polarity and regulating ion flow. Among these proteins are the tissue-specific claudins, proteins that have recently been suggested as tumor markers for several different types of cancer. An altered claudin expression has been observed in colon, prostatic, ovarian, and breast carcinoma. The aim of this study was to analyze the allele frequencies of three common single nucleotide polymorphisms (SNPs) in the genes for claudin 1 and claudin 7 in colon cancer (CC) patients and in a control population of healthy blood donors. Pyrosequencing was used to genotype the CLDN1 SNP rs9869263 (c.369C>T), and the CLDN7 SNPs rs4562 (c.590C>T) and rs374400 (c.606T>G) in DNA from 102 formalin fixed paraffin embedded (FFPE) colon cancer tissue, and 111 blood leukocyte DNA from blood/plasma donors. These results were correlated with clinical parameters such as TNM stage, tumor localization, tumor differentiation, complexity index, sex, and age. We found that there was a significant association between the CLDN1 genotype CC in tumor samples and a higher risk of colon cancer development (OR 3.0, p < 0.001). We also found that the CLDN7 rs4562 (c.590C>T) genotype CT had a higher risk of lymph node involvement (p = 0.031) and a lower degree of tumor differentiation (p = 0.028). In the control population, the allele frequencies were very similar to those in the HapMap cohort for CLDN7. The CLDN1 rs9869263 genotype (c.369C>T) was related to increased risk of colon cancer, and the CLDN7 rs4562 genotype (c.590C>T) was related to tumor differentiation and lymph node involvement in colon carcinoma. Further studies are warranted to ascertain their potential uses as biomarkers predicting tumor development, proliferation, and outcome in this disease.

  • 23.
    Holmgren, Klas
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Haapamäki, Markku M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer2021In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 23, no 11, p. 2859-2869Article in journal (Refereed)
    Abstract [en]

    AIM: To investigate the conflicting consequences of faecal diversion on stoma outcomes and anastomotic leakage in anterior resection for rectal cancer, including interaction effects determined by the extent of mesorectal excision.

    METHOD: Anterior resections between 2007 and 2016 were identified using the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine stoma outcome 2 years after surgery. Tumour distance from the anal verge constituted a proxy for extent of mesorectal excision [total mesorectal excision (TME): ≤10 cm; partial mesorectal excision (PME): 13-15 cm]. With confounder-adjusted probit regression, the total effect of defunctioning stoma on permanent stoma, and the interaction effect of extent of mesorectal excision, were estimated together with the indirect effect through anastomotic leakage. Baseline risks, risk differences (RDs) and relative risks (RRs) were reported.

    RESULTS: The main study cohort included 4529 patients. Defunctioning stomas influenced the absolute permanent stoma risk (TME: RD 0.11 [95% CI 0.09-0.13]; PME: RD 0.15 [95% CI 0.13-0.16]). The baseline risk was higher in TME, with a resulting greater RR in PME (2.23 [95% CI 1.43-3.02] vs 4.36 [95% CI 3.05-5.68]). The indirect reduction in permanent stoma rates, due to the alleviating effect of faecal diversion on anastomotic leakage, was small (TME: 0.89 [95% CI 0.81-0.96]; PME: 0.96 [95% CI 0.91-1.00]).

    CONCLUSION: In anterior resection for rectal cancer, defunctioning stomas may reduce chances of a stoma-free outcome. Considering leakage reduction benefits, consequences of routine diversion in TME might be fairly balanced, while this seems questionable in PME.

  • 24.
    Holmgren, Klas
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Jonsson, Pär
    Department of Chemistry, Umeå University, Umeå, Sweden.
    Lundin, Christina
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Sund, Malin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland .
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden .
    Preoperative biomarkers related to inflammation may identify high-risk anastomoses in colorectal cancer surgery: explorative study2022In: BJS Open, E-ISSN 2474-9842, Vol. 6, no 3, article id zrac072Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Colorectal anastomotic leakage can be considered a process of failed wound healing, for which related biomarkers might be a promising research area to decrease leak rates.

    METHODS: Patients who had elective surgery with a primary anastomosis for non-metastatic colorectal cancer, at two university hospitals between 1 January 2010 and 31 December 2015 were included. Patients with an anastomotic leak were identified and matched (1:1) to complication-free controls on the basis of sex, age, tumour stage, tumour location, and operating hospital. Preoperative blood samples were analysed by use of protein panels associated with systemic or enteric inflammation by proteomics, and enzyme-linked immunosorbent assays. Multivariable projection methods were used in the statistical analyses and adjusted for multiple comparisons to reduce false positivity. Rectal cancer tissue samples were evaluated with immunohistochemistry to determine local expression of biomarkers that differed significantly between cases and controls.

    RESULTS: Out of 726 patients undergoing resection, 41 patients with anastomotic leakage were matched to 41 controls. Patients with rectal cancer with leakage displayed significantly elevated serum levels of 15 proteins related to inflammation. After controlling for a false discovery rate, levels of C-X-C motif chemokine 6 (CXCL6) and C-C motif chemokine 11 (CCL11) remained significant. In patients with colonic cancer with leakage, levels of high-sensitivity C-reactive protein (hs-CRP) were increased before surgery. Local expression of CXCL6 and CCL11, and their receptors, were similar in rectal tissues between cases and controls.

    CONCLUSION: Patients with anastomotic leakage could have an upregulated inflammatory response before surgery, as expressed by elevated serological levels of CXCL6 and CCL11 for rectal cancer and hs-CRP levels in patients with colonic cancer respectively.

  • 25.
    Lillo-Felipe, Miriam
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden .
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, USA.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Center-Level Procedure Volume Does Not Predict Failure-to-Rescue After Severe Complications of Oncologic Colon and Rectal Surgery2021In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 45, no 12, p. 3695-3706Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The relationship between hospital surgical volume and outcome after colorectal cancer surgery has thoroughly been studied. However, few studies have assessed hospital surgical volume and failure-to-rescue (FTR) after colon and rectal cancer surgery. The aim of the current study is to evaluate FTR following colorectal cancer surgery between clinics based on procedure volume.

    METHODS: Patients undergoing colorectal cancer surgery in Sweden from January 2015 to January 2020 were recruited through the Swedish Colorectal Cancer Registry. The primary endpoint was FTR, defined as the proportion of patients with 30-day mortality after severe postoperative complications in colorectal cancer surgery. Severe postoperative complications were defined as Clavien-Dindo ≥ 3. FTR incidence rate ratios (IRR) were calculated comparing center volume stratified in low-volume (≤ 200 cases/year) and high-volume centers (> 200 cases/year), as well as with an alternative stratification comparing low-volume (< 50 cases/year), medium-volume (50-150 cases/year) and high-volume centers (> 150 cases/year).

    RESULTS: A total of 23,351 patients were included in this study, of whom 2964 suffered severe postoperative complication(s). Adjusted IRR showed no significant differences between high- and low-volume centers with an IRR of 0.97 (0.75-1.26, p = 0.844) in high-volume centers in the first stratification and an IRR of 2.06 (0.80-5.31, p = 0.134) for high-volume centers and 2.15 (0.83-5.56, p = 0.116) for medium-volume centers in the second stratification.

    CONCLUSION: This nationwide retrospectively analyzed cohort study fails to demonstrate a significant association between hospital surgical volume and FTR after colorectal cancer surgery. Future studies should explore alternative characteristics and their correlation with FTR to identify possible interventions for the improvement of quality of care after colorectal cancer surgery.

  • 26.
    Lillo-Felipe, Miriam
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bass, G. A.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    Hospital academic status is associated with failure-to-rescue after colorectal cancer surgery2021In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 170, no 3, p. 863-869Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status.

    METHODS: Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals.

    RESULTS: A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46-0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals.

    CONCLUSION: University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.

  • 27.
    Petersson, Josefin
    et al.
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 416 85, Gothenburg, Sweden; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Dehlaghi Jadid, Kaveh
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bock, David
    School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Angenete, Eva
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 416 85, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
    Short term results in a population based study indicate advantage for laparoscopic colon cancer surgery versus open2023In: Scientific Reports, E-ISSN 2045-2322, Vol. 13, no 1, article id 4335Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to compare LAP with OPEN regarding short-term mortality, morbidity and completeness of the cancer resection for colon cancer in a routine health care setting using population based register data. All 13,683 patients who were diagnosed 2012-2018 and underwent elective surgery for right-sided or sigmoid colon cancer were included from the Swedish Colorectal Cancer Registry and the National Patient Registry. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, length of hospital stay, reoperation, readmission and positive resection margin (R1). Weighted and unweighted multi regression analyses were performed. There were no difference in 30-day mortality: LAP (0.9%) and OPEN (1.3%) (OR 0.89, 95% CI 0.62-1.29, P = 0.545). The weighted analyses showed an increased 90-day mortality following OPEN, P < 0.001. Re-operations and re-admission were more frequent after OPEN and length of hospital stay was 2.9 days shorter following LAP (P < 0.001). R1 resections were significantly more common in the OPEN group in the unweighted and weighted analysis with P = 0.004 and P < 0.001 respectively. Therefore, the favourable short-term outcomes following elective LAP versus OPEN resection for colon cancer in routine health care indicate an advantage of laparoscopic surgery.

  • 28.
    Petersson, Josefin
    et al.
    Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden; Sunshine Coast University Hospital, Britinya, QLD, Australia.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden.
    Dehlaghi Jadid, Kaveh
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden.
    Bock, David
    Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden.
    Angenete, Eva
    Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden; Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden.
    Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open2024In: BMC Surgery, E-ISSN 1471-2482, Vol. 24, no 1, article id 52Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting.

    METHODS: All 9,464 patients diagnosed with rectal cancer 2012-2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry.

    PRIMARY OUTCOMES: Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%. SECONDARY OUTCOMES: 30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses.

    RESULTS: The CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS.

    CONCLUSIONS: In this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.

  • 29.
    Pourlotfi, Arvid
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin therapy and its association with long-term survival after colon cancer surgery2022In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 171, no 4, p. 890-896Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The current study aims to address the clinical equipoise regarding the association of ongoing statin therapy at time of surgery with long-term postoperative mortality rates after elective, curative, surgical resections of colon cancer by analyzing data from a large validated national register.

    METHODS: All adults with stage I to III colon cancer who underwent elective surgery with curative intent between January 2007 and October 2016 were retrieved from the Swedish Colorectal Cancer Register, a prospectively collected national register. Patients were identified as having ongoing statin therapy if they filled a prescription within 12 months pre- and postoperatively. Study outcomes included 5-year all-cause and cancer-specific postoperative mortality. To reduce the impact of confounding from covariates owing to nonrandomization, the inverse probability of treatment weighting method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts.

    RESULTS: In total, 19,118 patients underwent elective surgery for colon cancer in the specified period, of whom 31% (5,896) had ongoing statin therapy. Despite being older, having a higher preoperative risk, and having more comorbidities, patients with statin therapy had a higher postoperative survival. After inverse probability of treatment weighting, patients with statin therapy displayed a significantly lower mortality risk up to 5 years after surgery for both all-cause (hazard ratio 0.68, 95% confidence interval 0.63-0.74, P < .001) and cancer-specific mortality (hazard ratio 0.76, 95% confidence interval 0.66-0.89, P < .001).

    CONCLUSION: The results of this study indicate that statin therapy is associated with a sustained reduction in all-cause and cancer-specific mortality up to 5 years after elective colon cancer surgery. The findings warrant validation in future prospective clinical trials.

  • 30.
    Pourlotfi, Arvid
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Therapy is Associated with Decreased 90-day Postoperative Mortality After Colon Cancer Surgery2022In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 65, no 4, p. 559-565Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery.

    OBJECTIVE: This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery.

    DESIGN: This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register.

    SETTINGS: Patient inclusion was achieved by inclusion through a nationwide register.

    PATIENTS: All adult patients undergoing elective surgery for colon cancer between the period of January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin positive cohort.

    MAIN OUTCOME MEASURES: The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality.

    RESULTS: A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, multiorgan failure, or of cardiovascular and respiratory origin.

    LIMITATIONS: The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded.

    CONCLUSIONS: Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study, however, further research is needed to ascertain if this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738.

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  • 31.
    Pourlotfi, Arvid
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Bass, G. A.
    Örebro University, School of Medical Sciences. Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Therapy and Postoperative Short-Term Mortality after Rectal Cancer Surgery2021In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 23, no 4, p. 875-881Article in journal (Refereed)
    Abstract [en]

    AIM: The study aimed to assess the correlation between regular statin therapy and postoperative mortality following resection surgery for rectal cancer.

    METHOD: This retrospective cohort included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data was gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics.

    RESULTS: 11,966 patients underwent resection surgery for rectal cancer, of whom 3,019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3,017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% versus 5.5%, p < 0.001), additionally displaying significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity.

    CONCLUSION: Preoperative statin therapy displays a strong association with reduced postoperative mortality following resectional surgery for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.

  • 32.
    Pourlotfi, Arvid
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery & Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Use and Long-Term Mortality after Rectal Cancer Surgery2021In: Cancers, ISSN 2072-6694, Vol. 13, no 17, article id 4288Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival.

    METHODS: Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality.

    RESULTS: The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery.

    CONCLUSIONS: Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.

  • 33.
    Rutegård, Martin
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Holmgren, Klas
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Haapamäki, Markku M.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Correspondence: The right kind of rectal cancer operation for the right patient requires information on all relevant outcomes2022In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 24, no 1, p. 136-137Article in journal (Other academic)
  • 34.
    Rutegård, Martin
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Häggström, Jenny
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Back, Erik
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Holmgren, Klas
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Wixner, Jonas
    Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Rutegård, Jörgen
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Sjöström, Olle
    Department of Radiation Sciences, Umeå University, Umeå, Sweden.
    Defunctioning loop ileostomy in anterior resection for rectal cancer and subsequent renal failure: nationwide population-based study2023In: BJS Open, E-ISSN 2474-9842, Vol. 7, no 3, article id zrad010Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Electrolyte disturbances and dehydration are common after anterior resection for rectal cancer with a defunctioning loop ileostomy. High-quality population-based studies on the impact of a defunctioning loop ileostomy on renal failure are lacking.

    METHODS: This was a nationwide observational study, based on the Swedish Colorectal Cancer Registry of patients undergoing anterior resection for rectal cancer between 2008 and 2016, with follow-up until 2017. Patients with severe co-morbidity, with age greater than 80 years, and with pre-existing renal failure were excluded. Loop ileostomy at index surgery constituted exposure, while a diagnosis of renal failure was the outcome. Acute and chronic events were analysed separately. Inverse probability weighting with adjustment for confounding derived from a causal diagram was employed. Hazards ratios (HRs) with 95 per cent c.i. are reported.

    RESULTS: A total of 5355 patients were eligible for analysis. At 5-year follow-up, all renal failure events (acute and chronic) were 7.2 per cent and 3.3 per cent in the defunctioning stoma and no stoma groups respectively. In the weighted analysis, a HR of 11.59 (95 per cent c.i. 5.68 to 23.65) for renal failure in ostomates was detected at 1 year, with the largest effect from acute renal failure (HR 24.04 (95 per cent c.i. 8.38 to 68.93)). Later follow-up demonstrated a similar pattern, but with smaller effect sizes.

    CONCLUSION: Patients having a loop ileostomy in combination with anterior resection for rectal cancer are more likely to have renal failure, especially early after surgery. Strategies are needed, such as careful fluid management protocols, and further research into alternative stoma types or reduction in stoma formation.

  • 35.
    Rutegård, Martin
    et al.
    Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Glimelius, Bengt
    Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
    Blomqvist, Lennart
    Department of Radiation Physics/Nuclear Medicine, Karolinska University Hospital, Stockhom, Sweden.
    Implications of pretreatment extramural venous invasion in rectal cancer patients: A population-based study2024In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318Article in journal (Refereed)
    Abstract [en]

    AIM: Extramural venous invasion detected by MRI (mrEMVI) has in several expert centre studies been identified as an important prognostic factor in rectal cancer, and in guiding neoadjuvant therapy. However, population-based evidence for mrEMVI as a predictor for recurrent disease is lacking.

    METHOD: This was a multicentre retrospective study based on the Swedish Colorectal Cancer Registry. The study period encompassed patients operated with abdominal resection for rectal cancer 2017-2021, with follow-up until January 2023. Patients diagnosed at hospitals with radiological registry data coverage <90% or with metastatic disease were excluded. Pretreatment mrEMVI constituted exposure, while recurrence-free survival was the main outcome. Distant and local recurrence, and overall survival were secondary outcomes, and pretreatment and postoperative scenarios were explored using multivariable Cox regression with multiple imputation. Hazard ratios (HRs) with 95% confidence intervals (CIs) were reported.

    RESULTS: A total of 2737 patients from 13 hospitals were eligible for analysis. Pretreatment mrEMVI was reported in 14.5% of patients, while 71.9% had negative findings and 13.6% had missing data. In the pretreatment scenario, mrEMVI was an independent predictor for worse recurrence-free survival with an adjusted HR of 1.64 (95% CI: 1.31-2.06). In the postoperative MDT setting, the influence of mrEMVI on recurrence-free survival decreased with an adjusted HR of 1.27 (95% CI: 1.00-1.61).

    CONCLUSION: mrEMVI at diagnosis is an independent predictor of recurrence-free survival in an unselected population of rectal cancer patients undergoing abdominal resection.

  • 36.
    Rutegård, Martin
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Svensson, Johan
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Segelman, Josefin
    Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lydrup, Marie-Louise
    Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden.
    Park, Jennifer
    Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Anastomotic Leakage in Relation to Type of Mesorectal Excision and Defunctioning Stoma Use in Anterior Resection for Rectal Cancer2024In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 67, no 3, p. 398-405Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Anastomotic leakage after anterior resection for rectal cancer is more common after total compared to partial mesorectal excision but might be mitigated by a defunctioning stoma.

    OBJECTIVE: The aim is to assess how anastomotic leakage is affected by type of mesorectal excision and defunctioning stoma use.

    DESIGN: This is a retrospective multicenter cohort study evaluating anastomotic leakage after anterior resection. Multivariable Cox regression with hazard ratios and 95% confidence intervals was employed to contrast mesorectal excision types and defunctioning stoma use with respect to anastomotic leakage, with adjustment for confounding.

    SETTINGS: This multicenter study included patients from 11 Swedish hospitals between 2014 and 2018.

    PATIENTS: Patients who underwent anterior resection for rectal cancer were included.

    MAIN OUTCOMES MEASURES: Anastomotic leakage rates within and after 30 days of surgery are described up to one year after surgery.

    RESULTS: Anastomotic leakage occurred in 24.2% and 9.0% of 1126 patients operated with total and partial mesorectal excision, respectively. Partial compared to total mesorectal excision was associated with a reduction in leakage, with an adjusted HR of 0.46 (95% CI: 0.29-0.74). Early leak rates within 30 days were 14.9% with and 12.5% without a stoma, while late leak rates after 30 days were 7.5% with and 1.9% without a stoma. After adjustment, defunctioning stoma was associated with a lower early leak rate (HR 0.47; 95% CI: 0.28-0.77). However, the late leak rate was non-significantly higher in defunctioned patients (HR 1.69; 95% CI: 0.59-4.85).

    LIMITATIONS: This study was limited by its retrospective observational study design.

    CONCLUSIONS: Anastomotic leakage is common up to one year after anterior resection for rectal cancer, where partial mesorectal excision is associated with a lower leak rate. Defunctioning stomas seem to decrease the occurrence of leakage, though partially by only delaying the diagnosis.

  • 37.
    Rutegård, Martin
    et al.
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Svensson, Johan
    Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden.
    Segelman, Josefin
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lydrup, Marie-Louise
    Department of Surgery, Skåne University Hospital and Lund University, Lund, Sweden.
    Park, Jennifer
    Department of Surgery, Scandinavian Surgical Outcomes Research Group (SSORG), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Splenic flexure mobilization and anastomotic leakage in anterior resection for rectal cancer: A multicentre cohort study2023In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 112, no 4, p. 246-255Article in journal (Refereed)
    Abstract [en]

    Background and objective: Some colorectal surgeons advocate routine splenic flexure mobilization (SFM) when performing anterior resection for rectal cancer to ensure a tensionfree anastomosis. Meta-analyses of smaller studies suggest that this approach does not influence anastomotic leakage rates, but larger multicentre studies are needed to confirm the safety of a selective strategy. The aim of this study is to evaluate the impact of SFM on anastomotic leakage.

    Methods: This is a retrospective multicentre cohort study, comprising 1109 patients operated with anterior resection for rectal cancer in 2014-2018. Exposure was SFM, while anastomotic leakage within a year constituted the outcome. Stratified analyses were performed for type of mesorectal excision and surgical approach, as well as sensitivity analysis considering vascular tie placement. Multivariable Cox regression with hazard ratios (HRs) and 95% confidence intervals (CIs) was employed to adjust for confounding, while multiple imputation was used for missing data.

    Results: SFM was performed in 381 patients (34.4%). Anastomotic leakage occurred in 83 (21.8%) and 123 (20.3%) patients operated with and without SFM, respectively. SFM was neither clearly detrimental nor beneficial regarding anastomotic leakage (adjusted HR = 0.82; 95% CI: 0.59-1.15), with no apparent differences for total or partial mesorectal excision and minimally invasive or open surgery. Concurrent high vascular ligation did not impact these results, and there was no evidence of interaction from centers with a more common use of SFM.

    Conclusions: SFM did not seem to influence the risk of anastomotic leakage after anterior resection for rectal cancer, regardless of type of mesorectal excision, use of minimally invasive surgery, or high vascular ligation.

  • 38.
    Shahrivar, Mehrnoosh
    et al.
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Weibull, Caroline E.
    Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Ekström Smedby, Karin
    Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Glimelius, Bengt
    Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
    Syk, Ingvar
    Department of Surgery, Skåne University Hospital, Malmö, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Nordenvall, Caroline
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI oncology and colorectal surgery unit, Karolinska University Hospital, Stockholm, Sweden.
    Martling, Anna
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI oncology and colorectal surgery unit, Karolinska University Hospital, Stockholm, Sweden.
    Low-dose aspirin use and colorectal cancer survival in 32,195 patients: A national cohort study2023In: Cancer Medicine, E-ISSN 2045-7634, Vol. 12, no 1, p. 315-324Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Results from previous studies indicate that use of aspirin may improve colorectal cancer (CRC) survival. The aim of this study was to assess whether use of aspirin influences overall survival or CRC-specific survival in an unselected cohort of patients diagnosed with CRC.

    METHODS: The study was performed using the Colorectal Cancer Data Base Sweden (CRCBaSe), a mega-linkage originating from the Swedish Colorectal Cancer Register, with additional linkages to other national health care registers. All patients diagnosed with primary CRC stage I-III treated with curative surgery, aged 18-85 years at diagnosis, from 2007 through 2016 were identified. Information on low-dose aspirin use was extracted from the Swedish Prescribed Drug Register. Exposure was defined as dispensed prescription for at least 6 months. Aspirin exposure was analyzed at the time of surgery (yes/no) and as a time-varying exposure during follow-up. Follow-up was restricted to a maximum 6 years, to model 5-year survival. Cox regression models were fitted to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Adjustments were performed for sex, age, year of diagnosis, Charlson comorbidity index, hypertension, and ASA score as potential confounders.

    RESULTS: A total of 32,195 patients diagnosed with CRC were included. 6764 (21%) were exposed to aspirin at the time of CRC surgery. The median time of follow-up was 4.2 years. Aspirin use at the time of surgery was not associated with all-cause (adjusted HR = 1.03, 95% CI: 0.97-1.08) nor CRC-specific mortality (adjusted HR = 0.99, 95% CI: 0.91-1.07). Aspirin use during follow-up was associated with increased all-cause (adjusted HR = 1.09, 95% CI: 1.04-1.15) but not CRC-specific mortality (adjusted HR = 0.98, 95% CI: 0.91-1.06). A CRC-specific effect associated with aspirin was noted from approximately 3 years following surgery.

    CONCLUSIONS: In this large nation-wide cohort study there was no convincing association between aspirin use after CRC and OS or CRC-specific survival.

  • 39.
    Siekmann, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Eintrei, Christina
    Department of Anesthesiology and Intensive care, County Council of Östergötland, Linköping, Sweden.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Sjölander, Anita
    Cell and Experimental Pathology, Department of Translational Medicine, Lund University, Malmö, Sweden.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Myrelid, Pär
    Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, County Council of Östergötland, Linköping, Sweden.
    Gupta, Anil
    Örebro University, School of Medical Sciences. Karolinska University Hospital, Stockholm, Sweden.
    Surgical and not analgesic technique affects postoperative inflammation following colorectal cancer surgery: a prospective, randomized study2017In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 19, no 6, p. O186-O195Article in journal (Refereed)
    Abstract [en]

    AIM: Epidural analgesia reduces the surgical stress response. However, its effect on pro- and anti-inflammatory cytokines in the genesis of inflammation following major abdominal surgery remains unclear. Our main objective was to elucidate whether perioperative epidural analgesia prevents the inflammatory response following colorectal cancer surgery.

    METHODS: 96 patients scheduled for open or laparoscopic surgery were randomized to epidural analgesia (group E) or patient controlled intravenous analgesia (group P). Surgery and anaesthesia were standardized in both groups. Plasma cortisol, insulin and serum cytokines (IL-1β,IL-4,IL-5,IL-6,IL-8,IL-10,IL-12p70,IL-13,TNFα,IFNγ,GM-CSF,PGE2 and VEGF) were measured preoperatively (T0), 1-6 hours postoperatively (T1) and 3-5 days postoperatively (T2). Mixed model analysis was used, after logarithmic transformation when appropriate, for analyses of cytokines and stress markers.

    RESULTS: There were no significant differences in any serum cytokine concentration between groups P and E at any time point except in IL-10 which was 87% higher in group P (median and range 4.1 (2.3-9.2) pg/ml,) compared to group E (2.6 (1.3-4.7) pg/ml) (p=0.002) at T1. There was no difference in plasma cortisol and insulin between the groups at any time point after surgery. Significant difference in median serum cytokine concentration was found between open and laparoscopic surgery with higher levels of IL-6,IL-8 and IL-10 at T1 in patients undergoing open surgery compared to laparoscopic surgery. No difference in serum cytokine concentration was detected between the groups or between the surgical technique at T2.

    CONCLUSIONS: Open surgery, compared to laparoscopic surgery, has greater impact on these inflammatory mediators than epidural analgesia vs. intravenous analgesia. This article is protected by copyright. All rights reserved.

  • 40.
    Warps, A. K.
    et al.
    Department of Surgery, Leiden University Medical Centre, ZA, Leiden, Netherlands; Dutch Institute for Clinical Auditing, Leiden, Netherlands.
    Saraste, D.
    Department of Surgery, Södersjukhuset, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Insitutet, Stockholm, Sweden.
    Westerterp, M.
    Department of Surgery, Haagland Medisch Centrum, VA, Den Haag, Netherlands.
    Detering, R.
    Department of Surgery, Amsterdam University Medical Centres, AZ, Amsterdam, Netherlands.
    Sjövall, A.
    Department of Molecular Medicine and Surgery, Karolinska Insitutet, Stockholm, Sweden; Department of Surgery, Karolinska University Hospital, Solna, Sweden.
    Martling, A.
    Department of Molecular Medicine and Surgery, Karolinska Insitutet, Stockholm, Sweden; Department of Surgery, Karolinska University Hospital, Solna, Sweden.
    Dekker, J. W. T.
    Department of Surgery, Reinier de Graaf Groep, AD, Delft, Netherlands.
    Tollenaar, R. A. E. M.
    Department of Surgery, Leiden University Medical Centre, ZA, Leiden, Netherlands; Dutch Institute for Clinical Auditing, Leiden, Netherlands.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Tanis, P. J.
    Department of Surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, Netherlands.
    National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes2022In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 36, no 8, p. 5986-6001Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden.

    METHODS: Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012-2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012-2013 versus Sweden 2017-2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes.

    RESULTS: A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012-2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017-2018.

    CONCLUSION: This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

  • 41.
    Weibull, Caroline E.
    et al.
    Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Boman, Sol Erika
    Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Glimelius, Bengt
    Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
    Syk, Ingvar
    Department of Surgery, Skåne University Hospital, Malmö, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Smedby, Karin E.
    Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.
    Nordenvall, Caroline
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden.
    Martling, Anna
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden.
    CRCBaSe: a Swedish register-based resource for colorectal adenocarcinoma research2023In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 62, no 4, p. 342-349Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To facilitate high-quality register-based research on colorectal cancer (CRC) in Sweden by constructing a database consisting of CRC patients, matched comparators, and relatives.

    MATERIAL AND METHODS: Patients with adenocarcinoma in the colon and/or rectum were identified in the Swedish Colorectal Cancer Register, a nationwide quality-of-care register. For each patient, six comparators from the general population were matched on birth year, sex, year of CRC diagnosis, and county. Comparators were free from CRC at the time of matching, but could later become cases. For both patients and comparators, first-degree relatives (parents, siblings, and children) were identified. Information from nationwide population-based registers was retrieved and linked to each individual in the database using the personal identification number unique to all Swedish residents.

    RESULTS: A total of 76,831 CRC patients diagnosed between 1995 and 2016 were identified (51% colon, 49% rectal; before 2007 only rectal cancer patients were included). Among all patients, 37% were stage I-II, 22% stage III, and 22% stage IV. The median follow-up time was 11.9 years (inter-quartile range, IQR: 8.6-15.3). Together with comparators and relatives, the database contains 2,413,139 individuals with information on demographics, dates and causes of death, in- and outpatient healthcare records, cancer diagnoses, prescribed and dispensed drugs, childbirths (among women), and social security information (such as sick leave and early retirement).

    CONCLUSION: The Colorectal Cancer Database Sweden (CRCBaSe) is a large and unique register-based data research platform, which opens up for clinically important, large epidemiological studies with innovative design in the field of colorectal adenocarcinoma.

  • 42.
    Wikner, Franciska
    et al.
    Department of Radiation Sciences, Umeå University, Umeå, Sweden.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery.
    Sörelius, Karl
    Department of Vascular Surgery, Rigshospitalet, Copenhagen, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
    Legrell, Petter
    Department of Radiation Sciences, Umeå University, Umeå, Sweden.
    Rutegård, Martin
    Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
    Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer-impacting registry-based research and surgical practice2021In: World Journal of Surgical Oncology, E-ISSN 1477-7819, Vol. 19, no 1, article id 115Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer.

    METHODS: Patients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement.

    RESULTS: A total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment.

    CONCLUSION: This study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice.

    TRIAL REGISTRATION: Clinical Trials identifier NCT03875612.

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