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Gunnarsson, Ulf
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Söderbäck, H., Gunnarsson, U., Martling, A., Hellman, P. & Sandblom, G. (2019). Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer. International Journal of Colorectal Disease, 34(10), 1757-1762
Open this publication in new window or tab >>Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer
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2019 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 34, no 10, p. 1757-1762Article in journal (Refereed) Published
Abstract [en]

Background: Patient-related risk factors for wound dehiscence after colorectal surgery remain obscure.

Methods: All open abdominal procedures for colorectal cancer registered in the Swedish Colorectal Cancer Registry (SCRCR, 5) 2007-2013 were identified. Potential risk factors for wound dehiscence were identified by cross-matching between the SCRCR and the National Patient Register (NPR). The endpoint in this study was reoperation for wound dehiscence registered in either the SCRCR or NPR and patients not reoperated were considered controls.

Results: A total of 30,050 patients were included in the study. In a multivariable regression analysis, age > 70 years, male gender, BMI > 30, history of chronic obstructive pulmonary disease, history of generalised inflammatory disease, and duration of surgery less than 180 min were independently and significantly associated with increased risk for wound dehiscence. A history of diabetes, chronic renal disease, liver cirrhosis, and distant metastases was not associated with wound dehiscence. The hazard ratio for postoperative death was 1.24 for patients who underwent reoperation for wound dehiscence compared with that for controls.

Discussion: Patients reoperated for wound dehiscence face a significantly higher postoperative mortality than those without. Risk factors include male gender, age > 70 years, obesity, history of chronic obstructive pulmonary disease, and history of generalised inflammatory disease. Patients at high risk for developing wound dehiscence may, if identified preoperatively, benefit from active prevention measures implemented in routine surgical practice.

Place, publisher, year, edition, pages
Springer, 2019
Keywords
Wound dehiscence, Colorectal cancer, Surgery
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:umu:diva-164041 (URN)10.1007/s00384-019-03390-3 (DOI)000487143200015 ()31501927 (PubMedID)
Available from: 2019-10-16 Created: 2019-10-16 Last updated: 2019-10-16Bibliographically approved
Näverlo, S., Strigård, K. & Gunnarsson, U. (2019). Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. International Journal of Colorectal Disease, 34(6), 993-1000
Open this publication in new window or tab >>Long distance to hospital is not a risk factor for non-reversal of a defunctioning stoma
2019 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 34, no 6, p. 993-1000Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To see if road distance to hospital influences stoma reversal rate, time from index operation to stoma reversal, and occurrence of permanent stoma.

METHODS: Data from all diagnosed cases of rectal cancer from three counties in northern Sweden were extracted from the Swedish Rectal Cancer Registry. The three counties are sparsely populated, with a population density roughly one fifth the average density in Sweden. Distances to nearest, operating, and largest hospital were obtained using Google Maps™. Matched data on socioeconomic variables were retrieved from Statistics Sweden.

RESULTS: In univariate logistic regression analysis, patients living closer to the operating hospital had a higher likelihood of non-reversal than those living farther away (OR 0.3; 95% CI 0.12-0.76). However, no difference was seen in the multivariate analysis. Of the 717 cases included, 54% received a permanent stoma and 38% a defunctioning stoma at index surgery. The reversal rate of a defunctioning stoma was 83%. At follow-up, 61% still had a stoma, 89% of these were permanent, and 11% non-reversed defunctioning stomas. Median time to stoma reversal was 287 days (82-1557 days). Of all 227 stoma reversals, 77% were done more than 6 months after index surgery.

CONCLUSIONS: Longer distance to hospital is not a risk factor for non-reversal of a defunctioning stoma. Only 23% had their defunctioning stoma reversed within 6 months after index surgery. Future studies aiming to determine reversal rate need to extend their follow-up time in order to receive accurate results.

Place, publisher, year, edition, pages
Springer, 2019
Keywords
Defunctioning stoma, Distance, Permanent stoma, Rectal cancer, Rural, Stoma reversal
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-156475 (URN)10.1007/s00384-019-03258-6 (DOI)30747282 (PubMedID)
Funder
Västerbotten County Council, VLL-675981
Available from: 2019-02-18 Created: 2019-02-18 Last updated: 2019-06-11Bibliographically approved
Lindmark, M., Strigård, K., Nordin, P. & Gunnarsson, U. (2019). Patient Reported Injuries After Ventral Hernia Repair. Scandinavian Journal of Surgery, 108(1), 30-35
Open this publication in new window or tab >>Patient Reported Injuries After Ventral Hernia Repair
2019 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 108, no 1, p. 30-35Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIMS: The Swedish National Patient Insurance Company (LÖF) can compensate patients who believe they have been exposed to an avoidable injury or malpractice in healthcare. Its register covers 95% of Swedish healthcare providers.

MATERIAL AND METHODS: Data on patients operated for primary or incisional ventral hernia in Sweden between 2010 and 2015 and who had filed a claim, were retrieved from LÖF. A total of 290 cases were identified and included. Files include a copy of records, relevant imaging, and an expert advisor's opinion.

RESULTS: Inadvertent enterotomy occurred during 25 repairs and in these cases, laparoscopic repair was clearly overrepresented ( p  < 0.001). Complications related to the surgical site (infection and ugly scar) were predominantly related to open repairs ( p  < 0.001). Twenty percentage (57/290) of the claims were directly related to an anesthetic mishap. Univariate ordinal regression showed that the odds of receiving a high reimbursement was significantly increased if laparoscopic repair was performed p  < 0.001 (odds ratio: 0.37; 95% confidence interval: 0.21-0.65). Sixty-three percentage of claims were filed by women.

CONCLUSION: Inadvertent enterotomy is overrepresented, and the probability that a claim filed for an avoidable injury leads to high reimbursement is greater if laparoscopic repair is performed rather than open ventral hernia repair. The high amount of injuries related to general anesthesia during umbilical hernia repair may be reduced with an increased proportion executed in local anesthesia.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
Ventral hernia, enterotomy, hernia repair, iatrogenic patient injury, insurance, laparoscopic repair, local anesthesia
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-150228 (URN)10.1177/1457496918783727 (DOI)000461561500005 ()29966500 (PubMedID)
Funder
Västerbotten County Council, VLL-675981
Available from: 2018-07-20 Created: 2018-07-20 Last updated: 2019-04-23Bibliographically approved
Olsson, A., Sandblom, G., Fränneby, U., Sondén, A., Gunnarsson, U. & Dahlstrand, U. (2019). The Short-Form Inguinal Pain Questionnaire (sf-IPQ): An Instrument for Rating Groin Pain After Inguinal Hernia Surgery in Daily Clinical Practice. World Journal of Surgery, 43(3), 806-811
Open this publication in new window or tab >>The Short-Form Inguinal Pain Questionnaire (sf-IPQ): An Instrument for Rating Groin Pain After Inguinal Hernia Surgery in Daily Clinical Practice
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2019 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 43, no 3, p. 806-811Article in journal (Refereed) Published
Abstract [en]

Background: The Inguinal Pain Questionnaire (IPQ) is a standardised and validated instrument for assessing persisting pain after groin hernia surgery. The IPQ is often perceived as being too extensive for routine use. The aim of this study was to develop and evaluate a condensed version of the IPQ in order to facilitate its use in daily clinical practice.

Methods: The condensed form, i.e. Short-Form Inguinal Pain Questionnaire (sf-IPQ), comprises two main items taken from the IPQ. Four hundred patients were recruited from the Swedish Hernia Register and were sent the IPQ, sf-IPQ and the Short-Form McGill Pain Questionnaire (SF-MPQ) three years after hernia repair. Ratings from the IPQ and the sf-IPQ were converted to a 12-point scale. The reported scores for the two shared items in the IPQ and sf-IPQ were compared using the Intraclass Correlation Coefficient (ICC), Cohen’s kappa and McNemar’s test.

Results: After two reminders, the response rate was 69.8% (n = 279/400). The ICC for the IPQ and sf-IPQ scores was 0.78 (95% confidence interval 0.73–0.82, p < 0.001). Cohen’s kappa was 0.66 (95% confidence interval 0.55–0.77, p < 0.001). The sf-IPQ systematically indicated a higher pain score than the IPQ (p = 0.013).

Conclusions: Despite the systematic difference in level of pain scored, correlation, consistency and agreement were seen between the IPQ and sf-IPQ. The forms appear to be interchangeable, though the sf-IPQ may be a more sensitive instrument. The condensed structure of the sf-IPQ is more user-friendly and shows promise as a useful tool in daily clinical practice.

Place, publisher, year, edition, pages
Springer, 2019
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-154255 (URN)10.1007/s00268-018-4863-8 (DOI)000457455400016 ()30478683 (PubMedID)
Available from: 2018-12-14 Created: 2018-12-14 Last updated: 2019-02-20Bibliographically approved
Odensten, C., Strigård, K., Rutegård, J., Dahlberg, M., Ståhle, U., Gunnarsson, U. & Näsvall, P. (2019). Use of prophylactic mesh when creating a colostomy does not prevent parastomal hernia: a randomized controlled trial—STOMAMESH. Annals of Surgery, 269(3), 427-431
Open this publication in new window or tab >>Use of prophylactic mesh when creating a colostomy does not prevent parastomal hernia: a randomized controlled trial—STOMAMESH
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2019 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 269, no 3, p. 427-431Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to determine whether parastomal hernia (PSH) rate can be reduced by using synthetic mesh in the sublay position when constructing permanent end colostomy. The secondary aim was to investigate possible side-effects of the mesh.

Background: Prevention of PSH is important as it often causes discomfort and leakage from stoma dressing. Different methods of prevention have been tried, including several mesh techniques. The incidence of PSH is high; up to 78%.

Methods: Randomized controlled double-blinded multicenter trial. Patients undergoing open colorectal surgery, including creation of a permanent end colostomy, were randomized into 2 groups, with and without mesh. A lightweight polypropylene mesh was placed around the colostomy in the sublay position. Follow up after 1 month and 1 year. Computerized tomography and clinical examination were used to detect PSH at the 1-year follow up. Data were analyzed on an intention-to-treat basis.

Results: After 1 year, 211 of 232 patients underwent clinical examination and 198 radiologic assessments. Operation time was 36 minutes longer in the mesh arm. No difference in rate of PSH was revealed in the analyses of clinical (P = 0.866) and radiologic (P = 0.748) data. There was no significant difference in perioperative complications.

Conclusions: The use of reinforcing mesh does not alter the rate of PSH. No difference in complication rate was seen between the 2 arms. Based on these results, the prophylactic use of mesh to prevent PSH cannot be recommended.

Place, publisher, year, edition, pages
Wolters Kluwer, 2019
Keywords
mesh, parastomal hernia, prophylaxis
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-142585 (URN)10.1097/SLA.0000000000002542 (DOI)000467458600023 ()29064900 (PubMedID)
Available from: 2017-12-07 Created: 2017-12-07 Last updated: 2019-06-13Bibliographically approved
Skoglar, A., Gunnarsson, U. & Falk, P. (2018). Band adhesions not related to previous abdominal surgery: A retrospective cohort analysis of risk factors. Annals of Medicine and Surgery, 36, 185-190
Open this publication in new window or tab >>Band adhesions not related to previous abdominal surgery: A retrospective cohort analysis of risk factors
2018 (English)In: Annals of Medicine and Surgery, ISSN 2049-0801, Vol. 36, p. 185-190Article in journal (Refereed) Published
Abstract [en]

Background: Postoperative intra-abdominal adhesion formation is a common cause of small bowel obstruction (SBO). Adhesions causing SBO are classed as either matted adhesions or solitary band adhesions. The aim of this study was to investigate the prevalence of previous abdominal surgery in a cohort of patients operated for bowel obstruction and to analyze the causes of obstruction discovered at surgery.

Materials and methods: The study was performed at a county hospital with a catchment population of 120 000 inhabitants. Records of operations performed for bowel obstruction over a period of 70 months were retrieved.

Results: Of the 196 surgical procedures for intestinal obstruction included, 108 (55%) were caused by adhesions. In this group, 42 (39%) were due to solitary band adhesions and 66 (61%) were due to matted adhesions. Ten of 18 male patients (56%) with a solitary obstructing band had not undergone previous abdominal surgery (p < 0.05). In the cohort as a whole, a significant number of surgical procedures were performed for solitary band adhesions in patients without prior history of surgery (p < 0.01).

Conclusion: In male patients, not only previous abdominal surgery but also other factors appear to increase the risk for bowel obstruction due to a solitary band. For intestinal obstruction caused by matted adhesions, however, previous abdominal surgery is the main risk factor in both genders. Patients with signs of SBO but without previous abdominal surgery should be managed bearing in mind that solitary band adhesion and thereby strangulation may be present regardless of previous surgery or not.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Intestinal obstruction, Surgery-induced tissue adhesion, Surgical adhesion
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-154248 (URN)10.1016/j.amsu.2018.11.007 (DOI)30505438 (PubMedID)2-s2.0-85056772564 (Scopus ID)
Available from: 2018-12-14 Created: 2018-12-14 Last updated: 2018-12-18Bibliographically approved
Blind, N., Strigård, K., Gunnarsson, U. & Brännström, F. (2018). Distance to hospital is not a risk factor for emergency colon cancer surgery.. International Journal of Colorectal Disease, 33(9), 1195-1200
Open this publication in new window or tab >>Distance to hospital is not a risk factor for emergency colon cancer surgery.
2018 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 33, no 9, p. 1195-1200Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The purpose of this study is to see if the distance to a hospital performing colon cancer surgery is a risk factor for emergency surgical intervention and to determine the variability between defined but demographically divergent catchment areas.

METHODS: Data on patients living in Västerbotten County who underwent colon cancer surgery between 2007 and 2010 were extracted from the Swedish Colorectal Cancer Register (SCRCR). Of the 436 registrations matching these criteria, 380 patients were used in the analysis, and their distance to the nearest hospital providing care for colorectal cancer (CRC) was estimated using Google Maps™. The correlations between the risk for emergency surgery and the distance to a hospital, gender, age, income level and hospital catchment area were analysed in uni- and multivariate models.

RESULTS: Distance to the nearest hospital had no significant effect on the proportion of emergency operations for colon cancer. There was significant variability in risk for emergency surgery between hospital catchment areas, where the catchment areas of the university hospital and the most rural hospital had a higher proportion than the other local hospital catchment area (OR, 2.00 (p = 0.038) and OR, 2.97 (p = 0.005)). These results were still significant when analysed with multivariate logistic regression (OR, 2.13 (p = 0.026) and OR, 3.05 (p = 0.013)).

CONCLUSION: Distance to a hospital performing colon cancer surgery had no effect on the proportion of emergency surgeries. However, a variability between defined catchment areas was seen. Future studies will focus on possible factors behind this variability.

Keywords
Colon cancer, Distance, Emergency surgery, Rural
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-148535 (URN)10.1007/s00384-018-3074-y (DOI)000441102200006 ()29797050 (PubMedID)
Available from: 2018-06-07 Created: 2018-06-07 Last updated: 2018-09-11Bibliographically approved
Winsnes, A., Gunnarsson, U., Falk, P., Stark, B., Moskaug, J. Ø. & Strigård, K. (2018). Evaluating full-thickness skin grafts in intraperitoneal onlay mesh position versus onlay position in mice. Journal of Surgical Research, 230, 155-163
Open this publication in new window or tab >>Evaluating full-thickness skin grafts in intraperitoneal onlay mesh position versus onlay position in mice
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2018 (English)In: Journal of Surgical Research, ISSN 0022-4804, E-ISSN 1095-8673, Vol. 230, p. 155-163Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Importance: Hernia surgery requires reinforcement material with few side effects when used in the intraperitoneal position. Autologous skin grafting may meet this requirement, but animal experiments are obligatory before being applied in humans.

OBJECTIVE: To compare survival and effects of isogeneic full-thickness skin grafts in the intraperitoneal onlay mesh (IPOM) position in mice, with a control group using the onlay position. Primary end point was graft survival and secondary end point adhesion formation and inflammation through NF-κB activity.

METHODS: Design: Intervention study with 8-week follow-up in accordance with ARRIVE criteria, performed between 2015 and 2016.

SETTING: Animal laboratory.

PARTICIPANTS: Transgenic C57BL/6 mice with isogeneic background were used. Recipients were female wild-type phenotype mice >3 mo (n = 24). Donors were male or female mice >7 mo, with phenotype-positive for the luciferase gene (n = 20) or positive for NF-κB-luciferase gene (n = 4).

INTERVENTION: Full-thickness skin was grafted in the IPOM position and compared with grafts in the onlay position as controls. Survival was evaluated by regular longitudinal postoperative luminescence imaging over 8 wk. Adherence formation was evaluated macroscopically after sacrifice. Inflammation of full-thickness skin grafts in IPOM position of NF-κB mice was evaluated in four additional mice. Main outcome and measure: Survival of grafts, evaluated by luminescence.

RESULTS: Ten animals received grafts in the IPOM position, and 10 in the onlay position as controls. Graft survival after 8 wk was 100% (20/20). Average luminescence at the end of the 8-week period was 999,597 flux (min 162,800, max 2,521,530) in the IPOM group (n = 10) and 769,708 flux (min 76,590, max 2,164,080) in the onlay control group (n = 10). No adhesions requiring sharp dissection (Jenkins' scale >2) were seen. Four animals with grafts in the IPOM position showed peak inflammation (NF-κB activity) 5 d after surgery subsiding toward the end of follow-up.

CONCLUSIONS: Full-thickness skin survives as well in the IPOM position as in the onlay control position, and few adherences develop. Further studies are required to fully characterize the tissue remodeling and repair processes associated with IPOM skin grafting. The result is relevant in the search for alternative reinforcement materials to be used in complex hernia surgery in humans.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Abdominal wall reinforcement, Acellular scaffold, Autologous full-thickness skin graft, Hernia repair, IPOM/onlay, Intraperitoneal, Isogeneic
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-151807 (URN)10.1016/j.jss.2018.04.041 (DOI)000441170900023 ()30100033 (PubMedID)2-s2.0-85047625025 (Scopus ID)
Available from: 2018-09-13 Created: 2018-09-13 Last updated: 2018-10-05Bibliographically approved
Clay, L., Stark, B., Gunnarsson, U. & Strigård, K. (2018). Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study. Hernia (2), 325-332
Open this publication in new window or tab >>Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study
2018 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, no 2, p. 325-332Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair.

METHODS: Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment.

RESULTS: There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit.

CONCLUSION: No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Abdominal wall reconstruction, Full-thickness skin, Hernia complication, Incisional hernia, Infection, Ventral hernia
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-143226 (URN)10.1007/s10029-017-1712-x (DOI)000428248700014 ()29247365 (PubMedID)
Available from: 2017-12-19 Created: 2017-12-19 Last updated: 2018-08-07Bibliographically approved
Söderbäck, H., Gunnarsson, U., Hellman, P. & Sandblom, G. (2018). Incisional hernia after surgery for colorectal cancer: a population-based register study.. International Journal of Colorectal Disease, 33(10), 1411-1417
Open this publication in new window or tab >>Incisional hernia after surgery for colorectal cancer: a population-based register study.
2018 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 33, no 10, p. 1411-1417Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Our knowledge on the incidence of incisional hernia and risk factors for developing incisional hernia following surgery for colorectal cancer is far from complete.

METHODS: All procedures registered in the Swedish Colorectal Cancer Register (SCRCR) 2007-2013 were identified. Patients with comorbid disease diagnoses, registered at admissions and visits prior to the procedure and relevant to this study, were obtained from the National Patient Register (NPR). These diagnoses included cardiovascular disease, connective tissue disorders, liver cirrhosis, renal failure, diabetes, chronic obstructive lung disease and chronic inflammatory conditions. Data on occurrence of incisional hernias were obtained by combining data from the SCRCR and the NPR (International Classification of Diseases code).

RESULTS: During 2007-2013, 39,984 procedures were registered in the SCRCR. After excluding laparoscopic procedures, procedures repeated on the same patient, procedures with concomitant liver resection and procedures without laparotomy, 28,913 cases remained for analysis. Five years after surgery, the cumulative incidence of incisional hernia was 5.3%. In multivariate proportional hazard analysis, significantly increased risk for incisional hernia was found for the male gender (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.21-1.62), operation time exceeding 180 min (HR 1.25, CI 1.08-1.45), body mass index (BMI) > 30 (HR 1.78, CI 1.51-2.09), age < 70 years (HR 1.34, CI 1.16-1.56) and postoperative wound complication (HR 2.09, CI 1.70-2.58).

DISCUSSION: Men, patients younger than 70 years and patients with BMI > 30 face a higher risk for incisional hernia. The risk is also increased in cases where the procedure takes longer than 3 h or where postoperative wound complications occur. These patients will benefit from measures aimed at preventing the development of incisional hernia.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Colorectal cancer, Incisional hernia, Risk factors
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-150229 (URN)10.1007/s00384-018-3124-5 (DOI)000444736000011 ()30019246 (PubMedID)
Available from: 2018-07-20 Created: 2018-07-20 Last updated: 2018-10-05Bibliographically approved
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