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  • 1.
    Boström, Petrus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamaki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, P.
    Ljung, R.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    High arterial ligation and risk of anastomotic leakage in anterior resection for rectal cancer in patients with increased cardiovascular risk2015In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 17, no 11, p. 1018-1027Article in journal (Refereed)
    Abstract [en]

    Aim: Controversy still exists as to whether division of the inferior mesenteric artery close to the aorta influences the risk of anastomotic leakage after anterior resection for rectal cancer. This population-based study was carried out to evaluate the independent association between high arterial ligation and anastomotic leakage in patients with increased cardiovascular risk.

    Method: All 2673 cases of registered anterior resection for rectal cancer from 2007 to 2010 were identified from the Swedish Colorectal Cancer Registry and cross-referenced with the Prescribed Drugs Registry, rendering a cohort of all patients with increased cardiovascular risk. Operative charts and registered data were reviewed for 722 patients. The association between high tie and anastomotic leakage, as quantified by ORs and 95% CIs, was evaluated in a logistic regression model, with adjustment for confounding, including assessment of interaction.

    Results: Symptomatic anastomotic leakage occurred in 12.3% (41/334) of patients in the high tie group and in 10.6% (41/388) in the low tie group. The use of high tie was not independently associated with a higher risk of anastomotic leakage (OR = 1.05; 95% CI: 0.61–1.84). In a post-hoc analysis, patients with a history of manifest cardiovascular disease and American Society of Anesthesiologists (ASA) score III–IV seemed to be at greater risk (OR = 3.66; 95% CI: 1.04–12.85).

    Conclusion: In the present population-based, observational setting, high tie was not independently associated with an increased risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. However, this conclusion may not hold for patients with severe cardiovascular disease.

  • 2.
    Brännström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgical Sciences, Uppsala University, Uppsala and Department of Surgical Sciences, Karolinska Institutet, Stockholm.
    Jestin, Pia
    Department of Surgical Sciences, Karolinska Institutet, Stockholm and Karlstad Hospital, Karlstad.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro.
    Gunnarsson, Ulf
    Department of Surgical Sciences, Karolinska Institutet, Stockholm, Sweden.
    Surgeon and hospital-related risk factors in colorectal cancer surgery2011In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 13, no 12, p. 1370-1376Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to identify surgeon and hospital-related factors in a well-defined population-based cohort; the results of this study could possibly be used to improve outcome in colorectal cancer.

    METHOD: Data from the colonic (1997-2006) and rectal (1995-2006) cancer registers of the Uppsala/Örebro Regional Oncology Centre were used to assess 1697 patients with rectal and 2692 with colonic cancer. Putative risk factors and their impact on long-term survival were evaluated using the Cox proportional hazard model.

    RESULTS: The degree of specialization of the operating surgeon had no significant effect on long-term survival. When comparing the surgeons with the highest degree of specialization, noncolorectal surgeons demonstrated a slightly lower long-term survival for rectal cancer stage I and II (HR, 2.03; 95% CI, 1.05-3.92). Surgeons with a high case-load were not associated with better survival in any analysis model. Regional hospitals had a lower survival rate for rectal cancer stage III surgery (HR, 1.47; 95% CI, 1.08-2.00).

    CONCLUSION: Degree of specialization, surgeon case-load and hospital category could not be identified as important factors when determining outcome in colorectal cancer surgery in this study.

  • 3. Egenvall, Monika
    et al.
    Mörner, Malin
    Martling, Anna
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Prediction of outcome after curative surgery for colorectal cancer: preoperative haemoglobin, C-reactive protein and albumin2018In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 20, no 1, p. 26-34Article in journal (Refereed)
    Abstract [en]

    AIM: The aim was to evaluate a scoring system using the values of preoperative haemoglobin, C-reactive protein (CRP) and serum albumin to predict colorectal cancer recurrence and survival.

    METHOD: Data on all curative resections for Stages I-III colorectal cancer performed at a tertiary referral hospital 2007-2010 have been recorded ion the Swedish Colorectal Cancer Registry and were matched to the local databases for laboratory results and blood transfusion. Patients who died within 30 days or during primary hospital admission were excluded. Preoperative haemoglobin, CRP and albumin levels were recorded for 417 patients. A score (0-3) was derived on presence of anaemia (Hb <120 g/l for women and <130 g/l for men), raised CRP (>10 mg/ml) and low albumin (<35g/dl). The risks for recurrence and impaired overall survival were assessed using Cox regression analyses.

    RESULTS: Impaired overall survival was found when one, two or three of the criteria, anaemia, elevated CRP and low albumin, were present prior to surgery (HR 3.61, 1.66-7.85; HR 3.91, 1.75-8.74; HR 4.85, 2.15-10.93, respectively). The risk for recurrence, however, was not related to the presence of these criteria.

    CONCLUSION: Overall survival after curative surgery for Stages I-III colorectal cancer is impaired when anaemia, elevated CRP or low albumin exist prior to surgery. This article is protected by copyright. All rights reserved.

  • 4. Egenvall, Monika
    et al.
    Mörner, Malin
    Påhlman, Lars
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Karolinska Univ Hosp, Dept Surg Gastroenterol, K53,Huddinge 141, S-14186 Stockholm, Sweden.
    Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 9, p. 696-702Article in journal (Refereed)
    Abstract [en]

    AIM: the hypothesis tested in this study was that major blood loss during surgery for rectal cancer increases the risk for surgical complications and for small bowel obstruction (SBO) due to adhesions or tumour recurrence and reduces overall survival.

    METHOD: data were retrieved from the Uppsala/Örebro Regional Rectal Cancer Registry for all patients undergoing radical resection for rectal cancer 1997-2003 (n=1,843) and matched against the Swedish National Patient Registry regarding surgery and admission for SBO. These patient records were scrutinized to determine the etiology of surgery for SBO. The registry was scrutinized for blood loss and other surgical complications associated with surgery. Uni- and multivariate Cox analysis and logistic regression were used.

    RESULTS: 94 (5.1%) patients underwent surgery for SBO >30 days after the index operation. Of these 82 were caused by adhesions and 12 by tumour recurrence. The volume of blood lost did not influence the risk of surgery for SBO due to adhesions, but blood loss above the median (>800 ml) increased the risk for surgery for SBO caused by tumour recurrence (HR 10.52; 95% CI 1.36-81.51). Increased blood loss increased the risk of surgical complications (OR 2,09; 95% CI 1.60-2.75 with blood loss of 450 ml or more) but did not reduce overall survival. Irradiation before surgery increased blood loss, complications and admission for SBO.

    CONCLUSION: major blood loss during surgery for rectal cancer increases the risk of later surgery for SBO caused by tumour recurrence and surgical complications, but overall survival is not affected. This article is protected by copyright. All rights reserved.

  • 5.
    Egenvall, Monika
    et al.
    CLINTEC and Department of Surgical Gastroenterology, Karolinska University Hospital.
    Schubert Samuelsson, Katja
    CLINTEC and Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Klarin, Inga
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Lökk, Johan
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Sjövall, Annika
    Department of Surgical Gastroenterology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet.
    Martling, Anna
    Department of Surgical Gastroenterology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. CLINTEC and Department of Surgical Gastroenterology, Karolinska University Hospital.
    Management of colon cancer in the elderly: a population-based study2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 6, p. 433-441Article in journal (Refereed)
    Abstract [en]

    AIM: although the median age of patients diagnosed with colon cancer is above 70 years, little is known about specific characteristics and management in the elderly. The aim of the study was to define characteristics of colon cancer in elderly patients and compare the quality of preoperative assessment and surgery with that of younger patients undergoing surgery for colon cancer.

    METHOD: data on 15.255 patients diagnosed with colon cancer between 2007 and 2010 were retrieved from the Swedish National Colon Cancer Register. Of these, 12.959 underwent surgical resection, 6.141 were 75 years or older while 6.818 were younger. The χ(2) test, Mann-Whitney U test and uni- and multivariable logistic regression analyses were used for comparison between groups.

    RESULTS: older patients were more likely to be female (54% older/48% younger) and have right-sided cancer (60% older/49% younger). Among patients who underwent resection, the elderly were less often evaluated regarding tumour stage prior to surgery (59% older/65% younger) and they were less often evaluated at a multidisciplinary team conference (26% older/34% younger). Elderly patients more frequently underwent emergency surgery (22% older/19% younger) despite having an earlier cancer stage. When adjusted for stage, fewer elderly patients underwent a radical curative procedure (OR for non-curative resection 1.19; 95% CI 1.06-1.33)

    CONCLUSION: routine management of patients with colon cancer is age-dependent. Patients 75 years and older are less often completely staged and less often evaluated at a multi-disciplinary team conference prior to surgery. Adjusted for stage, fewer elderly patients undergo curative resection.

  • 6.
    Floodeen, Hannah
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Hallböök, Olof
    Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sjödahl, Rune
    Department of Surgery, Linköping University Hospital, Linköping, Sweden.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities?2013In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 15, no 3, p. 334-340Article in journal (Refereed)
    Abstract [en]

    Aim The aim of the study was to compare patients with symptomatic anastomotic leakage following low anterior resection of the rectum (LAR) for cancer diagnosed during the initial hospital stay with those in whom leakage was diagnosed after hospital discharge. Method Forty-five patients undergoing LAR (n=234) entered into a randomized multicentre trial (NCT 00636948), who developed symptomatic anastomotic leakage, were identified. A comparison was made between patients diagnosed during the initial hospital stay on median postoperative day 8 (early leakage, EL; n=27) and patients diagnosed after hospital discharge at median postoperative day 22 (late leakage, LL; n=18). Patient characteristics, operative details, postoperative course and anatomical localization of the leakage were analysed. Results Leakage from the circular stapler line of an end-to-end anastomosis was more common in EL, while leakage from the stapler line of the efferent limb of the J-pouch or side-to-end anastomosis tended to be more frequent in LL (P=0.057). Intra-operative blood loss (P=0.006) and operation time (P=0.071) were increased in EL compared with LL. On postoperative day 5, EL performed worse than LL with regard to temperature (P=0.021), oral intake (P=0.006) and recovery of bowel activity (P=0.054). Anastomotic leakage was diagnosed most often by a rectal contrast study in EL and by CT scan in LL. The median initial hospital stay was 28days for EL and 10days for LL (P<0.001). Conclusion The present study has demonstrated that symptomatic anastomotic leakage can present before and after hospital discharge and raises the question of whether early and late leakage after LAR may be different entities.

  • 7.
    Folkesson, J
    et al.
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Nilsson, J
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    The circular stapling device as a risk factor for anastomotic leakage.2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 4, p. 275-9Article in journal (Refereed)
    Abstract [en]

    AIM: To investigate the relation between the type of circular stapler and anastomotic leak in rectal cancer surgery.

    BACKGROUND: During the past decades results from rectal cancer surgery have improved considerably regarding risk of local recurrence and survival. Two main paradigm changes are considered to be the cause for this: the introduction of total mesorectal excision (TME) and the increasing use of radiotherapy. However, rectal cancer surgery is associated with an unacceptably high frequency of complications of which anastomotic leak is one of the most severe ones. The hypothesis was raised that the choice of stapler influenced the leakage rates.

    METHODS: A questionnaire was sent to all departments of surgery (n = 66) performing rectal cancer surgery in Sweden to determine the choice of circular stapler when performing anterior resection for rectal cancer. These data were linked to the Swedish Rectal Cancer Registry for the period 1995-99.

    RESULTS: A total of 3316 patients had an anterior resection. The choice of circular stapling device was determined in 70% of the cases. When stapler A was used, the leakage rate was 11% whereas it was 7% when stapler B was used (P = 0.0039). In the cases where it was impossible to determine which stapler had been used the leakage rate was 8%.

    CONCLUSION: Quality control is an important part of medicine and the present study suggests that it also must include surgical instruments. A prospective randomised study is needed to confirm the results.

  • 8.
    Gunnarsson, Ulf
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Karlbom, U
    Docker, M
    Raab, Y
    Påhlman, L
    Proctocolectomy and pelvic pouch--is a diverting stoma dangerous for the patient?2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 1, p. 23-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: A diverting loop ileostomy was previously considered mandatory for minimizing the effects of septic complications in pelvic pouch surgery. During the past decade there has been a trend towards omission of the loop ileostomy without obvious signs of increased numbers of pouch complications or impaired long-term function. The aim of the present study was to evaluate the risk of complications associated with the construction and closure of the loop ileostomy itself.

    PATIENTS AND METHODS: Complications following diverting loop ileostomies in 143 patients subjected to restorative pelvic pouch surgery during the period 1983-97 were studied retrospectively by evaluation of case records.

    RESULTS: In the period between discharge after pelvic pouch surgery and closure of the loop ileostomy, 20 (14%) patients were hospitalized because of excessive stoma flow and 19 (13%) patients were treated for other surgical complications, of whom 10 (7%) required surgical intervention. In the early postoperative period (within 30 days) after closure of the loop ileostomy, 18 (13%) patients suffered complications necessitating surgery. Another 12 (8%) patients were hospitalized because of intestinal obstruction that could be treated conservatively.

    CONCLUSION: The proportion of complications associated with diverting loop ileostomies in pelvic pouch surgery was considerable. A randomised controlled multicentre study is ethically defensible and is recommended.

  • 9.
    Holmgren, Klas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kverneng Hultberg, Daniel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, P.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study2017In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 19, no 12, p. 1067-1075Article in journal (Refereed)
    Abstract [en]

    AIM: Fashioning a defunctioning stoma is common when performing an anterior resection for rectal cancer in order to avoid and mitigate the consequences of an anastomotic leakage. We investigated the permanent stoma prevalence, factors influencing stoma outcome and complication rates following stoma reversal surgery.

    METHOD: Patients who had undergone an anterior resection for rectal cancer between 2007 and 2013 in the northern healthcare region were identified using the Swedish Colorectal Cancer Registry and were followed until the end of 2014 regarding stoma outcome. Data were retrieved by a review of medical records. Multiple logistic regression was used to evaluate predefined risk factors for stoma permanence. Risk factors for non-reversal of a defunctioning stoma were also analysed, using Cox proportional-hazards regression.

    RESULTS: A total of 316 patients who underwent anterior resection were included, of whom 274 (87%) were defunctioned primarily. At the end of the follow-up period 24% had a permanent stoma, and 9% of patients who underwent reversal of a stoma experienced major complications requiring a return to theatre, need for intensive care or mortality. Anastomotic leakage and tumour Stage IV were significant risk factors for stoma permanence. In this series, partial mesorectal excision correlated with a stoma-free outcome. Non-reversal was considerably more prevalent among patients with leakage and Stage IV; Stage III patients at first had a decreased reversal rate, which increased after the initial year of surgery.

    CONCLUSION: Stoma permanence is common after anterior resection, while anastomotic leakage and advanced tumour stage decrease the chances of a stoma-free outcome. Stoma reversal surgery entails a significant risk of major complications.

  • 10.
    Holmgren, Klas
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kverneng Hultberg, Daniel
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, P
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Reply to: 'High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population‐based multicentre study'2018In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 20, no 4, p. 342-343Article in journal (Refereed)
  • 11.
    Jestin, Pia
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Påhlman, Lars
    rtment of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Gunnarsson, Ulf
    rtment of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Risk factors for anastomotic leakage after rectal cancer surgery: a case-control study.2008In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 10, no 7, p. 715-21Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: With introduction of the total mesorectal excision technique and preoperative radiotherapy in rectal cancer surgery, the local recurrence rate has decreased and the overall survival has improved. One drawback, however, is the high anastomotic leakage rate of approximately 10-18%. Male gender and low anastomoses are known risk factors for such leakage. The aim of this study was to identify potentially modifiable risk factors.

    METHOD: In a case-control study, data from the Swedish Rectal Cancer Registry (1995-2000) were analysed. Cases were all patients with anastomotic leakage after an anterior resection (n = 134). Two controls were randomly selected for each case. The medical records (n = 402) were checked against a study protocol. Due to incorrect recording two cases and 28 controls were excluded from further analyses.

    RESULTS: In the multivariate analysis significant risk factors were American Society of Anesthesiologists score > 2 [OR = 1.40 (95% CI 1.05-1.83)], preoperative radiotherapy [OR = 1.34 (95% CI 1.06-1.69)], intraoperative adverse events [OR = 1.85 (95% CI 1.32-2.58)], level of anastomosis <or= 6 cm [OR = 1.39 (95% CI 1.01-1.90)] and severe bleeding [OR = 1.45 (95% CI 1.14-1.84)]. Diverting stoma protected from leakage [OR = 0.68 (95% CI 0.52-0.88)]. Male gender was a risk factor in the univariate but not in the multivariate analysis [OR = 1.30 (95% CI 1.04-1.63) and OR = 1.26 (95% CI 1.00-1.58), respectively]. Except for a protective stoma, none of the variables considered as possible targets for improvement, such as postoperative epidural anaesthesia, observation at intensive care unit for more than 24 h, and intraabdominal drainage, proved to be protective factors either in the univariate or in the multivariate analyses.

    CONCLUSION: The most important risk factors for leakage were adverse intraoperative events, low anastomoses and preoperative radiotherapy. A diverting stoma is protective and can reduce the consequences when leakage occurs. Further analyses with focus on the surgical technique and individual surgeon may be valuable in identifying targets for improvement.

  • 12. Jorgren, F.
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, G.
    Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer-specific survival?2011In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 13, no 3, p. 272-283Article in journal (Refereed)
    Abstract [en]

    Aim The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Method Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. Results After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy (P = 0.055) and rectal washout (P = 0.046) reduced the LR rate, but did not influence survival. Conclusion Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified.

  • 13. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, Gudrun
    Risk factors of rectal cancer local recurrence: population-based survey and validation of the Swedish rectal cancer registry2010In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 12, no 10, p. 977-986Article in journal (Refereed)
    Abstract [en]

    Aim: Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method: Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results: The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion: Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.

  • 14. Kodeda, K.
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Zar, N.
    Birgisson, H.
    Dahlberg, M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Skullman, S.
    Lindmark, G.
    Glimelius, B.
    Pahlman, L.
    Martling, A.
    Time trends, improvements and national auditing of rectal cancer management over an 18-year period2015In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 17, no 9, p. O168-O179Article in journal (Refereed)
    Abstract [en]

    AimThe main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series. MethodData from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded. ResultsDuring the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited. ConclusionThere have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.

  • 15.
    Kverneng Hultberg, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Afshar, A. A.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Jörgen
    Lange, M.
    Haapamäki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, P.
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Level of vascular tie and its effect on functional outcome 2 years after anterior resection for rectal cancer2017In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 19, no 11, p. 987-995Article in journal (Refereed)
    Abstract [en]

    Aim Previous research indicates that high tie of the inferior mesenteric artery during anterior resection for rectal cancer might be associated with an increased risk of postoperative functional disturbances. The goal of this population-based retrospective cohort study was to further investigate that association.

    Method Patients who underwent anterior resection for rectal cancer from April 2011 to September 2012 were identified through the Swedish Colorectal Cancer Registry. Bowel and urogenital function were assessed by a postal questionnaire 2 years after surgery. Information on the level of mesenteric tie and clinical variables was retrieved from the registry. The outcome was defined as any defaecatory, urinary or sexual dysfunction as reported by the patient. The association between high tie and the outcome was evaluated with multivariable logistic and linear regression with adjustment for confounders, such as sex, body mass index, comorbidity and preoperative radiation.

    Results With a response rate of 86%, 805 patients were included in the study. Of these, 46% were operated with high tie. After adjustment for confounders, high tie did not affect the risk of faecal incontinence (OR 0.85; 95% CI 0.59-1.22), urinary incontinence (OR 0.94; 95% CI 0.63-1.41) or various aspects of sexual dysfunction (erectile dysfunction, anejaculation, dyspareunia and coital vaginal dryness). However, an association between high tie and defaecation at night was detected (OR 1.44; 95% CI 1.02-2.03).

    Conclusion This study does not support that the level of vascular tie influences the risk of major defaecatory, urinary or sexual disturbances 2 years after anterior resection for rectal cancer.

  • 16.
    Laurell, H
    et al.
    Department of Surgery at Mora Hospital, Mora, Sweden and Department of Surgery at Uppsala University Hospital, Uppsala.
    Hansson, L-E
    Department of Surgery at Sahlgrenska University Hospital, Gothenburg, Sweden.
    Gunnarsson, Ulf
    Department of Surgery at Uppsala University Hospital, Uppsala.
    Acute diverticulitis--clinical presentation and differential diagnostics.2007In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 9, no 6, p. 496-501; discussion 501Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the clinical presentation of acute diverticulitis in an emergency department and to characterize the natural history of diverticulitis in the short perspective. Comparisons are made with an important differential diagnosis, nonspecific abdominal pain (NSAP).

    METHOD: Patients admitted to our hospital with abdominal pain of up to 7 days' duration were registered prospectively using a detailed schedule for history, symptoms and signs, from 1 February 1997 to 1 June 2000. Of 3349 patients initially included, 3073 (92%) were eligible for follow up after 1-3 years.

    RESULTS: Acute diverticulitis was the final diagnosis in 145 patients and NSAP in 1142 patients. The incidence of hospitalized patients with diverticulitis was 47 per year and 100 000 population, with a mean hospital stay of 3.3 days. Patients with diverticulitis, more frequently than NSAP, had a longer history and laboratory signs of inflammatory activity. Isolated left abdominal tenderness was more common in diverticulitis, whereas isolated right abdominal tenderness was more common in NSAP. Duration of symptoms on arrival was independent of age and was not correlated to C-reactive protein, leucocytes or body temperature. Sensitivity of diverticulitis as primary diagnosis was 64% and specificity 97%. Corresponding figures for NSAP were 43% and 90% respectively. Age and gender did not influence diagnostic accuracy or risk of surgery.

    CONCLUSION: Diverticulitis differs significantly from NSAP in clinical presentation and laboratory parameters. Sensitivity of primary diagnosis for diverticulitis and NSAP was low.

  • 17.
    Lindberg, J
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences.
    Stenling, Roger
    Umeå University, Faculty of Medicine, Medical Biosciences, Pathology. Patologi.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Medical Biosciences, Pathology. Patologi.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery. Kirurgi.
    Surgery for neoplastic changes in ulcerative colitis - can limited resection be justified? Outcome for patients who underwent limited surgery.2006In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 8, no 7, p. 551-556Article in journal (Refereed)
  • 18. Matthiessen, Peter
    et al.
    Lindgren, Rickard
    Hallböök, Olof
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sjödahl, Rune
    Symptomatic anastomotic leakage diagnosed after hospital discharge following low anterior resection for cancer.2009In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318Article in journal (Refereed)
    Abstract [en]

    Background: The aim of this study was to investigate patients with symptomatic anastomotic leakage diagnosed after hospital discharge. Methods: Patients undergoing low anterior resection of the rectum for cancer (n=234) who were included in a prospective multicenter trial (NCT 00636948) and who developed symptomatic anastomotic leakage diagnosed after hospital discharge (late leakage, LL; n=18) were identified. These patients were assessed in regard to patient characteristics, operative details, recovery on postoperative day five, length of hospital stay, and how the leakage was diagnosed. A comparison with those who did not develop symptomatic leakage (no leakage, NL; n=189) was performed. Minimum follow up was 24 months. Results: Median age was 69 years, 61% were females, and 6% had UICC cancer stage IV in LL. On postoperative day 5, LL had a postoperative course similar to NL in regard to morning temperature, per oral intake and bowel activity. The proportion of patients being on antibiotic treatment on postoperative day 5, regardless of indication, was 28% in LL compared with 4% in NL (P<0.001). The initial hospital stay was median 10 days for both LL and NL. If adding readmission for any reason, planned or unplanned, hospital stay was median 21.5 and 13 days in LL and NL, respectively (P<0.001). Conclusion: Symptomatic anastomotic leakage diagnosed after hospital discharge following low anterior resection of the rectum for cancer is not uncommon and has an immediate clinical postoperative course which may appear uneventful.

  • 19.
    Näsvall, Pia
    et al.
    Department of Surgery, Sunderby Hospital, Luleå, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Reply to 'Preventing parastomal herniation in 2014 and beyond'2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 10, p. 831-832Article in journal (Refereed)
  • 20.
    Rutegård, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Haapamäki, Markku
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Early postoperative mortality after surgery for rectal cancer in Sweden 2000-20112014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 6, p. 426-432Article in journal (Refereed)
    Abstract [en]

    AIM: Postoperative mortality has traditionally been defined as death within 30 days of surgery. Such mortality after rectal cancer resection has declined significantly during the last decades. It is, however, possible that this decline can be explained merely by a shift towards an increase in 90-day mortality.

    METHOD: A nationwide cohort study was based on data from the Swedish Colorectal Cancer Registry and the Swedish Patient Registry concerning patients who had undergone surgical resection for rectal cancer in 2000-2011. Unconditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) regarding mortality in different calendar periods (2000-2003, 2004-2007 and 2008-2011) in two different postoperative time windows: 0 to 30 days and 31 to 90 days.

    RESULTS: Some 15,473 patients were included in this surgical cohort. Mortality within 30 days of surgery decreased from 2.1 to 1.6% between 2000-2003 and 2008-2011, while the corresponding mortality within 31 to 90 days decreased from 2.1 to 1.4%. The adjusted risk of 30-day mortality in the late period was statistically significantly decreased compared to the early period (OR 0.67; 95% CI 0.48-0.93), while the mortality from 31 to 90 days was also reduced (OR 0.71; 95% CI 0.51-0.99).

    CONCLUSION: This population-based, nationwide Swedish study indicates that postoperative mortality as measured within 30 days and 31 to 90 days after surgery has decreased with time. However, no relevant shift from earlier to later postoperative mortality was discerned. 

  • 21. Samuelsson, K. S.
    et al.
    Egenvall, M.
    Klarin, I.
    Lökk, J.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Clinical Science, Intervention and Technology, CLINTEC, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study2016In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 18, no 2, p. 155-162Article in journal (Refereed)
    Abstract [en]

    Aim The study aimed to investigate whether continuing potentially inappropriate medication (PIM) is associated with length of hospital stay (LOS) and postoperative mortality in elderly people undergoing colorectal cancer surgery.

    Method The Swedish National Colorectal Cancer Register and the Swedish Prescribed Drug Register provided matched data on 7279 patients aged 75 years or more who had undergone bowel resection for colorectal cancer between 2007 and 2010. Patients were divided into two groups depending on whether or not they were taking PIM at the time of surgery. The primary efficacy variables were the LOS and 30-day postoperative mortality.

    Results Of the 7279 patients, 22.5% (1641) of the patients were exposed to at least one PIM and the total number of drugs taken in this group was six, compared with three in the non-PIM group (P<0.001). Postoperative mortality was higher in the PIM group (7.1% vs 4.5%, P<0.001), and LOS was longer (10days vs 9, P=0.001). When adjusted for independent predictors, the differences in LOS (odds ratio 1.14; 95% confidence interval 1.00-1.29, P=0.046) and postoperative mortality (odds ratio 1.43; 95% confidence interval 1.11-1.85, P=0.006) remained significant.

    Conclusion The use of PIM prior to surgery is associated with increased postoperative mortality and prolonged hospital stay. Although no causal relationship is proved, the results add a further aspect to preoperative optimization of elderly patients about to have major colorectal surgery.

    What does this paper add to the literature? The study shows an association between the exposure to potentially inappropriate medication and increased length of stay and postoperative mortality in elderly patients undergoing colorectal cancer surgery. The finding adds an additional factor to take into account during the preoperative optimization of elderly people.

  • 22.
    Strigard, Karin
    et al.
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Öresland, T
    Department of GI Surgery, Akerhus University Hospital, University of Oslo, Lörenskog, Norway.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Transcutaneous implant evacuation system: a new approach to continent stoma construction2011In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 13, no 11, p. E379-E382Article in journal (Refereed)
    Abstract [en]

    Aim: Several attempts have been made to construct a mechanical continent stoma without success. A system based on a titanium implant has been developed in an animal model. Following evaluation of this device in animals, the transcutaneous implant evacuation system (TIES) has now been tested in humans.

    Method: The implant consists of a titanium cylinder including a mesh and a plastic cap. This design allows the intestine and subcutaneous tissue to grow into the device. Four patients with inflammatory bowel disease underwent surgery. The indications for surgery were malfunctioning pouches or skin problems around the stoma. Following abdominal surgery, implantation of the device was made behind the external fascia with diversion of the ileum through the device to create a permanent stoma.

    Results: Primary surgery was uncomplicated. Skin tissue growth into the implant was delayed in one case and one patient had impaired healing between intestine and the device. In these cases minor surgical correction was necessary. The tested cap design in the current device was inconvenient and needs to be further developed. No local infections occurred.

    Conclusion: This first clinical study of the TIES device has shown few device-related complications and no significant safety concerns. In our experience bridging of connective tissue between the intestine and skin is crucial for healing. Further development of the lid, the implant and the implantation method within clinical trials is necessary before the device can be introduced in general practice.

  • 23. Sörelius, K.
    et al.
    Svensson, Johan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Matthiessen, P.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rutegård, Martin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    A nationwide study on the incidence of mesenteric ischaemia after surgery for rectal cancer demonstrates an association with high arterial ligation2019In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 21, no 8, p. 925-931Article in journal (Refereed)
    Abstract [en]

    Aim: The incidence of mesenteric ischaemia after resection for rectal cancer has not been investigated in a population-based setting. The use of high ligation of the inferior mesenteric artery might cause such ischaemia, as the bowel left in situ depends on collateral blood supply after a high tie.

    Method: The Swedish Colorectal Cancer Registry was used to identify all patients subjected to an abdominal resection for rectal cancer during the years 2007-2017 inclusive. Mesenteric ischaemia within the first 30 postoperative days was recorded, classified as either stoma necrosis or colonic necrosis. Multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for mesenteric ischaemia in relation to high tie, with adjustment for confounding.

    Results: Some 14 657 patients were included, of whom 59 (0.40%) had a reoperation for any type of mesenteric ischaemia, divided into 34 and 25 cases of stoma necrosis and colonic necrosis, respectively. Compared with patients who did not require reoperation for mesenteric ischaemia following rectal cancer surgery, the proportion having high tie was greater (54.2% vs 38.5%; P = 0.032). The adjusted OR for reoperation due to any mesenteric ischaemia with high tie was 2.26 (95% CI 1.34-3.79), while the corresponding estimates for stoma and colonic necrosis, respectively, were 1.60 (95% CI 0.81-3.17) and 3.69 (95% CI 1.57-8.66).

    Conclusion: The incidence of reoperation for mesenteric ischaemia after abdominal resection for rectal cancer is low, but the use of a high tie might increase the risk of colonic necrosis demanding surgery.

1 - 23 of 23
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