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  • 1. Emanuelsson, Peter
    et al.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dahlstrand, Ursula
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: a randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures2016In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 160, no 5, p. 1367-1375Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The primary aim of this prospective, randomized, clinical, 2-armed trial was to evaluate the risk for recurrence using 2 different operative techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength, and quality of life and to compare those outcomes to a control group receiving physical training only.

    METHODS: Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with computed tomography scan and clinically. Pain was assessed using the ventral hernia pain questionnaire, a quality-of-life survey, SF-36, and abdominal muscle strength using the Biodex System-4.

    RESULTS: One early recurrence occurred in the Quill group, 2 encapsulated seromas in the mesh group, and 3 in the suture group. Significant improvements in perceived pain, the ventral hernia pain questionnaire, and quality of life appeared at the 1-year follow-up with no difference between the 2 operative groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analog scale improved similarly in both operative groups. This improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up.

    CONCLUSION: There was no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after operation. An operation improves functional ability and quality of life. Training strengthens the abdominal muscles, but patients still experience discomfort and pain.

  • 2.
    Hallén, Magnus
    et al.
    Department of Surgery, Clinical Sciences, Lund University and Lund University Hospital, Lund, Sweden.
    Sandblom, Gabriel
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Nordin, Pär
    Department of Surgery, Östersund Hospital.
    Gunnarsson, Ulf
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Kvist, Ulrik
    Center for Andrology and Sexual Medicine, Department of Medicine, Karolinska Institute, Stockholm, Sweden.
    Westerdahl, Johan
    Department of Surgery, Clinical Sciences, Lund University and Lund University Hospital, Lund, Sweden.
    Male infertility after mesh hernia repair: a prospective study2011In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 149, no 2, p. 179-184Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several animal studies have raised concern about the risk for obstructive azoospermia owing to vasal fibrosis caused by the use of alloplastic mesh prosthesis in inguinal hernia repair. The aim of this study was to determine the prevalence of male infertility after bilateral mesh repair.

    METHODS: In a prospective study, a questionnaire inquiring about involuntary childlessness, investigation for infertility and number of children was sent by mail to a group of 376 men aged 18-55 years, who had undergone bilateral mesh repair, identified in the Swedish Hernia Register (SHR). Questionnaires were also sent to 2 control groups, 1 consisting of 186 men from the SHR who had undergone bilateral repair without mesh, and 1 consisting of 383 men identified in the general population. The control group from the SHR was matched 2:1 for age and years elapsed since operation. The control group from the general population was matched 1:1 for age and marital status.

    RESULTS: The overall response rate was 525 of 945 (56%). Method of approach (anterior or posterior), type of mesh, and testicular status at the time of the repair had no significant impact on the answers to the questions. Nor did subgroup analysis of the men </=40 years old reveal any significant differences.

    CONCLUSION: The results of this prospective study in men do not support the hypothesis that bilateral inguinal hernia repair with alloplastic mesh prosthesis causes male infertility at a significantly greater rate than those operated without mesh.

  • 3.
    Hallén, Magnus
    et al.
    Department of Surgery, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden.
    Westerdahl, Johan
    Nordin, Pär
    Department of Surgery, Östersund Hospital.
    Gunnarsson, Ulf
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Mesh hernia repair and male infertility: a retrospective register study2012In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 151, no 1, p. 94-98Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have suggested that the use of mesh in groin hernia repair may be associated with an increased risk for male infertility as a result of inflammatory obliteration of structures in the spermatic cord. In a recent study, we could not find an increased incidence of involuntary childlessness. The aim of this study was to evaluate this issue further.

    METHODS: Men born between 1950 and 1989, with a hernia repair registered in the Swedish Hernia Register between 1992 and 2007 were cross-linked with all men in the same age group with the diagnosis of male infertility according to the Swedish National Patient Register. The cumulative and expected incidences of infertility were analyzed. Separate multivariate logistic analyses, adjusted for age and years elapsed since the first repair, were performed for men with unilateral and bilateral repair, respectively.

    RESULTS: Overall, 34,267 men were identified with a history of at least 1 inguinal hernia repair. A total of 233 (0.7%) of these had been given the diagnosis of male infertility after their first operation. We did not find any differences between expected and observed cumulative incidences of infertility in men operated with hernia repair. Men with bilateral hernia repair had a slightly increased risk for infertility when mesh was used on either side. However, the cumulative incidence was less than 1%.

    CONCLUSION: Inguinal hernia repair with mesh is not associated with an increased incidence of, or clinically important risk for, male infertility.

  • 4.
    Lundberg, Owe
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kristoffersson, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wound recurrences from gallbladder cancer after open cholecystectomy2000In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 127, no 3, p. 296-300Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Reports of port site recurrences from gallbladder cancer after laparoscopic cholecystectomy have raised considerable concern as to whether the laparoscopic technique implies an increased risk of metastatic disease. In a previous study of gallbladder cancer and laparoscopic cholecystectomy, we reported a frequency of 16% port site metastases. The purpose of the present study was to determine the frequency of wound metastases from gallbladder cancer after open cholecystectomy. METHODS: The registers from the Swedish Oncological Centers and the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for open cholecystectomy from 1991 to 1994. The study included all 8 university and 24 county hospitals in Sweden. The files from all patients with gallbladder cancer who had an open cholecystectomy were retrospectively reviewed. RESULTS: The study included 270 patients who had a cholecystectomy, of which 215 were classified as open and 55 as laparoscopic. Of the 215 patients, 11 patients were excluded because of an incorrect or deficient histopathologic or surgical classification. In 186 patients (91%), sufficient data were obtained for follow-up. Twelve patients (6.5%) had wound metastases from their gallbladder cancer. All patients with wound metastases died with a median survival of 10 months (range, 3 to 65 months). CONCLUSIONS: Wound metastases from gallbladder cancer after open cholecystectomy may be more common than previously assumed.

  • 5.
    Löfgren, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University Hospital, Umeå, Sweden.
    Kadobera, Daniel
    Forsberg, Birger C.
    Mulowooza, Jude
    Wladis, Andreas
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University Hospital, Umeå, Sweden.
    District-level surgery in Uganda: Indications, interventions and perioperative mortality2015In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 158, no 1, p. 7-16Article in journal (Refereed)
    Abstract [en]

    Background: The world's poorest 2 billion people, benefit from no more than about 3.5% of the world's operative procedures. The burden of surgical disease is greatest in Africa, where operations could save many lives. Previous facility-based studies have described operative procedure caseloads, but prospective studies investigating interventions, indications and perioperative mortality rates (POMR), are rare.

    Methods: A prospective, questionnaire-based collection of data on all major and minor operative procedures was undertaken at 2 hospitals in rural Uganda covering 4 and 3 months in 2011, respectively. Data included patient characteristics, indications for the interventions performed, and outcome after surgery.

    Results: We recorded 2,790 operative procedures on 2,701 patients. The rate of major operative procedures per 100,000 population per year was 225. Patients undergoing major operative procedures (n = 1,051) were mostly women (n = 923; 88%) because most interventions were performed owing to pregnancy-related complications (n = 747; 67%) or gynecologic conditions (n = 114; 10%). General operative interventions registered included herniorrhaphy (n = 103; 9%), exploratory laparotomy (n = 60; 5%), and appendectomy (n = 31; 3%). The POMR for major operative procedures was 1 % (n = 14) and was greatest after exploratory laparotomy (13%; n = 8) and caesarean delivery (1%; n = 4). Most deaths = 16) were a result of sepsis (n = 10-11) or hemorrhage (n = 3-5).

    Conclusion: The volume of surgery was low relative to the size of the catchment population. The POMR was high. Exploratory laparotomy and caesarean section were identified as high-risk procedures. Increased availability of blood, improved pen operative monitoring, and early intervention could be part of a solution to reduce the POMR

  • 6.
    Löfgren, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Mulowooza, Jude
    Iganga, Uganda.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wladis, Andreas
    Stockholm, Sweden.
    Forsberg, Birger C.
    Solna, Sweden.
    Cost of surgery in a low-income setting in eastern Uganda2015In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 157, no 6, p. 983-991Article in journal (Refereed)
    Abstract [en]

    Background. Operative interventions have traditionally been seen as expensive; therefore, surgery has been given low priority in global health care planning in low-income countries. A growing body of evidence indicates that surgery can also be highly cost effective in low-income settings, but our current knowledge of the actual cost of surgery in such settings is limited. This study was carried out to obtain data on the costs of commonly performed operative procedures in a rural/semiurban setting in eastern Uganda. Methods. A prospective, facility-based study carried out at a general district hospital (public) and a mission hospital (private, not-for-profit) in the Iganga and Mayuge districts in eastern Uganda. Items included in the cost calculations were staff time, materials and medicines, overhead costs, and capital costs. Results. The cost of surgery was higher at the mission hospital, with higher expenditure and lower productivity than the public hospital. The most commonly performed major procedures were caesarean section, uterine evacuation, and herniorrhaphy for groin hernia. The costs for these interventions varied between $68.4 and $74.4, $25.0 and $32.6, and $58.6 and $66.0, respectively. The most commonly performed minor procedures were circumcision, suture of cuts and lacerations, and incision and drainage of abscess. The costs for these interventions varied between $16.2 and $24.6, $15.8 and $24.3, and $10.1 and $18.6, respectively. Conclusion. The cost of surgery in the study setting compares favorably with other prioritized health care interventions, such as treatment for tuberculosis, human immunodeficiency virus/AIDS, and childhood immunization. Surgery in low-income settings can be made more cost effective, leading to increased quantity and improved quality of surgical services.

  • 7. Olsson, Anders
    et al.
    Sandblom, Gabriel
    Fränneby, Ulf
    Sondén, Anders
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dahlstrand, Ursula
    Impact of postoperative complications on the risk for chronic groin pain after open inguinal hernia repair2017In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 161, no 2, p. 509-516Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Chronic pain is common after inguinal hernia repair and has become one of the most important outcome measures for this procedure. The purpose of this study was to determine whether or not there is a relationship between specific postoperative complications and risk for chronic pain after open inguinal hernia repair.

    METHODS: A prospective cohort study was designed in which participants responded to the Inguinal Pain Questionnaire regarding postoperative groin pain 8 years after inguinal hernia repair. Responses to the questionnaire were matched with data from a previous study regarding reported postoperative complications after open inguinal hernia repair. Participants were recruited originally from the Swedish Hernia Register. Response rate was 82.4% (952/1,155). The primary outcome was chronic pain in the operated groin at follow-up. Grading of pain was performed using the Inguinal Pain Questionnaire.

    RESULTS: A total of 170 patients (17.9%) reported groin pain and 29 patients (3.0%) reported severe groin pain. The risk for developing chronic groin pain was greater in patients with severe pain in the preoperative or immediate postoperative period (odds ratio 2.09; 95% confidence interval 1.28-3.41). Risk for chronic pain decreased for every 1-year increase in age at the time of operation (odds ratio 0.99, 95% confidence interval 0.98-1.00).

    CONCLUSION: Both preoperative pain and pain in the immediate postoperative period are strong risk factors for chronic groin pain. Risk factor patterns should be considered before operative repair of presumed symptomatic inguinal hernias. The problem of postoperative pain must be addressed regarding both pre-emptive and postoperative analgesia.

  • 8.
    Rutegård, Martin
    et al.
    Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Charonis, Konstantinos
    Lu, Yunxia
    Lagergren, Pernilla
    Lagergren, Jesper
    Rouvelas, Ioannis
    Population-based esophageal cancer survival after resection without neoadjuvant therapy: an update2012In: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 152, no 5, p. 903-910Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There are few population-based studies addressing the survival after resection for esophageal cancer. This study represents an update of a nationwide Swedish cohort initiated in 1987.

    METHODS: Based on data from the Swedish Patient Register, Swedish Cancer Register, and histopathologic records, 1,008 patients who had undergone esophageal resection as the only treatment for esophageal cancer were identified between January 1, 1987 and December 31, 2005. These were followed until death or emigration through linkage to the Swedish Total Population Register until January 1, 2009. Tumor stage, location, and histology were assessed from histopathologic reports, and comorbidities were assessed from the Patient Register. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) regarding survival. The results were adjusted for age, sex, comorbidity, tumor stage, location, histology, surgical radicality, and hospital volume.

    RESULTS: The proportion of patients surviving for 5 years increased from 19.7% in 1987-1991 to 30.7% in 1997-2000, but remained at 30.5% between 2001 and 2005. No difference in overall adjusted survival was found between the periods of 2001-2005 and 1997-2000 (adjusted HR, 0.89; 95% CI, 0.70-1.13). Thirty-day mortality decreased from 4.9% in 1997-2000 to 2.0% in 2001-2005, rendering an adjusted HR of 0.26 (95% CI, 0.08-0.87).

    CONCLUSION: After adjusting for relevant prognostic factors, long-term population-based survival after resection for esophageal cancer was unchanged between 2001 and 2005 compared to 1997-2000, while the corresponding 30-day mortality improved.

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