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  • 1.
    Birgisson, H
    et al.
    Department of Surgery, University Hospital, University of Uppsala, Uppsala, Sweden.
    Påhlman, Lars
    Department of Surgery, University Hospital, University of Uppsala, Uppsala, Sweden.
    Gunnarsson, Ulf
    Department of Surgery, University Hospital, University of Uppsala, Uppsala, Sweden.
    Glimelius, B
    Departments of Oncology, Radiology and Clinical Immunology, University Hospital, University of Uppsala, Uppsala, Sweden and Department of Oncology and Pathology, Karolinska Hospital, Karolinska Institute, Stockholm, Sweden.
    Late gastrointestinal disorders after rectal cancer surgery with and without preoperative radiation therapy.2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 2, 206-13 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of the study was to analyse late gastrointestinal disorders necessitating hospital admission following rectal cancer surgery and to determine their relationship to preoperative radiation therapy.

    METHODS: Curatively treated patients participating in the Swedish Rectal Cancer Trial during 1987-1990, randomized to preoperative irradiation (454 patients) or surgery alone (454), were matched against the Swedish Hospital Discharge Registry. Hospital records for patients admitted with gastrointestinal diagnoses were reviewed.

    RESULTS: Irradiated patients had an increased relative risk (RR) of late small bowel obstruction (RR 2.49 (95 per cent confidence interval (c.i.) 1.48 to 4.19)) and abdominal pain (RR 2.09 (95 per cent c.i. 1.03 to 4.24)) compared with patients treated by surgery alone. The risk of late small bowel obstruction requiring surgery was greatly increased (RR 7.42 (95 per cent c.i. 2.23 to 24.66)). Irradiated patients with postoperative anastomotic leakage were at increased risk for late small bowel obstruction (RR 2.99 (95 per cent c.i. 1.07 to 8.31)). The risk of small bowel obstruction was also related to the radiation technique and energy used.

    CONCLUSION: Small bowel obstruction is more common in patients with rectal cancer treated with preoperative radiation therapy.

  • 2.
    Birgisson, H
    et al.
    Department of Surgery, Akademiska Sjukhuset, S-75185 Uppsala, Sweden.
    Talbäck, M
    Gunnarsson, Ulf
    Department of Surgery, Akademiska Sjukhuset, S-75185 Uppsala, Sweden.
    Påhlman, L
    Glimelius, B
    Improved survival in cancer of the colon and rectum in Sweden.2005In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 31, no 8, 845-53 p.Article in journal (Refereed)
    Abstract [en]

    AIMS: To analyse time-trends in survival of patients with colon and rectal cancer in Sweden.

    PATIENTS AND METHODS: Data including all patients diagnosed with adenocarcinoma of the colon and rectum between 1960 and 1999, from the Swedish Cancer Registry, were analysed. The observed and relative survival rates were calculated according to the Hakulinen cohort method.

    RESULTS: Five-year relative survival rate for cancer of the colon improved significantly from 39.6% in 1960--1964 to 57.2% in 1995--1999 and for rectal cancer from 36.1 to 57.6%, respectively. Corresponding observed survival improved from 31.2 to 44.3% for colon cancer and from 28.4 to 45.4% for rectal cancer. The largest improvement of survival were seen during the later part of the period observed.

    CONCLUSION: The survival of patients with colon and rectal cancer in Sweden continues to improve, especially in rectal cancer, which now has a 5-year observed and relative survival rate comparable to that for colon cancer. The survival improvement in rectal cancer is probably a result of the implementation of total mesorectal excision and pre-operative radiotherapy.

  • 3.
    Birgisson, Helgi
    et al.
    Uppsala universitet, Medicinska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper.
    Påhlman, Lars
    Gunnarsson, Ulf
    Department of Surgery, Oncology, Radiology, and Clinical Immunology, Akademiska Sjukhuset, Uppsala.
    Glimelius, Bengt
    Adverse effects of preoperative radiation therapy for rectal cancer: long-term follow-up of the Swedish Rectal Cancer Trial.2005In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 23, no 34, 8697-8705 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To analyze the occurrence of subacute and late adverse effects in patients treated with preoperative irradiation for rectal cancer.

    PATIENTS AND METHODS: The study population included 1,147 patients randomly assigned to preoperative radiation therapy or surgery alone in the Swedish Rectal Cancer Trial conducted 1987 through 1990. Patient data were matched against the Swedish Hospital Discharge Register to identify patients admitted to hospital after the primary treatment of the rectal cancer. Patients with known residual disease were excluded, and patients with a recurrence were censored 3 months before the date of recurrence. Relative risks (RR) with 95% CIs were calculated.

    RESULTS: Irradiated patients were at increased risk of admissions during the first 6 months from the primary treatment (RR = 1.64; 95% CI, 1.21 to 2.22); these were mainly for gastrointestinal diagnoses. Overall, the two groups showed no difference in the risk of admissions more than 6 months from the primary treatment (RR = 0.95; 95% CI, 0.80 to 1.12). Regarding specific diagnoses, however, RRs were increased for admissions later than 6 months from the primary treatment in irradiated patients for unspecified infections, bowel obstruction, abdominal pain, and nausea.

    CONCLUSION: Gastrointestinal disorders, resulting in hospital admissions, seem to be the most common adverse effect of short-course preoperative radiation therapy in patients with rectal cancer. Bowel obstruction was the diagnosis of potentially greatest importance, which was more frequent in irradiated than in nonirradiated patients.

  • 4.
    Birgisson, Helgi
    et al.
    Uppsala universitet, Medicinska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Gastrointestinal Surgery.
    Påhlman, Lars
    Gunnarsson, Ulf
    Department of Surgery and Oncology, Radiology, and Clinical Immunology, Akademiska Sjukhuset, Uppsala, Sweden.
    Glimelius, Bengt
    Occurrence of second cancers in patients treated with radiotherapy for rectal cancer.2005In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 23, no 25, 6126-6131 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To analyze the occurrence of second cancers in patients with rectal cancer treated with external radiotherapy (RT) in addition to surgery.

    PATIENTS AND METHODS: The analyses were based on the Uppsala Trial (completed in 1985), with patients randomly assigned to preoperative RT to all stages or postoperative RT for stage II and III cancers, and the Swedish Rectal Cancer Trial (completed in 1990), with patients randomly assigned to preoperative RT or surgery alone. Patients from the trials were matched against the Swedish Cancer Registry.

    RESULTS: A total of 115 (7%) of the 1,599 patients developed 122 second cancers. More patients treated with RT developed a second cancer (relative risk [RR], 1.85; 95% CI, 1.23 to 2.78). A significant increased risk for second cancers in the RT group was seen in organs within or adjacent to the irradiated volume (RR, 2.04; 95% CI, 1.10 to 3.79) but not outside the irradiated volume (RR, 1.78; 95% CI, 0.97 to 3.27). For the Swedish Rectal Cancer Trial, 20.3% of the RT patients got either a local recurrence or a second cancer, compared with 30.7% of the non-RT patients (RR, 0.55; 95% CI, 0.44 to 0.70).

    CONCLUSION: An increased risk of second cancers was found in patients treated with RT in addition to surgery for a rectal cancer, which was mainly explained by an increase in the risk of second cancers in organs within or adjacent to the irradiated volume. However, a favorable effect of radiation seemed to dominate, as shown by the reduced risk of the sum of local recurrences and second cancers.

  • 5.
    Blom, J
    et al.
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden and Division of Coloproctology, Center of Surgical Gastroenterology, K53, Karolinska University Hospital, 141 86, Stockholm, Sweden .
    Nyström, P O
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden .
    Gunnarsson, Ulf
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden .
    Strigård, Karin
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
    Endoanal ultrasonography may distinguish Crohn's anal fistulae from cryptoglandular fistulae in patients with Crohn's disease: a cross-sectional study2011In: Techniques in Coloproctology, ISSN 1123-6337, E-ISSN 1128-045X, Vol. 15, no 3, 327-330 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography.

    METHODS: The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions.

    RESULTS: The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169).

    CONCLUSIONS: Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

  • 6.
    Brännström, Fredrik
    et al.
    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.
    Risk Factors for Local Recurrence after Emergency Resection for Colon Cancer: Scenario in Sweden2016In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 33, no 6, 503-508 p.Article in journal (Refereed)
    Abstract [en]

    Background/Aims: Patients undergoing emergency resection for colon cancer have a worse outcome both in terms of short-and long-term survival than those having elective surgery. The aim of this population-based study was to determine factors associated with increased risk for local recurrence following emergency resection. Methods: The Stockholm-Gotland Healthcare Region Colon Cancer Register was used to identify all colon cancer patients who had undergone emergency colon resection with curative intent in that region 1997-2007. Patient records were scrutinised to obtain any missing information. The influence of the following factors was assessed: indication for emergency resection; time between admission and surgery; surgery daytime or at night; American Association of Anesthesiologists score; volume of blood lost; and T- and N-stage. Our endpoint was loco-regional recurrence. Results: Apart from stage, perforation as indication for emergency surgery was the only factor that influenced the risk for local recurrence (hazard ratio 1.96; 95% CI 1.12-3.43). Conclusion: In this study, the only factor associated with local recurrence after emergency resection for colon cancer was preoperative perforation. This implies that changes in our current management algorithm would be unlikely to lead to improvement. Efforts should therefore concentrate on reducing the proportion of patients operated on an emergency basis.

  • 7.
    Brännström, Fredrik
    et al.
    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.
    Risk factors for local recurrence in emergency resections for colon cancerManuscript (preprint) (Other academic)
  • 8.
    Brännström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgical Sciences, Uppsala University, Uppsala, Sweden and Department of Surgical Sciences, Karolinska Institute, Stockholm, Sweden .
    Jestin, Pia
    Department of Surgical Sciences, Uppsala University, Uppsala, bDepartment of Surgical Sciences, Karolinska Institute, Stockholm.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgical Sciences, Karolinska Institute, Stockholm.
    Degree of specialisation of the surgeon influences lymph node yield after right-sided hemicolectomy2013In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 30, no 4-6, 362-367 p.Article in journal (Refereed)
    Abstract [en]

    Aim: To investigate the degree to which specialisation or case-load of the surgeon is associated with the number of lymph nodes isolated from pathology specimens after right-sided hemicolectomy.

    Method: Data from 6 hospitals with well-defined catchment areas included in the Uppsala/Örebro Regional Oncology Centre Colon Cancer Register 1997-2006 were used to assess 821 patients undergoing right-sided hemicolectomy for stages I-III colon cancer. Factors influencing the lymph node yield were evaluated.

    Results: A surgeon with colorectal accreditation and a university pathology department were both associated with a significantly higher proportion of patients having 12 or more lymph nodes isolated from surgical specimens after right-sided hemicolectomy in both unadjusted and multivariate analyses. Emergency surgery did not affect the lymph node yield. Conclusion: The degree of specialisation of the surgeon influences the number of lymph nodes isolated from specimens obtained during routine right-sided colon cancer surgery.

    © 2013 S. Karger AG, Basel.

  • 9.
    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, 1370-1376 p.Article 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.

  • 10.
    Clay, L
    et al.
    Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden .
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Franklin, Karl A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Effect of an elastic girdle on lung function, intra-abdominal pressure, and pain after midline laparotomy: a randomized controlled trial2014In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 29, no 6, 715-721 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Girdles and abdominal binders may reduce pain and stabilize the abdominal wall after laparotomy, but a risk for increased intra-abdominal pressure and decreased lung function is also hypothesized. The aim of this study was to investigate the effect of an abdominal girdle after midline laparotomy in a randomized controlled trial. METHODS: Twenty-three patients undergoing laparotomy were randomized to wear an elastic girdle postoperatively and 25 were randomized to no girdle. Pulmonary function was evaluated with; forced vital capacity (FVC), forced expiratory volume during one second (FEV1), peak expiratory flow (PEF), and cough PEF. Pain was recorded using a visual analog scale (VAS). All patients completed the ventral hernia pain questionnaire (VHPQ) before surgery and at the end of the study. Intra-abdominal pressure was measured via an indwelling urinary catheter. Wound healing was assessed from photographs. RESULTS: FVC, FEV1, PEF, and cough PEF were reduced by about 30 % after surgery, but there were no differences between patients with or without a girdle (ANOVA). Intra-abdominal pressure and wound healing were the same in both groups. Pain was significantly lower on day 5 in the girdle group (p = 0.004). CONCLUSIONS: An individually fitted elastic girdle used after midline laparotomy was found to be safe, as this did not affect lung function, coughing, intra-abdominal pressure, or wound healing. The immediate decline in lung function after surgery is restrictive and due to anesthesia and the surgical procedure. Pain was significantly decreased in the girdle group. The study is registered at ClinicalTrials.gov, number NCT01517217.

  • 11.
    Clay, Leonard
    et al.
    Department of Clinical Science, Intervention and Technique, Division of Surgery, Karolinska Institutet, 171 86 Stockholm, Sweden.
    Franneby, Ulf
    Department of Clinical Research and Education, Division of Surgery, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden.
    Sandblom, Gabriel
    Department of Clinical Science, Intervention and Technique, Division of Surgery, Karolinska Institutet, 171 86 Stockholm, Sweden.
    Gunnarsson, Ulf
    Department of Clinical Science, Intervention and Technique, Division of Surgery, Karolinska Institutet, 171 86 Stockholm, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Validation of a questionnaire for the assessment of pain following ventral hernia repair-the VHPQ2012In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 397, no 8, 1219-1224 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia. The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4 weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3 years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people. For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p < 0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1 week postoperative (p < 0.05). Kappa levels for test-retest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p < 0.05) in the test-retest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p < 0.05) and more interference with daily activities (p < 0.05) than a non-operated group from the general population. The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.

  • 12.
    Dahlstrand, Ursula
    et al.
    CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Surgical Sciences, Uppsala University, Uppsala, Sweden and Department of Surgical Gastroenterology K53, Karolinska University Hospital, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Ljungdahl, Mikael
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Wollert, Staffan
    Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    CLINTEC, Karolinska Institutet, Stockholm, Sweden .
    TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 10, 3632-3638 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain.

    METHODS: Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)].

    RESULTS: A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups.

    CONCLUSIONS: Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

  • 13. Dahlstrand, Ursula
    et al.
    Sandblom, Gabriel
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wollert, Staffan
    Gunnarsson, Ulf
    CLINTEC, Karolinska Institute, Stockholm, Sweden and Gastro Center Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Chronic pain after femoral hernia repair: a cross-sectional study2011In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 254, no 6, 1017-1021 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To explore the prevalence of and to identify possible risk factors for chronic pain after surgery for femoral hernia.

    Background: Chronic pain has become a very important outcome in quality assessment of inguinal hernia surgery. There are no studies on the risk for chronic pain after femoral hernia surgery. Methods: The Inguinal Pain Questionnaire was sent to 1967 patients who had had a repair for primary unilateral femoral hernia between January 1, 1997 and December 31, 2006. A follow-up period of at least 18 months was chosen. Answers from 1461 patients were matched with data recorded in the Swedish Hernia Register and analyzed.

    Results: Some degree of pain during the previous week was reported by 24.2% (354) of patients. Pain interfered with daily activities in 5.5% (81) of patients. Emergency surgery (OR = 0.54; 95% CI = 0.40-0.74) and longer time since surgery (OR = 0.93; 95% CI = 0.89-0.98 for each year added) were associated with lower risk for chronic postoperative pain, whereas a high level of preoperative pain was associated with a higher risk for chronic pain (OR = 1.17; 95% CI = 1.10-1.25). Surgical technique was not found to influence the risk for chronic pain in multivariate logistic regression analysis.

    Conclusions: Chronic postoperative pain is as important a complication after femoral hernia surgery as it is after inguinal hernia surgery. In contrast to inguinal hernia surgery, no risk factor related to surgical technique was found. Further investigations into the role of preoperative pain are necessary.

  • 14.
    Dahlstrand, Ursula
    et al.
    Department of Surgical Science, Uppsala University, Uppsala, Sweden ; CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Sandblom, Gabriel
    CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Wollert, Staffan
    Department of Surgical Science, Uppsala University, Uppsala, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. CLINTEC, Karolinska Institutet, Stockholm, Sweden ; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    Limited potential for prevention of emergency surgery for femoral hernia2014In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 38, no 8, 1931-1936 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population.

    OBJECTIVE: The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery.

    METHODS: A total of 1,967 individuals operated on for a femoral hernia over 1997-2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register.

    RESULTS: A total of 1,441 (73.3%) patients responded. Awareness of their hernia prior to surgery was denied by 53.3% (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3% (135/432) negated symptoms in the affected groin prior to surgery and 22.2% (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001).

    CONCLUSIONS: Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.

  • 15.
    Dahlstrand, Ursula
    et al.
    Department of Surgery, Uppsala University, Uppsala University Hospital, 75185 Uppsala, Sweden.
    Wollert, Staffan
    Department of Surgery, Uppsala University, Uppsala, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, Gabriel
    Division of Surgery, CLINTEC, Karolinska University Hospital Huddinge and Karolinska Institute, Stockholm, Sweden.
    Gunnarsson, Ulf
    Division of Surgery, CLINTEC, Karolinska University Hospital Huddinge and Karolinska Institute, Stockholm, Sweden.
    Emergency femoral hernia repair: a study based on a national register.2009In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 249, no 4, 672-676 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the characteristics of femoral hernias and outcome of femoral repairs, with special emphasis on emergency operations. BACKGROUND: Femoral hernias account for 2% to 4% of all groin hernias. However, the lack of large-scale studies has made it impossible to draw conclusions regarding the best management of these hernias. METHODS: The study is based on patients 15 years or older who underwent groin hernia repair 1992 to 2006 at units participating in the Swedish Hernia Register. RESULTS: Three thousand nine hundred eighty femoral hernia repairs were registered, 1490 on men and 2490 on women: 1430 (35.9%) patients underwent emergency surgery compared with 4.9% of the 138,309 patients with inguinal hernias. Bowel resection was performed in 22.7% (325) of emergent femoral repairs and 5.4% (363) of emergent inguinal repairs. Women had a substantial over risk for undergoing emergency femoral surgery compared with men (40.6% vs. 28.1%). An emergency femoral hernia operation was associated with a 10-fold increased mortality risk, whereas the risk for an elective repair did not exceed that of the general population. In elective femoral hernias, laparoscopic (hazard ratio, 0.31; 95% confidence interval, 0.15-0.67) and open preperitoneal mesh (hazard ratio, 0.28; confidence interval, 0.12-0.65) techniques resulted in fewer re-operations than suture repairs. CONCLUSIONS: Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

  • 16.
    Dominguez, Cecilia A
    et al.
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Kalliomäki, Maija
    Department of Surgical Sciences, Anaesthesiology/Pain research, Uppsala University, Uppsala, Sweden; Department of Anaesthesiology, University of Tammerfors, Tampere, Finland.
    Gunnarsson, Ulf
    Department of Clinical Science, Intervention and Technology (Surgery), Karolinska Institutet, Huddinge, Sweden.
    Moen, Aurora
    National Institute of Occupational Health, Oslo, Norway; Department of Molecular Biosciences, University of Oslo, Norway.
    Sandblom, Gabriel
    Department of Clinical Science, Intervention and Technology (Surgery), Karolinska Institutet, Huddinge, Sweden.
    Kockum, Ingrid
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Lavant, Ewa
    Department of Biomedical Laboratory Science, Faculty of Health and Society, Malmö University/Labmedicine Skåne, Clinical Chemistry, Malmö, Sweden.
    Olsson, Tomas
    Nyberg, Fred
    Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
    Rygh, Lars Jørgen
    Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway.
    Røe, Cecilie
    Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ullevaal, Norway.
    Gjerstad, Johannes
    National Institute of Occupational Health, Oslo, Norway; Department of Molecular Biosciences, University of Oslo, Norway.
    Gordh, Torsten
    Department of Surgical Sciences, Anaesthesiology/Pain research, Uppsala University, Uppsala, Sweden.
    Piehl, Fredrik
    Neuroimmunology Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    The DQB1*03:02 HLA haplotype is associated with increased risk of chronic pain after inguinal hernia surgery and lumbar disc herniation2013In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 154, no 3, 427-433 p.Article in journal (Refereed)
    Abstract [en]

    Neuropathic pain conditions are common after nerve injuries and are suggested to be regulated in part by genetic factors. We have previously demonstrated a strong genetic influence of the rat major histocompatibility complex on development of neuropathic pain behavior after peripheral nerve injury. In order to study if the corresponding human leukocyte antigen complex (HLA) also influences susceptibility to pain, we performed an association study in patients that had undergone surgery for inguinal hernia (n=189). One group had developed a chronic pain state following the surgical procedure, while the control group had undergone the same type of operation, without any persistent pain. HLA DRB1genotyping revealed a significantly increased proportion of patients in the pain group carrying DRB1*04 compared to patients in the pain-free group. Additional typing of the DQB1 gene further strengthened the association; carriers of the DQB1*03:02 allele together with DRB1*04 displayed an increased risk of postsurgery pain with an odds risk of 3.16 (1.61-6.22) compared to noncarriers. This finding was subsequently replicated in the clinical material of patients with lumbar disc herniation (n=258), where carriers of the DQB1*03:02 allele displayed a slower recovery and increased pain. In conclusion, we here for the first time demonstrate that there is an HLA-dependent risk of developing pain after surgery or lumbar disc herniation; mediated by the DRB1*04 - DQB1*03:02 haplotype. Further experimental and clinical studies are needed to fine-map the HLA effect and to address underlying mechanisms.

  • 17. 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, 696-702 p.Article 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.

  • 18.
    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, 433-441 p.Article 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.

  • 19.
    Emanuelsson, Peter
    et al.
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, 117 76, Stockholm, Sweden .
    Dahlstrand, Ursula
    Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Strömsten, U
    Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden .
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm.
    Stark, Birgit
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden .
    Analysis of the abdominal musculo-aponeurotic anatomy in rectus diastasis: comparison of CT scanning and preoperative clinical assessment with direct measurement intraoperatively2014In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 18, no 4, 465-471 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate and compare the consistency of agreement of two methods for measuring abdominal rectus diastasis (ARD), preoperative computed tomography (CT) scanning and preoperative clinical assessment were compared with direct measurement intraoperatively.

    METHODS: Fifty-five consecutive patients were retrieved from an ongoing prospective randomised trial comparing two operative techniques for the repair of ARD. All patients underwent a preoperative clinical assessment and CT scan, and the results were compared with intraoperative measurement of the ARD width. Agreement between methods was described with Bland-Altman plots (BA plots) and calculated using Lin's Concordance Correlation Coefficient (CCC).

    RESULTS: The median width of the diastasis was 4.0 cm in the upper midline and 3.0 cm in the lower midline for the intraoperative measurement. BA plots showed that measurements on CT and intraoperatively are not in agreement in the lower midline, whereas the agreement was stronger between the clinical and the intraoperative method. The CCC was higher for clinical vs. intraoperative measurement (0.479) than for CT vs. intraoperative measurement (-0.002) in the lower midline, although the agreement was over all low. CT scanning underestimated the width of the ARD when compared to 87 % of preoperative clinical assessments, and 83 % of intraoperative measurements. Preoperative clinical assessment overestimated ARD in 35 % when compared with intraoperative measurements.

    CONCLUSION: Clinical assessment prior to surgery provides more accurate information than CT scanning in the assessment of ARD width. CT scanning underestimates ARD width when compared with intraoperative measurement.

  • 20.
    Emanuelsson, Peter
    et al.
    Department for Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Department for Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up.2014In: Journal of plastic, reconstructive & aesthetic surgery : JPRAS, ISSN 1878-0539, Vol. 67, no 8, 1082-1088 p.Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study was to evaluate early complications following retromuscular mesh repair with those after dual layer suture of the anterior rectus sheath in a randomised controlled clinical trial for abdominal rectus muscle diastasis (ARD).

    METHODS: Patients with an ARD wider than 3 cm and clinical symptoms related to the ARD were included in a prospective randomised study. They were assigned to either retromuscular inset of a lightweight polypropylene mesh or to dual closure of the anterior rectus fascia using Quill self-locking technology. All patients completed a validated questionnaire for pain assessment (Ventral Hernia Pain Questionnaire, VHPQ) and for quality of life (SF36) prior to and 3 months after surgery.

    RESULTS: The most frequently seen adverse event was minor wound infection. Of the patients, 14/57 had a superficial wound infection; five related to Quill and nine to mesh repair. No deep wound infections were reported. Patient rating for subjective muscular improvement postoperatively was better in the mesh technique group with a mean of 6.9 (range 0-10) compared to a mean of 4.8 (range 0-10) in the Quill group (p=0.01). The pre- and post-operative SF36 scores improved in both groups.

    CONCLUSIONS: There was no significant difference between the two surgical techniques in terms of early complications and perceived pain at the 3-month follow-up. Both techniques may be considered equally reliable for ARD repair in terms of adverse outcomes during the early postoperative phase, even though patients operated with a mesh experienced better improvement in muscular strength.

  • 21.
    Eriksson, S
    et al.
    Department of Physiology, Karolinska Institute, Stockholm, Sweden.
    Andersson, B
    Gunnarsson, Ulf
    Department of Physiology, Karolinska Institute, Stockholm, Sweden.
    Rundgren, M
    Hypertension and thirst outlasting renal vasoconstriction as effects of a brief evaluation of systemic angiotensin II in sheep.1994In: Acta Physiologica Scandinavica, ISSN 0001-6772, E-ISSN 1365-201X, Vol. 150, no 2, 181-8 p.Article in journal (Refereed)
    Abstract [en]

    The influence of 10 min intracarotid (i.c.) and intravenous (i.v.) infusions of angiotensin II (Ang II; 20 pmol kg-1 min-1) on carotid blood pressure (cBP) and renal blood flow (RBF) was studied in unanaesthetized ewes without and with pre-treatment with the alpha 1- and beta-adrenoceptor blocker labetalol. RBF was also monitored during 30 min intracerebroventricular (ICV) infusions of Ang II at 2 pmol kg-1 min-1. The i.c. infusions of Ang II induced about 50 mmHg rise in cBP. A steep decline occurred during 5 min post-infusion, followed by a much slower reduction with the cBP remaining above control level at 40 min post-infusion. The pressure elevation induced by i.v. Ang II was less pronounced but exhibited a similar pattern. Labetalol significantly reduced the pressor response to i.c. as well as i.v. Ang II. The i.c. and i.v. infusions of Ang II conspicuously reduced the RBF regardless of whether the ewes were labetalol-treated or not. At 5 min after the infusions RBF had returned to control level. The ICV infusions did not influence the RBF. Ang II i.c. elicited thirst in 50% of the ewes with the urge to drink remaining at 40 min post-infusion. The dipsogenic response was not reduced by labetalol pretreatment. The results imply that no cerebral component contributes to the reduction in RBF induced by systemic Ang II. However, a centrally mediated action seems to be the cause of the long-lasting post-infusion cBP elevation and dipsogenic response.(ABSTRACT TRUNCATED AT 250 WORDS)

  • 22.
    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, 275-9 p.Article 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.

  • 23.
    Folkesson, Joakim
    et al.
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Birgisson, Helgi
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Pahlman, Lars
    Department of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Cedermark, Bjorn
    Glimelius, Bengt
    Gunnarsson, Ulf
    Departments of Surgical Sciences and Oncology, Radiology, and Clinical Immunology, Uppsala University Hospital, Uppsala, Sweden.
    Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate2005In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 23, no 24, 5644-5650 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate the long-term effects on survival and recurrence rates of preoperative radiotherapy in the treatment of curatively operated rectal cancer patients.

    PATIENTS AND METHODS: Of 1,168 randomly assigned patients in the Swedish Rectal Cancer Trial between 1987 and 1990, 908 had curative surgery; 454 of these patients had surgery alone, and 454 were administered preoperative radiotherapy (25 Gy in 5 days) followed by surgery within 1 week. Follow-up was performed by matching against three Swedish nationwide registries (the Swedish Cancer Register, the Hospital Discharge Register, and the Cause of Death Register).

    RESULTS: Median follow-up time was 13 years (range, 3 to 15 years). The overall survival rate in the irradiated group was 38% v 30% in the nonirradiated group (P = .008). The cancer-specific survival rate in the irradiated group was 72% v 62% in the nonirradiated group (P = .03), and the local recurrence rate was 9% v 26% (P < .001), respectively. The reduction of local recurrence rates was observed at all tumor heights, although it was not statistically significant for tumors greater than 10 cm from the anal verge.

    CONCLUSION: Preoperative radiotherapy with 25 Gy in 1 week before curative surgery for rectal cancer is beneficial for overall and cancer-specific survival and local recurrence rates after long-term follow-up.

  • 24.
    Folkesson, Joakim
    et al.
    Department of Surgery, Uppsala University Hospital, 751 85, Uppsala, Sweden .
    Brown, Steven S R
    Sheffield Teaching Hospitals, Sheffield, UK .
    Gunnarsson, Ulf
    Centre of Surgical Gastroenterology, Karolinska University Hospital, Huddinge and Karolinska Institute, Stockholm, Sweden.
    Påhlman, Lars
    Department of Surgery, Uppsala University Hospital, 751 85, Uppsala, Sweden .
    Randomised multicentre trial of circular stapling devices2012In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 27, no 2, 227-232 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: In a register study, the risk of anastomotic leakage correlated to the choice of circular stapling device with a 4% difference between the two brands used. Based on those data, a randomised multicentre study was started to explore the risk of an anastomotic leakage based upon the surgical device.

    METHODS: Patients above 18 years with a rectal cancer, able to give informed consent, and scheduled for an anterior resection were eligible for the study. Perioperative randomisation was to Ethicon™ PROXIMATE™ ILS™ or Autosuture™ Premium Plus CEEA™. Anastomotic leakage was defined as a clinically manifest leak.

    RESULTS: Five hundred twenty-nine patients were randomised (58% male). A leak occurred in 8.3%. The anastomoses created by PROXIMATE™ ILS™ leaked in 25/265 (9.4%) anastomoses, and the Premium Plus CEEA™ leaked in 19/260 (7.3%), p = .419.

    CONCLUSION: No difference in the leak rate could be revealed. Several centres replaced one of the staplers by a new product, and the study was ended before the stipulated number of patients was reached. In the future, surgical devices may have to prove superiority in randomised trials or be monitored in quality registers before they can be introduced into day to day surgical practice. The study was registered at ClinicalTrials.gov: NCT00399009.

  • 25.
    Folkesson, Joakim
    et al.
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Påhlman, Lars
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Gunnarsson, Ulf
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Population-based study of local surgery for rectal cancer2007In: The British journal of surgery, ISSN 1365-2168, Vol. 94, no 11, 1421-1426 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to determine long-term survival and recurrence rates after local excision of rectal cancer from a prospectively registered population-based database. METHODS: Swedish Rectal Cancer Registry data from 1995 to 2001, including 10 181 patients of whom 643 (6.3 per cent) had a local excision, were analysed. Complete 5-year follow-up data from 1995 to 1998 were available. Cumulative relative and cancer-specific survival rates, and rates of local recurrence and distant metastases, were calculated by actuarial methods. RESULTS: The 5-year cancer-specific survival rate for 256 patients with stage I disease who had local excision was 95.3 (95 per cent confidence interval 91.5 to 99.1) per cent. The 5-year local recurrence rate was 7.2 per cent. After adjustment for age, sex, tumour stage and preoperative radiotherapy, the relative risk of death from cancer was the same as that after major resection. CONCLUSION: Population-based results after local excision of rectal cancer are the same as those reported in controlled series for early-stage tumours after abdominal resection. A low relative survival and a high median age indicate the use of local excision in patients with a high level of co-morbidity. To achieve acceptable long-term results, optimal preoperative and postoperative staging is needed.

  • 26.
    Fränneby, Ulf
    et al.
    Department of Surgery, Sodersjukhuset, Stockholm, Sweden.
    Gunnarsson, Ulf
    Department of Surgery, Akademiska Sjukhuser, Uppsala, Sweden.
    Andersson, M
    Department of Surgery, Mora District Hospital, Mora, Sweden.
    Heuman, R
    Department of Surgery, Mora District Hospital, Mora, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nyrén, Olof
    Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.
    Sandblom, Gabriel
    Department of Surgery, University Hospital of Lund, Lund, Sweden.
    Validation of an Inguinal Pain Questionnaire for assessment of chronic pain after groin hernia repair.2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 4, 488-493 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Long-term pain is an important outcome after inguinal hernia repair. The aim of this study was to test the validity and reliability of a specific Inguinal Pain Questionnaire (IPQ). METHODS: The study recruited patients aged between 15 and 85 years who had undergone primary inguinal or femoral hernia repair. To test the validity of the questionnaire, 100 patients received the IPQ and the Brief Pain Inventory (BPI) 1 and 4 weeks after surgery (group 1). To test reliability and internal consistency, 100 patients received the IPQ on two occasions 1 month apart, 3 years after surgery (group 2). Non-surgery-related pain was analysed in group 3 (2853 patients). RESULTS: A significant decrease in IPQ-rated pain intensity was observed in the first 4 weeks after surgery (P < 0.001). Significant correlations with corresponding BPI pain intensity items corroborated the criterion validity (P < 0.050). Logical incoherence did not exceed 5.5 per cent for any item. Values for kappa in the test-retest in group 2 were higher than 0.5 for all but three items. Cronbach's alpha was 0.83 for questions on pain intensity and 0.74 for interference with daily activities. CONCLUSION: This study found good validity and reliability for the IPQ, making it a useful instrument for assessing pain following groin hernia repair.

  • 27.
    Fränneby, Ulf
    et al.
    Dept of Surgery, Sodersjukhuset, Stockholm, Sweden.
    Gunnarsson, Ulf
    The Department of Surgical Sciences, Akademiska sjukhuset, Colorectal Unit, Uppsala University, SE 751 85, Uppsala, Sweden.
    Wollert, S
    Sandblom, G
    Discordance between the patient's and surgeon's perception of complications following hernia surgery.2005In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 9, no 2, 145-9 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The study was undertaken in order to assess the degree of concordance between the patient's and surgeon's perceptions of adverse events after groin hernia surgery.

    METHODS: 206 patients who underwent elective surgery for groin hernia at Samariterhemmet, Uppsala, Sweden in 2003 were invited to a follow-up visit after 3-6 weeks. At this visit the patient was instructed to answer a questionnaire including 12 questions concerning postoperative complications. A postoperative history was taken and a clinical examination performed by a surgeon who was not present at the operation and did not know the outcome of the questionnaire. All complications noted by the physician were recorded for corresponding questions in the questionnaire.

    RESULTS: 174 (84.5%) patients attended the follow up, 161 men and 13 women. A total of 190 complications were revealed by the questionnaire, 32 of which had caused the patient to seek help from the health-care system. There were 131 complications registered as a result of the follow-up clinical examinations and history. Kappa levels ranged from 0.11 for urinary complications to 0.56 for constipation.

    CONCLUSION: In general, the concordance was poor. These results emphasise the importance of providing detailed information about the usual postoperative course prior to the operation. Whereas the surgeon, from a professional point of view, has a better idea about what should be expected in the postoperative period and how any complications should be categorised, only the patient has a complete picture of the symptoms and adverse events. This makes it impossible to reach complete agreement between the patient's and surgeon's perceptions of complications, even under the most ideal circumstances.

  • 28.
    Fränneby, Ulf
    et al.
    Department of Surgery, Södersjukhuset, Stockholm.
    Sandblom, Gabriel
    Department of Surgery, Akademiska Sjukhuset, Uppsala.
    Nordin, Pär
    Department of Surgery, östersunds Sjukhus, östersund.
    Nyrén, Olof
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm.
    Gunnarsson, Ulf
    Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden.
    Risk factors for long-term pain after hernia surgery2006In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 244, no 2, 212-219 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To estimate the prevalence of residual pain 2 to 3 years after hernia surgery, to identify factors associated with its occurrence, and to assess the consequences for the patient.

    SUMMARY BACKGROUND DATA: Iatrogenic chronic pain is a neglected problem that may totally annul the benefits from hernia repair.

    METHODS: From the population-based Swedish Hernia Register 3000 patients aged 15 to 85 years were sampled from the 9280 patients registered as having undergone a primary groin hernia operation in the year 2000. Of these, the 2853 patients still alive in 2003 were requested to fill in a postal questionnaire.

    RESULTS: After 2 reminders, 2456 patients (86%), 2299 men and 157 women responded. In response to a question about "worst perceived pain last week," 758 patients (31%) reported pain to some extent. In 144 cases (6%), the pain interfered with daily activities. Age below median, a high level of pain before the operation, and occurrence of any postoperative complication were found to significantly and independently predict long-term pain in multivariate logistic analysis when "worst pain last week" was used as outcome variable. The same variables, along with a repair technique using anterior approach, were found to predict long-term pain with "pain right now" as outcome variable.

    CONCLUSION: Pain that is at least partly disabling appears to occur more often than recurrences. The prevalence of long-term pain can be reduced by preventing postoperative complications. The impact of repair technique on the risk of long-term pain shown in our study should be further assessed in randomized controlled trials.

  • 29.
    Fränneby, Ulf
    et al.
    Department of Surgery, Södersjukhuset, Stockholm, Sweden.
    Sandblom, Gabriel
    Lund University Hospital, Lund, Sweden.
    Nyrén, Olof
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Akademiska Sjukhuset, Uppsala, Sweden.
    Self-reported adverse events after groin hernia repair, a study based on a national register.2008In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 11, no 5, 927-932 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In most clinics, follow-up after inguinal hernia surgery is not a routine procedure and complications may pass unnoticed, thus impairing quality assessment. The aim of this study was to investigate the frequency, spectrum, and risk factors of short-term adverse events after groin hernia repair. METHODS: All patients aged 15 years or older with a primary unilateral inguinal or femoral hernia repair recorded in the Swedish Hernia Register (SHR) between November 1 and December 31, 2002 were sent a questionnaire asking about complications within the first 30 postoperative days. RESULTS: Of the 1643 recorded patients, 1448 (88.1%) responded: 1341 (92.6%) were men and 107 (7.4%) women, mean age 59 years. There were 195 (11.9%) nonresponders. Postoperative complications reported in the questionnaire were hematoma in 203 (14.0%) patients, severe pain in 168 (11.6%), testicular pain in 120 (8.3%), and infection in 105 (7.3%). Adverse events were reported in the questionnaire by 391 (23.8%) patients, whereas only 85 (5.2%) were affected according to the SHR. Risk factors for postoperative complications were age below the median (59 years) among the studied hernia patients (OR 1.36; 95% CI 1.06-1.74) and laparoscopic repair (OR 2.66; 95% CI 1.17-6.05). CONCLUSION: Questionnaires provide valuable additional information concerning postoperative complications. We recommend that they become an integrated part of routine postoperative assessment.

  • 30.
    Gunnarsson, Ulf
    Department of Physiology, Karolinska Institute, Stockholm, Sweden.
    Intracerebroventricular ANP(1-28) has no obvious effects on renal blood flow and function in conscious sheep.1994In: Clinical and experimental pharmacology & physiology, ISSN 0305-1870, E-ISSN 1440-1681, Vol. 21, no 3, 189-94 p.Article in journal (Refereed)
    Abstract [en]

    1. The study examines whether intracerebroventricular (ICV) infusion of atrial natriuretic peptide (human ANP,1-28) influences renal electrolyte and water excretion, vasopressin release, renal and femoral blood flows in conscious ewes. The blood flow was measured by chronically implanted ultrasonic flow probes. 2. ICV infusion of ANP(1-28) at 25 pmol/min for 60 min did not affect renal Na and K excretion or plasma vasopressin levels. In two out of six animals a mild water diuresis developed at about 50 min post-infusion. 3. The plasma osmolality, Na, K and protein concentrations did not change during the experiments. 4. The renal and femoral arterial blood flows were not influenced by 30 min ICV infusions of ANP(1-28) at 25 and 85 pmol/min. 5. It is concluded that human ANP(1-28) has no, or negligible, effects on renal function, femoral and renal blood flow when given ICV in amounts obviously elevating cerebrospinal fluid levels far above normal.

  • 31.
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Quality assurance in surgical oncology: Colorectal cancer as an example2003In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 29, no 1, 89-94 p.Article in journal (Refereed)
    Abstract [en]

    Quality assurance in surgical oncology is a field of growing importance. National, regional and local systems have been built up in many countries. Often the quality assurance projects are linked to different registers. The advantage of such a link is the possibility of obtaining population-based data from unselected health care institutions. Few discussions of results from such projects have been published. Quality assurance of colorectal cancer surgery implies the development and use of systems for improvement all the way from detection of the cancer to the outcome as survival and patient satisfaction. To achieve this we must know what methods are being used and the outcome of our treatments. Designing processes for improvement necessitates careful planning, including decisions about end-points. Some crucial issues are discussed step-by-step in the present paper. In addition to auditing and providing collegial feedback, quality assurance is a tool for closing the gap between clinical practice and evidence based medicine and for creating new evidences as well as monitoring the introduction of new techniques and their effects.

  • 32.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Mora Hospital, Sweden.
    Degerman, M
    Davidsson, A
    Heuman, R
    Is elective hernia repair worthwhile in old patients?1999In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 165, no 4, 326-32 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To find out if elective herniorraphy in patients aged 75 and over is worthwhile.

    DESIGN: Retrospective study.

    SETTING: District hospital, Sweden.

    SUBJECTS: 146 consecutive patients aged 75 years or more, who had their hernias repaired during the period 1992-95.

    MAIN OUTCOME MEASURES: Patient satisfaction measured by a five-point analogue scale. Clinical and personal details, morbidity, mortality, and surgical variables were obtained from case records.

    RESULTS: Community social service was not required by 114 (78%) of the patients and 15 (22%) had no preoperative complaints. Our patients rated their satisfaction with their choice to have an operation, as well as its effect on their preoperative symptoms as 4.9. Emergency operations (p = 0.02), femoral hernias (p = 0.01) and direct inguinal hernias (direct:indirect ratio 0.81) were more common in this age group. Femoral and direct inguinal hernias tended to recur more often than usual. Emergency operation, dementia, and diabetes were associated with a reduced short-term survival.

    CONCLUSION: Elective hernia repair in an elderly population is highly appreciated by the patients, and worthwhile. If coexisting disease and domestic arrangements are controlled, the patients' need for hospital care can be minimised. Mesh is recommended in femoral and direct inguinal hernias, which were associated with an increased reoperation frequency. A more vigilant protocol of indications for hernia surgery in the aged may minimise the need for both emergency and unnecessary operations.

  • 33.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Mora Hospital, Mora, Sweden .
    Heuman, R
    Patient experience ratings in surgery for recurrent hernia1999In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 3, no 2, 69-73 p.Article in journal (Refereed)
  • 34.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Heuman, R
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Wendel-Hansen, V
    Department of Surgery, Mora Hospital, S- 792 85 Mora, Sweden.
    Patient evaluation of routines in ambulatory hernia surgery1996In: Ambulatory Surgery, ISSN 0966-6532, E-ISSN 1873-2097, Vol. 4, no 1, 11-13 p.Article in journal (Refereed)
  • 35.
    Gunnarsson, Ulf
    et al.
    Kirurgiska kliniken, Mora lasarett.
    Heuman, Rolf
    Wendel-Hansen, Vidar
    Ljumskbråckskirurgi i öppen vård. Positiv patientupplevelse med förenklade rutiner.1997In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 94, no 14, 1292-1296 p.Article in journal (Other academic)
  • 36.
    Gunnarsson, Ulf
    et al.
    Department of Physiology and Pharmacology, Karolinska Institute, Stockholm.
    Hjelmqvist, H
    Rundgren, M
    Centrally mediated influences of hypertonic NaCl and angiotensin II on regional blood flow and hemodynamic responses to hypotensive hemorrhage in conscious sheep.1994In: Shock, ISSN 1073-2322, E-ISSN 1540-0514, Vol. 2, no 1, 60-7 p.Article in journal (Refereed)
    Abstract [en]

    The influence of separate and combined intracerebroventricular (ICV) infusions of hypertonic (.5 M) NaCl (HTNa) at .02 mL min-1 and angiotensin II (ANG II) at 1 pmol kg-1 min-1 on tolerance to hemorrhage, accompanying systemic hemodynamic changes, and regional blood flow was studied in adult conscious sheep. Corresponding measurements during ICV .9% NaCl served as controls. The hemorrhage volume needed to lower the blood pressure to about 50 mmHg was significantly larger during treatment with HTNa and HTNa/ANG II (27.8 +/- 2.2 and 28.3 +/- 2.5 mL kg-1, respectively; p < .001; about 45% of estimated blood volume) as well as during ANG II (20.1 +/- 1.3 mL kg-1; p < .01) compared to controls (15.1 +/- .7 mL kg-1; about 25% of estimated blood volume). In spite of a larger hemorrhage volume, the lowering of the cardiac output was not accentuated, and its subsequent recovery was not impaired during ICV infusion of HTNa or HTNa/ANG II. Similarly, the posthemorrhage restoration of the systemic blood pressure was not negatively affected by the more pronounced hypovolemia induced during the ICV treatments compared to controls. In contrast to ANG II, HTNa infusion, alone or in combination with ANG II, was accompanied by a significantly lower renal blood flow, and a higher renovascular resistance, during the posthemorrhage period. The femoral blood flow was maintained or even slightly elevated after hemorrhage in all experiments. The integrated results of the study imply differentiated hemodynamic effects of centrally administered HTNa and ANG II.(ABSTRACT TRUNCATED AT 250 WORDS)

  • 37.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Gastrocentrum K53, 141 86, Huddinge, Stockholm, Sweden .
    Johansson, M
    Department of Physiotherapy, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden .
    Strigård, Karin
    Department of Surgery, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Assessment of abdominal muscle function using the Biodex System-4. Validity and reliability in healthy volunteers and patients with giant ventral hernia2011In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 4, 417-421 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The decrease in recurrence rates in ventral hernia surgery have led to a redirection of focus towards other important patient-related endpoints. One such endpoint is abdominal wall function. The aim of the present study was to evaluate the reliability and external validity of abdominal wall strength measurement using the Biodex System-4 with a back abdomen unit.

    MATERIAL AND METHOD: Ten healthy volunteers and ten patients with ventral hernias exceeding 10 cm were recruited. Test-retest reliability, both with and without girdle, was evaluated by comparison of measurements at two test occasions 1 week apart. Reliability was calculated by the interclass correlation coefficients (ICC) method. Validity was evaluated by correlation with the well-established International Physical Activity Questionnaire (IPAQ) and a self-assessment of abdominal wall strength.

    RESULTS: One person in the healthy group was excluded after the first test due to neck problems following minor trauma. The reliability was excellent (>0.75), with ICC values between 0.92 and 0.97 for the different modalities tested. No differences were seen between testing with and without a girdle. Validity was also excellent both when calculated as correlation to self-assessment of abdominal wall strength, and to IPAQ, giving Kendall tau values of 0.51 and 0.47, respectively, and corresponding P values of 0.002 and 0.004.

    CONCLUSION: Measurement of abdominal muscle function using the Biodex System-4 is a reliable and valid method to assess this important patient-related endpoint. Further investigations will be made to explore the potential of this technique in the evaluation of the results of ventral hernia surgery, and to compare muscle function after different abdominal wall reconstruction techniques.

  • 38.
    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, 23-7 p.Article 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.

  • 39.
    Gunnarsson, Ulf
    et al.
    Department of Surgery, Uppsala Academic Hospital, Uppsala, Sweden.
    Lewenhaupt, Arvid
    Heuman, Rolf
    Ureteral wound caused by blunt abdominal trauma.2003In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 37, no 1, 88-89 p.Article in journal (Refereed)
    Abstract [en]

    A man fell on icy ground whilst walking to an outdoor toilet. An initial CT scan with intravenous contrast medium was negative. As the man experienced increasing pain a plain abdominal radiograph was performed 2 h later and revealed extravasation of contrast medium emanating from a ureteral injury. This case underlines the possibility that important injuries may not be visible on the initial CT scan that is often used in trauma diagnostics.

  • 40.
    Gunnarsson, Ulf
    et al.
    Department of Physiology, Karolinska Institute, Stockholm, Sweden.
    Rundgren, M
    Inefficiency of intracerebroventricular ANP to alter haemodynamic, plasma vasopressin and renin responses to haemorrhage in sheep.1994In: Acta Physiologica Scandinavica, ISSN 0001-6772, E-ISSN 1365-201X, Vol. 150, no 4, 441-7 p.Article in journal (Refereed)
    Abstract [en]

    Whether intracerebroventricular (i.c.v.) infusion of atrial natriuretic peptide (human-ANP, 1-28) 25 pmol min-1 influences the tolerance to blood loss and haemorrhage induced cardiovascular, vasopressin and renin responses were studied in five conscious sheep. The i.c.v. infusion was started 60 min prior to a slow (0.7 ml kg-1 min-1) venous haemorrhage, was run concurrently with bleeding, and for 90 min thereafter. Venous blood was removed until the mean systemic arterial pressure suddenly fell to about 50 mmHg. There were no statistically significant differences in either the bleeding volume necessary to induce the sudden decrease in blood pressure, or in cardiovascular parameters measured by venous heart thermodilution catheterization, compared with control experiments with i.c.v. infusion of artificial CSF. The plasma protein and vasopressin concentrations and renin activity were unaffected by the i.c.v. infusion of ANP as were the changes in these parameters occurring during the subsequent haemorrhage. The same negative findings were obtained with a three times higher dose of ANP(1-28) (75 pmol min-1), tested in three of the animals. Thus the i.c.v. infusion of ANP(1-28), in amounts expected to elevate the CSF concentration far above basal levels does apparently not influence normal blood pressure regulation or alter haemodynamic, vasopressin and renin responses to haemorrhage in conscious sheep.

  • 41.
    Gunnarsson, Ulf
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Seligsohn, E
    Jestin, P
    Påhlman, L
    Registration and validity of surgical complications in colorectal cancer surgery.2003In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 90, no 4, 454-9 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Population-based quality registers have become an important tool in quality assessment during the past decade. For registers to be reliable, however, data must be checked carefully for validity.

    METHODS: The present study describes the validity of surgical complications registered in a national register run by the National Board of Health and Welfare (NBH), a register run by Regional Oncological Centres (ROC) and, for comparison, a local quality assurance system at Uppsala University Hospital (UUH). A specialized, independent surgeon checked 10 per cent of patient records against datasheets from the registers.

    RESULTS: The local quality assurance system at UUH showed the best validity for surgical complications. Data for complications of colonic cancer surgery were more valid than those for rectal cancer surgery. Registration of serious complications was more valid than that of wound infections. The calculated proportion of missed surgical complications was 0.69, 0.64, 0.40, 0.22 and 0.07 for rectal and colonic cancer in the NBH register, rectal and colonic cancer in the ROC register, and the UUH register respectively. Corresponding figures for reoperation were 0.45, 0.48, 0.04, 0.09 and 0.21.

    CONCLUSION: Local interest and routine use of data for quality assurance are crucial factors for valid registers. Careful monitoring of validity is necessary for use of registry data in structured systems for improvement of surgical results.

  • 42.
    Gunnarsson, Ulf
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stark, Birgit
    Stockholm, Sweden.
    Dahlstrand, Ursula
    Stockholm, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Correlation between Abdominal Rectus Diastasis Width and Abdominal Muscle Strength2015In: Digestive Surgery, ISSN 0253-4886, E-ISSN 1421-9883, Vol. 32, no 2, 112-116 p.Article in journal (Refereed)
    Abstract [en]

    Background: Surgery for Abdominal Rectus Diastasis (ARD) is a controversial topic and some argue that it is solely an aesthetic problem. Many symptoms in these patients are indefinite, and no objective criteria have been established, indicating which patients are likely to benefit from surgery. This study investigated the correlation between preoperative assessment and intraoperative measurement of ARD width, and objective measurements of muscle strength. Methods: 57 patients undergoing surgery for ARD underwent preoperative assessment of ARD width by clinical measurement and CT scan, and thereafter intraoperative measurement. Abdominal muscle strength was investigated using the Biodex System 4 including flexion, extension and isometric measurements. Correlations were calculated by the Spearman test. Results: Intraoperative ARD width between the umbilicus and the symphysis correlated strongly with Biodex measurements during flexion (p = 0.007, R = -0.35) and isometric work load (p = 0.01, R = -0.34). The following measurements showed no correlation: between muscle strength and BMI; muscle strength and waistline; or between muscle strength and ARD width above the umbilicus, assessed preoperatively at the outpatient clinic, by CT scan, or measured intraoperatively. Conclusion: There is a strong correlation between intraoperatively measured ARD width below the umbilicus and flexion and isometric abdominal muscle strength measured with the Biodex System 4.

  • 43.
    Gunnarsson, Ulf
    et al.
    Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet at the Karolinska University Hospital/Huddinge, Stockholm, Sweden.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet at the Karolinska University Hospital/Huddinge, Stockholm, Sweden.
    3D intrastomal ultrasonography, an instrument for detecting stoma-related fistula2012In: Techniques in Coloproctology, ISSN 1123-6337, E-ISSN 1128-045X, Vol. 16, no 3, 233-236 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to evaluate the recently developed 3D intrastomal ultrasonography in diagnosing stoma-associated complaints and suspected complications after parastomal hernia repair such as peristomal fistula and abscesses. 3D intrastomal ultrasonography was used to image peristomal tissue in two patients with complaints after parastomal hernia repair performed with IPOM (intraperitoneal onlay mesh). One patient had ulcerative colitis and one Crohn's disease. Both patients were investigated because of pain and in one case also signs of a subcutaneous abscess. Intrastomal ultrasonography revealed fistulas connected to the intestinal segment leading to the stoma in both cases. Both cases also showed signs of a fistula descending to the abdominal cavity. In one case, a subcutaneous abscess was identified and in the other a small abscess adjacent to the fistula and the edge of the fascia. Stoma complaints after surgery for parastomal hernia with implantation of IPOM mesh can be diagnosed using 3D intrastomal ultrasonography. This new 3D technique for imaging intrastomal hernia can be used to complement traditional methods in the detection of stoma-associated abscesses and fistulas with or without foreign material such as mesh.

  • 44.
    Gurmu, A
    et al.
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Gunnarsson, Ulf
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Strigård, Karin
    Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Imaging of parastomal hernia using three-dimensional intrastomal ultrasonography2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 7, 1026-9 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Parastomal hernia is common in patients with a permanent stoma. At present there is no standard method for imaging a parastomal hernia. The aim of this study was to investigate the value of three-dimensional intrastomal ultrasonography in differentiating between a parastomal hernia and a bulge.

    METHODS: Twenty patients were divided into four groups according to ultrasonography setting and probe cover. All patients were tested using three different ultrasound probe frequencies (9, 13 and 16 MHz). The intrastomal examination was performed during provocation in both the supine and upright positions, with a protector or water-containing balloon surrounding the probe.

    RESULTS: The sharpest images were obtained using the rectal setting with a water-containing balloon surrounding the probe at 9 MHz in supine and erect positions, for evaluation of both fascia and muscle; in some instances even implanted mesh was detectable. When switched to render mode, the pictures improved in sharpness and it was easier to identify anatomical landmarks.

    CONCLUSION: Intrastomal ultrasonography using the rectal setting and a frequency of 9 MHz is a feasible method for imaging a parastomal hernia and differentiating it from an abdominal bulge. The image quality improves when render mode is used.

  • 45.
    Gurmu, Ambatchew
    et al.
    Department of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Nyköping Hospital, Nyköping, Sweden and Department of Surgical Gastroenterology, K53, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden .
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Sven
    Department of Radiology, Akademiska University Hospital, Uppsala, Sweden.
    Påhlman, Lars
    Department of Surgery, Akademiska University Hospital, Uppsala, Sweden.
    Rutegård, Jörgen
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Department of Surgical Gastroenterology, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    The inter-observer reliability is very low at clinical examination of parastomal hernia2011In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 26, no 1, 89-95 p.Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Parastomal hernia in patients with a permanent colostomy is common. The aim of this study was to evaluate the reliability of the diagnosis based on clinical examination and to compare this examination with the result of a specially designed questionnaire and computerised tomography (CT) scan.

    METHODS: Forty-one patients operated upon with an abdominoperineal resection due to rectal cancer at three hospitals between 1996 and 2002 were included. At minimum of 4 years after the operation, they underwent clinical examination by two or three independent surgeons, answered a colostomy questionnaire and were offered a CT scan of the abdominal wall.

    RESULT: At Hospital I, 17 patients were examined by three surgeons, with inter-observer kappa values between 0.35 and 0.64. At Hospital II, 13 patients were examined by three surgeons, the kappa values ranged between 0.29 and 0.43. At Hospital III, 11 patients were examined by two surgeons, with kappa value of 0.73. The kappa value between CT scan and the colostomy questionnaire was 0.45.

    CONCLUSION: The inter-observer reliability was low, indicating that parastomal hernia is difficult to diagnose by patient history and clinical examination. Some herniae may not be detected by CT scan, and the correlation to patient-reported complaints is low. A more sensitive radiological method to detect parastomal hernia is needed.

  • 46. Gustafsson, Pontus
    et al.
    Jestin, Pia
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindforss, Ulrik
    Higher Frequency of Anastomotic Leakage with Stapled Compared to Hand-Sewn Ileocolic Anastomosis in a Large Population-Based Study2015In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 39, no 7, 1834-1839 p.Article in journal (Refereed)
    Abstract [en]

    The stapling technique was recommended in a recent Cochrane analysis based on relatively small randomized trials between 1970 and 2009. Data from a large Swedish population-based quality register were analyzed in order to compare the leakage frequency between stapled and hand-sewn ileocolic anastomoses in colon cancer surgery. Three-thousand four-hundred and twenty-eight patients with an ileocolic anastomosis were entered in a Swedish regional quality register for colon cancer, including the type of anastomosis used. The patients were analyzed by logistic regression regarding risk for leakage, and Cox proportional hazard regression for survival associated with the technique used for anastomosis. Analyses were made for gender, age, elective or emergency surgery, duration of surgery, bleeding, cancer stage, and local radicality. Most anastomoses were hand sewn (1,908 of 3,428, 55.7 %, p < 0.001), whereas stapling was more common among emergency cases (342 of 618, 55.3 %, p < 0.001). Clinically relevant leakage appeared in 58 patients (1.7 %), of whom 51 (87.9 %) were re-operated. Leakage was found to be more frequent after stapled anastomosis (2.4 vs. 1.2 %, p = 0.006), and in multivariate analysis, stapled anastomosis was the only risk factor (OR = 2.04 95 % CI 1.19-3.50). There was no difference in overall survival related to the technique. Hand-sewn anastomosis is not associated with a higher leakage rate when comparing to a stapling procedure and is recommended for routine and emergency right-sided colon cancer surgery. This recommendation is based on what appears to be a lower leakage rate, similar survival and lower material cost.

  • 47. Gustavsson, Kajsa
    et al.
    Gunnarsson, Ulf
    Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 85, Stockholm, Sweden .
    Jestin, Pia
    Postoperative complications after closure of a diverting ileostoma-differences according to closure technique2012In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 27, no 1, 55-58 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The aim of this study was to compare three methods for closure of a diverting ileostoma according to development of postoperative small-bowel obstruction (SBO) and anastomotic leakage (AL).

    METHODS: Complications arising within 30 days after closure of a defunctioning loop ileostomy in 351 patients during the period 1999-2006 were studied retrospectively by evaluation of case records. The techniques employed were: hand-sewn anastomosis without bowel resection, hand-sewn anastomosis with bowel resection and stapled anastomosis.

    RESULTS: Of the 351 patients, 149 had a hand-sewn anastomosis without bowel resection (HS), 70 had a hand-sewn anastomosis with bowel resection (HSR) and 132 patients had a stapled anastomosis (S). The total number of SBOs was 44 patients (12.5%). In the two hand-sewn groups, 15.5% (34 patients) suffered postoperative SBO compared to 7.6% (10 patients) in the stapled group (p = 0.029). No difference in AL could be found between the groups, where the overall frequency was 2.8% (10 patients). Median hospital stay was 6 days in the HS group, 5 days in the HSR group and 4 days in the S group (p = 0.001).

    CONCLUSION: In the present study, stapled anastomosis was associated with a lower frequency of postoperative SBO and a shorter hospital stay compared to sutured anastomosis (either with or without a short small-bowel resection) after closure of a diverting ileostoma.

  • 48.
    Haapaniemi, S
    et al.
    Department of Surgery, Vrinnevi Hospital, Norrkoping, Sweden.
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Nordin, P
    Nilsson, E
    Reoperation after recurrent groin hernia repair.2001In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 234, no 1, 122-6 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.

    METHODS: Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.

    RESULTS: From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.

    CONCLUSIONS: Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.

  • 49. Hallén, M
    et al.
    Sevonius, D
    Westerdahl, J
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Sandblom, G
    Risk factors for reoperation due to chronic groin postherniorrhaphy pain2015In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 19, no 6, 863-869 p.Article in journal (Refereed)
    Abstract [en]

    Chronic groin postherniorrhaphy pain (CGPP) is common and sometimes so severe that surgical treatment is necessary. The aim of this study was to identify risk factors for being reoperated due to CGPP. All 195,707 repairs registered in the Swedish Hernia Register between 1999 and 2011 were included in the study. Out of these, 28,947 repairs were excluded since they were registered as procedures on the same patient after a previous repair. Age, gender, hernia anatomy (indirect reference), method of repair (anterior sutured repair reference) and postoperative complications were included in a multivariate Cox analysis with reoperation due to CGPP as endpoint. Of the patients included in the study cohort, 218 (0.13 %) later underwent reoperation due to CGPP, including 31 (14 %) women. Median age at the primary repair was 61.5 years. Risk factors for being reoperated were age < median [hazard ratio (HR) 3.03, 95 % confidence interval (CI) 2.22-4.12], female gender (HR 2.13, CI 1.41-3.21), direct hernia (HR 1.35, CI 1.003-1.81), other hernia (HR 6.03, CI 3.08-11.79), Lichtenstein repair (HR 2.22, CI 1.16-4.25), plug repair (HR 3.93, CI 1.96-7.89), other repair (HR 2.58, CI 1.08-6.19), bilateral repair (HR 2.58, CI 1.43-4.66) and postoperative complication (HR 4.40, CI 3.25-5.96). Risk factors for being reoperated due to CGPP in this cohort included low age, female gender, a direct hernia, a previous Lichtenstein or plug repair, bilateral repair and postoperative complications. Further research on how to avoid CGPP and explore the effectiveness of surgery for CGPP is necessary.

  • 50.
    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, 179-184 p.Article 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.

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