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  • 1. Ademuyiwa, Adesoji O.
    et al.
    Arnaud, Alexis P.
    Drake, Thomas M.
    Fitzgerald, J. Edward F.
    Poenaru, Dan
    Bhangu, Aneel
    Harrison, Ewen M.
    Fergusson, Stuart
    Glasbey, James C.
    Khatri, Chetan
    Mohan, Midhun
    Nepogodiev, Dmitri
    Soreide, Kjetil
    Gobin, Neel
    Freitas, Ana Vega
    Hall, Nigel
    Kim, Sung-Hee
    Negeida, Ahmed
    Khairy, Hosni
    Jaffry, Zahra
    Chapman, Stephen J.
    Tabiri, Stephen
    Recinos, Gustavo
    Amandito, Radhian
    Shawki, Marwan
    Hanrahan, Michael
    Pata, Francesco
    Zilinskas, Justas
    Roslani, April Camilla
    Goh, Cheng Chun
    Irwin, Gareth
    Shu, Sebastian
    Luque, Laura
    Shiwani, Hunain
    Altamimi, Afnan
    Alsaggaf, Mohammed Ubaid
    Spence, Richard
    Rayne, Sarah
    Jeyakumar, Jenifa
    Cengiz, Yucel
    Raptis, Dmitri A.
    Fermani, Claudio
    Balmaceda, Ruben
    Marta Modolo, Maria
    Macdermid, Ewan
    Chenn, Roxanne
    Yong, Cheryl Ou
    Edye, Michael
    Jarmin, Martin
    D'amours, Scott K.
    Iyer, Dushyant
    Youssef, Daniel
    Phillips, Nicholas
    Brown, Jason
    Dickfos, Marilla
    Mitul, Ashrarur Rahman
    Mahmud, Khalid
    Oosterkamp, Antje
    Assouto, Pamphile A.
    Lawani, Ismail
    Souaibou, Yacoubou Imorou
    Devadasar, Giridhar H.
    Chong, Chean Leung
    Qadir, Muhammad Rashid Minhas
    Aung, Kyaw Phyo
    Yeo, Lee Shi
    Castillo, Vanessa Dina Palomino
    Munhoz, Monique Moron
    Moreira, Gisele
    Palomino Castillo, Vanessa Dina
    Barros De Castro Segundo, Luiz Carlos
    Khouri Ferreira, Salim Anderson
    Careta, Maira Cassa
    Araujo, Rafael
    Menegussi, Juliana
    Leal, Marisa
    Barroso de Lima, Caio Vinicius
    Tatagiba, Luiza Sarmento
    Leal, Antonio
    Nigo, Samuel
    Kabba, Juana
    Ngwa, Tagang Ebogo
    Brown, James
    King, Sebastian
    Zani, Augusto
    Azzie, Georges
    Firdouse, Mohammed
    Kushwaha, Sameer
    Agarwal, Arnav
    Bailey, Karen
    Cameron, Brian
    Livingston, Michael
    Horobjowsky, Alexandre
    Deckelbaum, Dan L.
    Razek, Tarek
    Montes, Irene
    Sierra, Sebastian
    Mendez, Manuela
    Isabel Villegas, Maria
    Mendoza Arango, Maria Clara
    Mendoza, Ivan
    Aristiza Ibal, Fred Alexander Naranjo
    Montoya Botero, Jaime Andres
    Quintero Riaza, Victor Manuel
    Restrepo, Jakeline
    Morales, Carlos
    Cruz, Herman
    Munera, Alejandro
    Karlo, Robert
    Domini, Edgar
    Mihanovic, Jakov
    Radic, Mihael
    Zamarin, Kresimir
    Pezelj, Nikica
    Khyrallh, Ahmed
    Hassan, Ahamed
    Shimy, Gamal
    Fahmy, Mohamed A. Baky
    Nabawi, Ayman
    Gohar, Muhammad Saad Ali Muhammad
    Elfil, Mohamed
    Ghoneem, Mohamed
    Gohar, Muhammad El-Saied Ahmad Muhammad
    Asal, Mohamed
    Abdelkader, Mostafa
    Gomah, Mahmoud
    Rashwan, Hayssam
    Karkeet, Mohamed
    Gomaa, Ahmed
    Hasan, Amr
    Elgebaly, Ahmed
    Saleh, Omar
    Fattah, Ahmad Abdel
    Gouda, Abdullah
    Elshafay, Abd Elrahman
    Gharib, Abdalla
    Hanafy, Mohammed
    Al-Mallah, Abdullah
    Abdulgawad, Mahmoud
    Baheeg, Mohamad
    Alhendy, Mohammed
    Fattah, Ibrahim Abdel
    Kenibar, Abdalla
    Osman, Omar
    Gemeah, Mostafa
    Mohammed, Ahmed
    Adel, Abdalrahman
    Mesreb, Ahmed Maher Menshawy
    Mohammed, Abdelrahman
    Sayed, Abdelrahman
    Abozaid, Mohamed
    Kotb, Ahmed Hafez El-Badri
    Ata, Ali Amin Ahmed
    Nasr, Mohammed
    Alkammash, Abdelrahman
    Saeed, Mohammed
    El Hamid, Nader Abd
    Attia, Attia Mohamed
    Abd El Galeel, Ahmed
    Elbanby, Eslam
    El-Dien, Khalid Salah
    Hantour, Usama
    Alahmady, Omar
    Mansour, Billal
    Elkorashy, Amr Muhammad
    Taha, Emad Mohamed Saeed
    Lasheen, Kholod Tarek
    Elkolaly, Salma Said
    Abdel-Wahab, Nehal Yosri Elsayed
    Abozyed, Mahmoud Ahmed Fathi
    Adel, Ahmed
    Saeed, Ahmed Moustafa
    El Sayed, Gehad Samir
    Youssif, Jehad Hassan
    Ahmed, Soliman Magdy
    El-Shahat, Nermeen Soubhy
    Khedr, Abd El-Rahman Hegazy
    Elsebaaye, Abdelrhman Osama
    Elzayat, Mohamed
    Abdelraheim, Mohamed
    Elzayat, Ibrahim
    Warda, Mahmoud
    El Deen, Khaled Naser
    Essam, Abdelrhman
    Salah, Omar
    Abbas, Mohamed
    Rashad, Mona
    Elzayyat, Ibrahim
    Hemeda, Dalia
    Tawfik, Gehad
    Salama, Mai
    Khaled, Hazem
    Seisa, Mohamed
    Elshaer, Kareem
    Hussein, Abdelfatah
    Elkhadrawi, Mahmoud
    Afifi, Ahmed Mohamed
    Ebrahim, Osama Saadeldeen
    Metwally, Mahmoud Mohamed
    Elmelegy, Rowida
    Elsawahly, Diaa Moustafa Elbendary
    Safa, Hisham
    Nofal, Eman
    Elbermawy, Mohamed
    Raya, Metwally Abo
    Ghazy, Ahmed Abdelmotaleb
    Samih, Hisham
    Abdelgelil, Asmaa
    Abdelghany, Sarah
    El Kholy, Ahmed
    Elkady, Fatma
    Salma, Mahmoud
    Samy, Sarah
    Fakher, Reem
    Aboarab, Aya
    Samir, Ahmed
    Sakr, Ahmed
    Haroun, Abdelrahman
    Al-Aarag, Asmaa Abdel-Rahman
    Elkholy, Ahmed
    Elshanwany, Sally
    Ghanem, Esraa
    Tammam, Ahmed
    Hammad, Ali Mohamed
    El Shoura, Yousra
    El Ashal, Gehad
    Antar, Sarah
    Mehrez, Sara
    Abdelshafy, Mahmoud
    Hamad, Maha Gamal Mohamad
    Hosh, Mona
    Abdallah, Emad
    Magdy, Basma
    Alzayat, Thuraya
    Gamaly, Elsayed
    Elfeki, Hossam
    Abouzahra, Amany
    Elsheikh, Shereen
    Elgendy, Fatimah I.
    Abd El-Salam, Fathia
    Seifelnasr, Osama
    Ammar, Mohamed
    Eysa, Athar
    Sadek, Aliaa
    Toeema, Aliaa Gamal
    Nasr, Aly
    Abuseif, Mohamed
    Zidan, Hagar
    Barakat, Sara Abd Elmageed
    Elsayed, Nadin
    Abd Elrasoul, Yasmin
    El-Kelany, Ahmed
    Ammar, Mohamed Sabry
    Mustafa, Mennat-Allah
    Makhlouf, Yasmin
    Etman, Mohamed
    Saad, Samar
    Alrahawy, Mahmoud
    Raslan, Ahmed
    Morsi, Mahmoud
    Sabry, Ahmed
    Elwakil, Hager
    Shaker, Heba
    Elkelany, Ahmed
    El-Kashef, Hussein
    Shaalan, Mohamed
    Tarek, Areej
    Elwan, Ayman
    Nayel, Ahmed Ragab
    Seif, Mostafa
    Shafik, Doaa Emadeldin
    Ghoname, Mohamed Ali
    Almallah, Ahmad
    Fouad, Ahmed
    Sayma, Eman Adel
    Elbatahgy, Ahmad
    El-Ma'doul, Angham Solaiman
    Mosad, Ahmed
    Tolba, Hager
    Elsorogy, Diaa Eldin Abdelazeem Amin
    Mostafa, Hassan Ali
    Omar, Amira Atef
    Abd El Hameed, Ola Sherief
    Lasheen, Ahmed
    Abd El Salam, Yasser
    Morsi, Ashraf
    Ismail, Mohammed
    Ahmed, Hager
    Amer, Mohamed A.
    El-Hamouly, Ahmed Sabry
    Attallah, Noura
    Mosalum, Omnia
    Afandy, Ahmed
    Mokhtar, Ahmed
    Abouelnasr, Alaa
    Ayad, Sara
    Shaker, Ramdan
    Sakr, Rokia
    Amreia, Mahmoud
    Elsobky, Soaad
    Mustafa, Mohamed
    El Magd, Ahmed Abo
    Marey, Abeer
    Tarek, Amr
    Fadel, Mohamed
    Mohamed, Mohamed Moamen
    Fadel, Amr
    Ahmed, Emad Ali
    Ali, Ahmad
    Alwafai, Mohammad Ghassan
    Alnawam, Ehab Abdulkader Hemida Ghazy
    Dwydar, Abdullah
    Kharsa, Sara
    Mamdouh, Ehab
    El-Sheemy, Hatem
    Alyoussef, Ibrahim
    Aly, Abouelatta Khairy
    Aldalaq, Ahmad
    Alnawam, Ehab
    Alkhabbaz, Dalia
    Saad, Mahmoud
    Hussein, Shady
    Elazayem, Ahmed Abo
    Meshref, Ahmed
    Elashmawy, Marwa
    Mousa, Mohammed
    Nashaat, Ahmad
    Ghanem, Sara
    Elsayed, Zaynab M.
    Elwaey, Aya
    Elkadsh, Iman
    Darweesh, Mariam
    Mohameden, Ahmed
    Hafez, Mennaallah
    Badr, Ahmed
    Badwy, Assmaa
    Abd El Slam, Mohamed
    Elazoul, Mohamed
    Al-Nahrawi, Safwat
    Eldamaty, Lotfy
    Nada, Fathee
    Ameen, Mohamed
    Hagar, Aya
    Elsehimy, Mohamed
    Abo-ryia, Mohammad
    Dawoud, Hossam
    El Mesery, Shorouk
    El Gendy, Abeer
    Abdelkareem, Ahmed
    Marey, Ahmed Safwan
    Allam, Mostafa
    Shehata, Sherif
    Abozeid, Khaled
    Elshobary, Marwa
    Fahiem, Ahmed
    Sarsik, Sameh
    Hashish, Amel
    Zidan, Mohamed
    Hashish, Mohamed
    Aql, Shaimaa
    Elhendawy, Abdelaziz Osman Abdelaziz
    Husseini, Mohamed
    Khater, Omar
    Kasem, Esraa Abdalmageed
    Gheith, Ahmed
    Elfouly, Yasmin
    Soliman, Ahmed Ragab
    Hani, Yasmein
    Elfouly, Nesma
    Fawzy, Ahmed
    Hassan, Ahmed
    Rashid, Mohammad
    Elsherbiny, Abdallah Salah
    Sieda, Basem
    Badwi, Nermin Mohamed
    Mohammed, Mohammed Mustafa Hassan
    Mohamed, Osama
    Habeeb, Mohammad Abdulkhalek
    Worku, Mengistu
    Starr, Nichole
    Desta, Semay
    Wondimu, Sahlu
    Abebe, Nebyou Seyoum
    Thomas, Efeson
    Asele, Frehun Ayele
    Dabessa, Daniel
    Abebe, Nebiyou Seyoum
    Zerihun, Abebe Bekele
    Scalabre, Aurelien
    Frade, Fernanda
    Irtan, Sabine
    Parent, Valentine
    Martin, Amandine
    Graffeille, Vivien
    Gaignard, Elodie
    Alimi, Quentin
    Abbo, Olivier
    Mouttalib, Sofia
    Bouali, Ourdia
    Hervieux, Erik
    Aigrain, Yves
    Botto, Nathalie
    Faure, Alice
    Fievet, Lucile
    Panait, Nicoleta
    Eyssartier, Emilie
    Schmitt, Francoise
    Podevin, Guillaume
    Muller, Cecile
    Bonnard, Arnaud
    Peycelon, Matthieu
    Abantanga, Francis
    Boakye-Yiadom, Kwaku
    Bukari, Mohammed
    Owusu, Frank
    Awuku-Asabre, Joseph
    Bray, Lemuel Davies
    Lytras, Dimitrios
    Psarianos, Kyriakos
    Bamicha, Anastasia
    Anthoulakis, Christos
    Nikoloudis, Nikolaos
    Mitroudis, Nikolaos
    Estupinian, Sergio
    Forno, Walter
    Guevara, Romeo
    Aguilera, Maria
    Mendez, Napoleon
    Mendizabal, Cesar Augusto Azmitia
    Ramazzini, Pablo
    Urquizu, Mario Contreras
    Rodriguez, Daniel Estuardo Marroquin
    Velsquez, Carlos Ivan Perez
    Merida, Sara Maria Contreras
    Regalado, Francisco
    Lopez, Mario
    Siguantay, Miguel
    Prasad, S. S.
    Kirishnan, Anand
    Gyanchandani, Nidhi
    Bhat, Sriram
    Sreedharan, Anjana
    Kinnera, S. V.
    Nadkami, Shravan
    Lakshmi, Harish Neelamraju
    Malik, Puneet
    Bin Mahamood, Abid
    Khajanchi, Monty
    Satoskar, Savni
    Satoskar, Rajeev
    Reddy, Yella
    Venugopal, Caranj
    Kumar, Sunil
    Sutanto, Eldaa Prisca Refianti
    Soeselo, Daniel Ardian
    Tedjaatmadja, Chintya
    Rahmawati, Fitriana Nur
    Mayasari, Maria
    Al-Hasani, Ruqaya Kadhim Mohammed Jawad
    Al-Hameedi, Hasan Ismael Ibraheem
    Al-Azraqi, Israa Abdullah Aziz
    Sabeeh, Lubna
    Kamil, Rahma
    Rasendran, Amoudtha
    Sheehan, Jacqueline
    Kerley, Robert
    Normile, Caoimhe
    Gilbert, Richard William
    Song, Jiheon
    Mauro, Linnea
    Dablouk, Mohammed Osman
    Kielty, Paul
    Marks, Eleanor
    Gosling, Simon
    Mccarthy, Michelle
    Mirghani, Diya
    Naqvi, Syed Altaf
    Wong, Chee Siong
    Gosling, Simon George
    Fahy, Ciara
    Cadogan, Diana Duarte
    Powell, Anna
    Gilbert, Richard
    Clifford, Caroline
    Driscoll, Aoife
    Paul, Stassen
    Lee, Chris
    Bowe, Ross
    Hutch, William
    Mohan, Helen
    O'Neill, Maeve
    Mealy, Kenneth
    Danelli, Piergiorgio
    Bondurri, Andrea
    Maffioli, Anna
    Bonavina, Luigi
    Macchitella, Yuri
    Ceriani, Chiara
    Veronese, Ezio
    Bortolasi, Luca
    Hasheminia, Alireza
    Benevento, Angelo
    Tessera, Gaetano
    Turati, Luca
    Sgroi, Giovanni
    Rausa, Emanuele
    Venskutonis, Donatas
    Bradulskis, Saulius
    Urbanavicius, Linas
    Austraite, Aiste
    Riauka, Romualdas
    Dambrauskas, Zilvinas
    Coomber, Ross
    Johnson, Kenneth
    Nowers, Jennifer
    Periasammy, Dineshwary
    Salleh, Afizah
    Das, Andre
    Tze, Reuben Goh Em
    Kumar, Milaksh Nirumal
    Abdullah, Nik Azim Nik
    Chong, Hoong Yin
    Agius, Marija
    Borg, Elaine
    Bezzina, Maureen
    Bugeja, Roberta
    Vella-Baldacchino, Martinique
    Spina, Andrew
    Psaila, Josephine
    Francois-Coridon, Helene
    Tolg, Cecilia
    Colombani, Jean-Francois
    Jacobe, Mario
    Mapasse, Domingos
    Snyder, Elizabeth
    Oumer, Ramadan
    Osman, Mohammed
    Mohammad, Aminu
    Anyanwu, Lofty-John
    Sheshe, Abdulrahman
    Adesina, Alaba
    Faturoti, Olubukola
    Taiwo, Ogechukwu
    Ibrahim, Muhammad Habib
    Nasir, Abdulrasheed A.
    Suleiman, Siyaka Itopa
    Adeniyi, Adewale
    Adesanya, Opeoluwa
    Adebanjo, Ademola
    Osuoji, Roland
    Atobatele, Kazeem
    Ogunyemi, Ayokunle
    Wiiliams, Omolara
    Oludara, Mobolaji
    Oshodi, Olabode
    Razzaq, Abdul
    Lawal, Oluwagbemiga
    Alakaloko, Felix
    Elebute, Olumide
    Osinowo, Adedapo
    Bode, Christopher
    Adesuyi, Abidemi
    Tade, Adesoji
    Adekoya, Adeleke
    Nwokoro, Collins
    Ayandipo, Omobolaji O.
    Lawal, Taiwo Akeem
    Ajao, Akinlabi E.
    Ali, Samuel Sani
    Odeyemi, Babatunde
    Olori, Samson
    Popoola, Ademola
    Adeyeye, Ademola
    Adeniran, James
    Lossius, William J.
    Havemann, Ingemar
    Thorsen, Kenneth
    Narvestad, Jon Kristian
    Wold, Trude Beate
    Nymo, Linn
    Elsiddig, Mohammed
    Dar, Manzoor
    Bhopal, Kamran Faisal
    Iftikhar, Zainab
    Furqan, Muhammad Mohsin
    Nighat, Bakhtiar
    Jawaid, Masood
    Khalique, Abdul
    Zil-E-Ali, Ahsan
    Rashid, Anam
    Aguilar, Wendy Leslie Messa
    Chiong, Jose Antonio Cabala
    Cecilia, Ana
    Bautista, Manchego
    Huaman, Eduardo
    Zegarra, Sergio
    Camacho, Rony
    Vergara Celis, Jose Maria
    Romani Pozo, Diego Alonso
    Hamasaki, Jose
    Temoche, Edilberto
    Herrera-Matta, Jaime
    Garcia Torres, Carla Pierina
    Alvarez Barreda, Luis Miguel
    Barrionuevo Ojeda, Ronald Renato
    Garaycochea, Octavio
    Mollo, Melanie Castro
    Delgado, Mitchelle Solange De Fa Tima Linares
    Fujii, Francisco
    Manchego Bautista, Ana Cecilia
    Messa Aguilar, Wendy Leslie
    Cabala Chiong, Jose Antonio
    Aranzabal Durand, Susana Yrma
    Arroyo Basto, Carlos Alejandro
    Urbina Rojas, Nelson Manuel
    Shu Yip, Sebastian Bernardo
    Contreras Vergara, Ana Lucia
    Rosas Moran, Andrea Echevarria
    Borda Luque, Giuliano
    Rodriguez Castro, Manuel
    Alvarado Jaramillo, Ramon
    Sila, George Manrique
    Lopez, Crislee Elizabeth
    De Leon, Mardelangel Zapata Ponze
    Machaca, Massiell
    Coasaca Huaraya, Ronald
    Arenas, Andy
    Herrera Puma, Clara Milagros
    Pino, Wilfredo
    Hinojosa, Christian
    Ponze De Leon, Melanie Zapata
    Limache, Susan
    Manrrique Sila, George
    Mercado Rodriguez, Layza-Alejandra
    Sauvat, Frederique
    Vida, Lucian Corneliu
    Muntean, Liviu Iuliu
    Mironescu, Aurel Sandu
    Alomar, Ibrahim N.
    Alnuqaydan, Saleh A.
    Altwigry, Abdulrahman M.
    Othman, Moayad
    Osman, Nohad
    Alqahtani, Enas
    Alzahrani, Mohammed
    Alyami, Rifan
    Aljohani, Emad
    Alhabli, Ibrahim
    Mikwar, Zaher
    Almuallem, Sultan
    Nawawi, Abrar
    Bakhaidar, Mohamad
    Maghrabi, Ashraf A.
    Alsaggaf, Mohammed
    Aljiffry, Murad
    Altaf, Abdulmalik
    Khoja, Ahmad
    Habeebullah, Alaa
    Akeel, Nouf
    Ghandora, Nashat
    Almoflihi, Abdullah
    Huwait, Abdulmalik
    Al-Shammari, Abeer
    Al-Mousa, Mashael
    Alghamdi, Masood
    Adham, Walid
    Albeladi, Bandar
    Alfarsi, Muayad Ahmed
    Mahdi, Atif
    Al Awwad, Saad
    Nouh, Thamer
    Hassanain, Mazen
    Aldhafeeri, Salman
    Sadig, Nawal
    Algohary, Osama
    Aledrisy, Mohannad
    Gudal, Ahmad
    Alrifaie, Ahmad
    AlRowais, Mohammed
    Althwainy, Amani
    Shabkah, Alaa
    Alamoudi, Uthman
    Alrajraji, Mawaddah
    Alghamdi, Basim
    Aljohani, Saud
    Daqeeq, Abdullah
    Al-Faifi, Jubran J.
    Jennings, Vicky
    Ngayu, Nyawira
    Moore, Rachel
    Kong, Victor
    Sampson, Colleen
    Panieri, Eugenio
    Tun, Myint
    Mphatsoe, Albert Mohale
    Carreira, Jo-Anne
    Teasdale, Ella
    Wagener, Mark
    Botes, Stefan
    Du Plessis, Danelo
    Pagnozzi, Janet
    Quezada, Jimy Harold Jara
    Rodicio, Jose Luis
    Minguez, German
    Rodriguez-Uria, Raquel
    Ugalde, Paul
    Lopez-Arevalo, Camilo
    Barneo, Luis
    Gonzales Stuva, Jessica Patricia
    Aguilar-Jimenez, Jose
    Andres Garcia-Marin, Jose
    Ortega-Vazquez, Irene
    Rodriguez, Lorena
    Herrera, Norberto
    Arachchi, Prasad Pitigala
    Jan, Wanigasekara Senanayake Mudiyanselage Kithsiri
    Arachchige, Lalith Asanka Jayasooriya Jayasooriya
    Sivaganesh, Sivasuriya
    Samaraweera, Dulan Irusha
    Thanusan, Vimalakanthan
    Musa, Ahmed Elgaili Khalid
    Balila, Reem Mohammed Hassan
    Mohamed, Mohamed Awad Elkarim Hamad
    Ali, Hussein
    Elabdin, Hagir Zain
    Hassan, Alaa
    Mahdi, Sefeldin
    Ahmed, Hala
    Idris, Sahar Abdoun Ishag
    Elsayed, Makki
    Elsayed, Mohammed
    Mahmoud, Mohamed
    Thorarinsdottir, Hildur
    Utter, Maria
    Sundstrom, Sami Martin
    Wredberg, Cecilia
    Kjellin, Ann
    Nyberg, Johanna
    Frisk, Bjorn
    Ahlqvist, Sandra
    Bjorklund, Ida
    Hjertberg, Maria
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Andersson, Linda
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Royson, Hanna
    Weber, Per
    Schmid, Roger
    Schivo, Debora
    Despotidis, Vasileios
    Breitenstein, Stefan
    Staerkle, Ralph F.
    Schadde, Erik
    Deichsel, Fabian
    Gerosa, Alexandra
    Nocito, Antonio
    Raptis, Dimitri Aristotle
    Mijuskovic, Barbara
    Zuber, Markus
    Eisner, Lukas
    Kruspi, Swantje
    Reinisch, Katharina Beate
    Schoewe, Christin
    Novak, Allan
    Palma, Adrian F.
    Teufelberger, Gerfried
    Balkan, Ali Zeynel Abidin
    Gumar, Mehmet
    Yavuz, Mehmet Ali
    Karabacak, Ufuk
    Lap, Gokhan
    Ozkan, Bahar Busra
    Adams, Ryan
    Morton, Robert
    Henderson, Liam
    Gratton, Ruth
    Clement, Keiran David
    Chang, Kate Yu-Ching
    McNish, David
    McIntosh, Ryan
    Milligan, William
    Skelly, Brendan
    Anderson-Knight, Hannah
    Lawther, Roger
    Onimowo, Jemina
    Shatkar, Veereanna
    Tharmalingam, Shivanee
    Woin, Evelina
    Fautz, Tessa
    Ziff, Oliver
    Dindyal, Shiva
    Arman, Sam
    Talukder, Shagorika
    Gadhvi, Vijay
    Chew, Luen Shaun
    Heath, Jonathan
    Mannu, Gurdeep Singh
    Zachariades, Dimitris-Christos
    Snaith, Ailsa Claire
    Hettiarachchi, Thusitha Sampath
    Nesaratnam, Arjun
    Wheeler, James
    Sykes, Mark
    Behar, Nebil
    Jordan, Harriet
    Arulampalam, Tan
    Shah, Apar
    Brown, Damien
    Blower, Emma
    Sutton, Paul
    Gasteratos, Konstantinos
    Vimalachandran, Dale
    Magee, Cathy
    Mcguigan, Andrew
    Mcaleer, Stephen
    Morgan, Clare
    Braungart, Sarah
    Lafferty, Kirsten
    Labib, Peter
    Tanase, Andrei
    Mangan, Clodagh
    Reza, Lillian
    Woodward, Helen
    Gouldthorpe, Craig
    Turner, Megan
    Wild, Jonathan R. L.
    Malik, Tom Am
    Proctor, Victoria K.
    Hewage, Kalon
    Davies, James
    Dubois, Andre
    Sarwary, Sayed
    Zardab, Ali
    Grant, Alan
    Mcintyre, Robert
    Tewari, Shirish
    Humm, Gemma
    Farinella, Eriberto
    Parthiban, Sunil
    Hall, Nigel J.
    Wright, Naomi J.
    Major, Christina P.
    Xerri, Thelma
    De Bono, Phoebe
    Amin, Jasim
    Farhad, Mustafa
    Camilleri-Brennan, John F.
    Robertson, Andrew G. N.
    Swann, Joanna
    Richards, James
    Jabbar, Aijaz
    Attard, Myranda
    Burns, Hannah
    Macdonald, Euan
    Baldacchino, Matthew
    Skehan, Jennifer
    Camilleri-Brennan, Julian
    Hall, Tom Falconer
    Gimzewska, Madelaine
    Mclachlan, Greta
    Shah, Jamie
    Giles, James
    Hassan, Maleeha
    Beasley, William
    Vlachogiorgos, Apostolos
    Dias, Stephen
    Maharaj, Geta
    McDonald, Rosie
    Cross, Kate
    Rees, Clare M.
    Van Duren, Bernard
    Upchurch, Emma
    Karandikar, Sharad
    Bowley, Doug
    Karim, Ahmed
    Chachulski, Witold
    Richardson, Liam
    Dawnay, Giles
    Thompson, Ben
    Mistry, Ajayesh
    Ghetia, Millika
    Roy, Sudipta
    Al-Obaedi, Ossama
    Das, Kaustuv
    Prabhudesai, Ash
    Cocker, D. M.
    Tan, Jessica Juliana
    Vivekanantham, Sayinthen
    Gillespie, Michael
    Gudlaugsdottir, Katrin
    Pezas, Theodore
    Currow, Chelise
    Kim, Matthew Young-Han
    Salama, Yahya
    Shah, Rohi
    Ibrahem, Ahmad Aboelkassem
    Ebdewi, Hamdi
    Gravante, Gianpiero
    El-Rabaa, Saleem
    Chan, Zoe
    Hassan, Zaffar
    Makinde, Misty
    Hemingway, David
    Dean, Ramzana
    Boddy, Alexander
    Aber, Ahmed
    Patel, Vijay
    Kotecha, Deevia
    Ubhi, Harmony Kaur
    Hosein, Simon-Peter
    Ward, Simon
    Malik, Kamran
    Jennings, Leifa
    Newton, Tom
    Alkhouri, Mirna
    Kang, Min Kyu
    Houlden, Christopher
    Barry, Jonathan
    Wilson, Michael S. J.
    Neo, Yan Ning
    Ibrahim, Ibrahim
    Chan, Emily
    Peck, Fraser S.
    Lim, Pei J.
    North, Alexander S.
    Blundell, Rebecca
    Williamson, Adam
    Fouad, Dina
    Minocha, Ashish
    Mccarthy, Kathryn
    Court, Emma
    Chambers, Alice
    Yee, Jenna
    Tham, Ji Chung
    Beaton, Ceri
    Walsh, Una
    Lockey, Joseph
    Bokhari, Salman
    Howells, Lara
    Griffiths, Megan
    Yallop, Laura
    Singh, Shailinder
    Nasher, Omar
    Jackson, Paul
    Ramzi, Saed
    Zeidan, Shady
    Doughty, Jennifer
    Sinha, Sidhartha
    Davenport, Ross
    Lewis, Jason
    Duffy, Leo
    Mcaleer, Elizabeth
    Williams, Eleanor
    Obute, Rhalumi Daniel
    Glover, Thomas E.
    Clark, David J.
    Boshnaq, Mohamed
    Akhtar, Mansoor
    Capleton, Pascale
    Doughan, Samer
    Rabie, Mohamed
    Mohamed, Ismail
    Samuel, Duncan
    Dickson, Lauren
    Kennedy, Matthew
    Dempster, Eleanor
    Brown, Emma
    Maple, Natalie
    Monaghan, Eimear
    Wolf, Bernhard
    Garland, Alicia
    Lund, Jonathan
    Boereboom, Catherine
    Murphy, Jennifer
    Tierney, Gillian
    Tou, Samson
    Zimmermann, Eleanor Franziska
    Smart, Neil James
    Warwick, Andrea Marie
    Stasinou, Theodora
    Daniels, Ian
    Findlay-Cooper, Kim
    Mitrasinovic, Stefan
    Ray, Swayamjyoti
    Varcada, Massimo
    D'souza, Rovan
    Omara, Sharif
    Boyce, Tamsin
    Whewell, Harriet
    Jones, Elin
    Ma, Jennifer
    Abington, Emily
    Ramcharn, Meera
    Williams, Gethin
    Winstanley, Joseph
    Kennedy, Ewan D.
    Yeung, Emily N. W.
    Fergusson, Stuart J.
    Jones, Catrin
    O'neill, Stephen
    Lim, Shujing Jane
    Liew, Ignatius
    Nair, Hari
    Fairfield, Cameron
    Oh, Julia
    Koh, Samantha
    Wilson, Andrew
    Fairfield, Catherine
    Th'ng, Francesca
    Robertson, Nichola
    Anandkumar, Delran
    Kirupagaran, Ashok
    Jones, Timothy F.
    Torrance, Hew D.
    Fowler, Alexander J.
    Chandrakumar, Charmilie
    Patel, Priyank
    Ashraf, Syed Faaz
    Lakhani, Sonam M.
    Mclean, Aaron Lawson
    Basson, Sonia
    Batt, Jeremy
    Bowman, Catriona
    Stoddart, Michael
    Benons, Natasha
    Barker, Tom
    Summerour, Virginia
    Harper, Edward
    Smith, Caroline
    Hampton, Matthew
    Mckechnie, Doug
    Farah, Ayaan
    Chun, Anita
    Pereira, Bernadette
    Nemeth, Kristof
    Decker, Emily
    Giuliani, Stefano
    Shalaby, Aly
    Szczap, Aleksandra
    Chidambaram, Swathikan
    Chen, Chee Yang
    Kulasabanathan, Kavian
    Chhabra, Srishti
    Kostov, Elisabeth
    Harbord, Philippe
    Barnacle, James
    Palliyil, Madan Mohan
    Zikry, Mina
    Porter, Johnathan
    Raslan, Charef
    Hafiz, Shazia
    Soltani, Niksa
    Baillie, Katie
    Mirza, Ahmad
    Saeed, Haroon
    Galloway, Simon
    Elena, Gia
    Afzal, Mohammad
    Zakir, Mohamed
    Sodde, Peter
    Hand, Charles
    Sriram, Aiesha
    Clark, Tamsyn
    Holton, Patrick
    Livesey, Amy
    Sinha, Yashashwi
    Iqbal, Fahad Mujtaba
    Bharj, Indervir Singh
    Rotundo, Adriana
    Jenvey, Cara
    Slade, Robert
    Golding, David
    Haines, Samuel
    Abdullah, Ali Adel Ne'ma
    Tilston, Thomas W.
    Loughran, Dafydd
    Donoghue, Danielle
    Giacci, Lorenzo
    Sherif, Mohamed Ashur
    Harrison, Peter
    Tang, Alethea
    Elshaer, Mohamed
    Urbonas, Tomas
    Riaz, Amjid
    Chapman, Annie
    Acharya, Parisha
    Shalhoub, Joseph
    Grossart, Cathleen
    McMorran, David
    Mlotshwa, Makhosini
    Hawkins, William
    Loizides, Sofronis
    Thomson, Peter
    Khan, Shahab
    Taylor, Fiona
    Shukla, Jalak
    Howie, Emma Elizabeth
    Macdonald, Linda
    Komolafe, Olusegun
    Mcintyre, Neil
    Cragg, James
    Parker, Jody
    Stewart, Duncan
    Lintin, Luke
    Tracy, Julia
    Farooq, Tahir
    Sion, Melanie
    Weinstein, Michael S.
    Punja, Viren
    Bugaev, Nikolay
    Goodstein, Monica
    Razmdjou, Shadi
    Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries2016In: BMJ Global Health, ISSN 2059-7908, Vol. 1, no 4, article id e000091Article in journal (Refereed)
    Abstract [en]

    Background: Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally.

    Methods: Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression.

    Results: This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed.

    Conclusions: Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas.

  • 2. Bhangu, A
    et al.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University Hospital.
    Andersson, Linda
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University Hospital.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University Hospital.
    Escobar, EG
    Mortality of emergency abdominal surgery in high-, middle- and low-income countries2016In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 103, no 8, p. 971-988Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).

    METHODS: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

    RESULTS: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days.

    CONCLUSION: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role.

  • 3.
    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, p. 206-13Article 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.

  • 4.
    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, p. 845-53Article 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.

  • 5.
    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, p. 8697-8705Article 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.

  • 6.
    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, p. 6126-6131Article 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.

  • 7.
    Blind, Niillas
    et al.
    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.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Brännström, Fredrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Distance to hospital is not a risk factor for emergency colon cancer surgery.2018In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 33, no 9, p. 1195-1200Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 8.
    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, p. 327-330Article 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.

  • 9.
    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, p. 503-508Article 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.

  • 10.
    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)
  • 11.
    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, p. 362-367Article 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.

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

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

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

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

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

  • 13.
    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, p. 715-721Article 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.

  • 14.
    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, p. 1219-1224Article 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.

  • 15.
    Clay, Leonard
    et al.
    Department of Clinical Science, Intervention and Technology (CLINTEC), H9, Karolinska Institutet, 171 64, Stockholm, Sweden.
    Stark, Birgit
    Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 64, 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.
    Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study2018In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, no 2, p. 325-332Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 16.
    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, p. 3632-3638Article 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.

  • 17. 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, p. 1017-1021Article 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.

  • 18.
    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, p. 1931-1936Article 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.

  • 19.
    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, p. 672-676Article 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.

  • 20.
    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, p. 427-433Article 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.

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

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

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

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

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

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

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

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

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

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

  • 23.
    Egenvall, Monika
    et al.
    CLINTEC and Department of Surgical Gastroenterology, Karolinska University Hospital.
    Schubert Samuelsson, Katja
    CLINTEC and Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Klarin, Inga
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Lökk, Johan
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Department of Geriatrics, Karolinska University Hospital.
    Sjövall, Annika
    Department of Surgical Gastroenterology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet.
    Martling, Anna
    Department of Surgical Gastroenterology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. CLINTEC and Department of Surgical Gastroenterology, Karolinska University Hospital.
    Management of colon cancer in the elderly: a population-based study2014In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 16, no 6, p. 433-441Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 24.
    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, p. 465-471Article 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.

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

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

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

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

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

  • 26.
    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-up2014In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 67, no 8, p. 1082-1088Article 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.

  • 27.
    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, p. 181-8Article 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)

  • 28. Falk, Peter
    et al.
    Ruiz-Jasbon, Fernando
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ivarsson, Marie-Lois
    An ex vivo model using human peritoneum to explore mesh-tissue integration2017In: Biology open, ISSN 2046-6390, Vol. 6, no 9, p. 1391-1395Article in journal (Refereed)
    Abstract [en]

    Biological compatibility, in terms of implantation of foreign mesh material in hernia surgery, still needs experimental investigation. Present study develops an experimental model using human peritoneum to study the integration between tissue and different mesh material. The ex vivo model using peritoneal tissue was studied with different mesh material, and integration was monitored over time using microscopy.It could be demonstrated that the peritoneal model may be kept viable in culture for several weeks. Cell migration was seen after 7-10 days in culture and could be further monitored over several weeks. The use of a human artificial model environment enabling the investigation of tissue/mesh integration has, to our knowledge, not been described previously.This proof-of-concept model was developed, for the investigation of peritoneal biology and the integration between tissue and different mesh material. It has the potential to be useful in studies on other important biological mechanisms involving the peritoneum.

  • 29.
    Folkesson, J
    et al.
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    Nilsson, J
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
    The circular stapling device as a risk factor for anastomotic leakage.2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 4, p. 275-9Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

  • 30.
    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, p. 5644-5650Article 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.

  • 31.
    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, p. 227-232Article 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.

  • 32.
    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, p. 1421-1426Article 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.

  • 33.
    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, p. 488-493Article 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.

  • 34.
    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, p. 145-9Article 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.

  • 35.
    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, p. 212-219Article 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.

  • 36.
    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, p. 927-932Article 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.

  • 37.
    Gkekas, Ioannis
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Novotny, Jan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Fabian, Pavel
    Department of Oncological Pathology, Masaryk Memorial Cancer Institute, Brno, Czech Republic.
    Nemecek, Radim
    Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Pecen, Ladislav
    Faculty Hospital Pilsen, Charles University, Prague, Czech Republic.
    Svoboda, Tomas
    Faculty Hospital Pilsen, Charles University, Prague, Czech Republic.
    Gurlich, Robert
    Department of Surgery, University Hospital Kralovske Vinohrady, Prague, Czech Republic.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Deficient mismatch repair as a prognostic marker in stage II colon cancer patients2019In: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 45, no 10, p. 1854-1861Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A number of reports have evaluated the relationship between deficient DNA mismatch repair (dMMR) and colorectal cancer prognosis. Unfortunately, the exact prognostic role of dMMR has not been clearly established due to contradictory results. This study aims to determine the prognostic impact of dMRR in stage II colon cancer patients only. The appropriate identification of high-risk stage II colon cancers is of paramount importance in the selection of patients who may benefit from adjuvant treatment after surgery.

    METHODS: Four hundred and fifty-two patients with curative resection of stage II colon cancer were included. Hospital records were used as data source, providing clinical, surgical, pathology, oncology and follow-up information for statistical analysis focusing on overall survival (OS) and time to progression (TTP). Mismatch repair status was determined by immunohistochemistry. Patient survival was followed-up for a mean of 77·35 months.

    RESULTS: dMMR was detected in 93 of 452 patients (20·6%). No impact on overall survival (Log-Rank, p = 0·583, 95% CI 0·76-1·67). However, the hazard ratio 0·50 for TTP was highly significant (Log-Rank, p = 0·012, 95% CI 0·28-0·87) in patients with dMMR compared with those with mismatch repair proficient tumours (pMMR).

    CONCLUSIONS: Patients with dMMR tumours have a lower risk for recurrence compared to those with pMMR tumours, but this finding did not correlate to better overall survival.

  • 38.
    Gkekas, Ioannis
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery, Sunderby hospital Luleå, Luleå, Sweden.
    Novotny, Jan
    Department of Surgery, Sunderby hospital Luleå, Luleå, Sweden..
    Pecen, Ladislav
    Faculty Hospital Pilsen, Charles University, Prague, Czech Republic.
    Strigård, Karin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Gunnarsson, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Microsatellite instability as a prognostic factor in stage II colon cancer patients: a meta-analysis of published literature2017In: Anticancer Research, ISSN 0250-7005, E-ISSN 1791-7530, Vol. 37, no 12, p. 6563-6574Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND/AIM: The prognostic role of microsatellite instability (MSI) in stage II colon cancer patients remains controversial despite the fact that it has been investigated in a number of studies. Hazard ratios differ considerably among these studies. We performed a meta-analysis to define the significance of MSI in this group of patients.

    MATERIALS AND METHODS: Studies indexed in PubMed presenting separate data on MSI status and survival outcomes for stage II colon cancer patients have been analyzed using fixed-effect meta-analysis of hazard ratio (HR) according to the method of Peto.

    RESULTS: Analysis was performed on 19 studies including 5,998 patients. A 47.3% of patients received postoperative chemotherapy and included 52.8% males and 47.2% females. Eight studies included some rectal cancer patients although this cohort was not clearly defined in 3 of these. MSI observed in 20.8% (mean) of patients (median 19.9%). HR for overall survival (OS) of MSI vs. microsatellite stable (MSS) tumors for the entire population: 0.73 (95% confidence interval (CI)=0.33-1.65); HR for disease-free survival (DFS):0.60 (95%CI=0.27-1.32). No statistical significant difference was found when studies analyzing MSI with genotyping (MG) and immunohistochemistry (IHC) were compared separately (MG vs. IHC: HR OS 0.45, 95%CI=0.10-2.05 vs. 0.95, 95%CI=0.57-1.58; HR DFS 0.51, 95%CI=0.14-1.85 vs. 0.67, 95%CI=0.26-1.70). However, numerically MSI determination with genotyping shows significantly lower hazard ratios for both DFS and OS. Separate analysis of studies describing colon cancer patients only showed HR OS 0.72 (95%CI=0.31-1.71); HR DFS 0.60 (95%CI=0.27-1.31).

    CONCLUSION: No significant relation was found between MSI status and OS or DFS. Routine determination of MSI status to guide postoperative management of stage II colon cancer patients cannot be recommended. New large scale high quality studies are needed to answer this question definitively, since currently analyzed studies vary considerably.

  • 39.
    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, p. 189-94Article 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.

  • 40.
    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, p. 89-94Article 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.

  • 41.
    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, p. 326-32Article 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.

  • 42.
    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, p. 69-73Article in journal (Refereed)
  • 43.
    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, p. 11-13Article in journal (Refereed)
  • 44.
    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, p. 1292-1296Article in journal (Other academic)
  • 45.
    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, p. 60-7Article 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)

  • 46.
    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, p. 417-421Article 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.

  • 47.
    Gunnarsson, Ulf
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Karlbom, U
    Docker, M
    Raab, Y
    Påhlman, L
    Proctocolectomy and pelvic pouch--is a diverting stoma dangerous for the patient?2004In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 1, p. 23-7Article in journal (Refereed)
    Abstract [en]

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

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

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

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

  • 48.
    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, p. 88-89Article 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.

  • 49.
    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, p. 441-7Article 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.

  • 50.
    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, p. 454-9Article 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.

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