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  • 1. Collin, A.
    et al.
    Jung, B.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Pahlman, L.
    Folkesson, J.
    Impact of mechanical bowel preparation on survival after colonic cancer resection2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 12, p. 1594-+Article in journal (Refereed)
    Abstract [en]

    Background: A randomized study in 1999-2005 of mechanical bowel preparation (MBP) preceding colonic resection found no decrease in postoperative complications. The aim of the present study was to evaluate the long-term effect of MBP regarding cancer recurrence and survival after colonic resections. Methods: The cohort of patients with colonic cancer in the MBP study was followed up for 10 years. Data were collected from registers run by the National Board of Health and Welfare. Register data were validated against information in patient charts. Cox proportional hazards model was used for multivariable analysis of factors predictive of cancer-specific survival. Results: Register analysis showed significantly fewer recurrences, and better cancer-specific and overall survival in the MBP group. After validation, 839 of 1343 patients remained for analysis (448 MBP, 391 no MBP). Eighty (17.9 per cent) of 448 patients in the MBP group and 88 (22.5 per cent) of 391 in the no-MBP group developed a cancer recurrence (P = 0.093). The 10-year cancer-specific survival rate was 84.1 per cent in the MBP group and 78.0 per cent in the no-MBP group (P = 0.019). Overall survival rates were 58.8 and 56.0 per cent respectively (P = 0.186). Conclusion: Patients receiving MBP before elective colonic cancer surgery had significantly better cancer-specific survival after 10 years.

  • 2.
    Haapamäki, Markku
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandzén, Birger
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Open cholecystectomy in the laparoscopic era:  Comment on (Br J Surg 2007; 94(11): 1382-1385)2008In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 4, p. 531-Article in journal (Refereed)
  • 3. Jung, Bärbel
    et al.
    Lannerstad, Olof
    Påhlman, Lars
    Arodell, Malin
    Unosson, Mitra
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Kirurgi.
    Preoperative mechanical preparation of the colon: the patient's experience2007In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 7, p. 5-Article in journal (Refereed)
    Abstract [en]

    Background Preoperative mechanical bowel preparation can be questioned as standard procedure in colon surgery, based on the result from several randomised trials.

    Methods As part of a large multicenter trial, 105 patients planned for elective colon surgery for cancer, adenoma, or diverticulitis in three hospitals were asked to complete a questionnaire regarding perceived health including experience with bowel preparation. There were 39 questions, each having 3 – 10 answer alternatives, dealing with food intake, pain, discomfort, nausea/vomiting, gas distension, anxiety, tiredness, need of assistance with bowel preparation, and willingness to undergo the procedure again if necessary.

    Results 60 patients received mechanical bowel preparation (MBP) and 45 patients did not (No-MBP). In the MBP group 52% needed assistance with bowel preparation and 30% would consider undergoing the same preoperative procedure again. In the No-MBP group 65 % of the patients were positive to no bowel preparation. There was no significant difference between the two groups with respect to postoperative pain and nausea. On Day 4 (but not on Days 1 and 7 postoperatively) patients in the No-MBP group perceived more discomfort than patients in the MBP group, p = 0.02. Time to intake of fluid and solid food did not differ between the two groups. Bowel emptying occurred significantly earlier in the No-MBP group than in the MBP group, p = 0.03.

    Conclusion Mechanical bowel preparation is distressing for the patient and associated with a prolonged time to first bowel emptying.

  • 4.
    Jung, Bärbel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Matthiessen, Peter
    Smedh, Kenneth
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Ransjö, Ulrika
    Påhlman, Lars
    Mechanical bowel preparation does not affect the intramucosal bacterial colony count2010In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 25, no 4, p. 439-442Article in journal (Refereed)
    Abstract [en]

    Purpose The aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon.

    Materials and methods Macroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection.

    Results MBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study.

    Conclusions MBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.

  • 5.
    Jung, Bärbel
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Påhlman, Lars
    Johansson, Robert
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish Rectal Cancer Registry 1995-20042009In: BMC Cancer, ISSN 1471-2407, E-ISSN 1471-2407, Vol. 9, p. 68-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Limited information is available regarding the effect of age on choice of surgical and oncological treatment for rectal cancer. The objective of this study was to assess the influence of age on treatment and outcome of rectal cancer. METHODS: We utilized data in the Swedish Rectal Cancer Registry (SRCR) from patients treated for rectal cancer in Sweden in 1995-2004. RESULTS: A total of 15,104 patients with rectal cancer were identified, 42.4% of whom were 75 years or older. Patients > or = 75 years were less likely to have distant metastases than younger patients (14.8% vs. 17.8%, P < 0.001), and underwent abdominal tumor resection less frequently (68.5% vs. 84.4%, P < 0.001). Of 11,725 patients with abdominal tumor resection (anterior resection [AR], abdominoperineal excision [APE], and Hartmann's procedure [HA]), 37.4% were > or = 75 years. Curative surgery was registered for 85.0% of patients > or = 75 years and for 83.9% of patients < 75 years, P = 0.11. Choice of abdominal operation differed significantly between the two age groups for both curative and non-curative surgery, The frequency of APE was similar in both age groups (29.5% vs. 28.6%), but patients > or = 75 years were more likely to have HA (16.9% vs. 4.9%) and less likely to have preoperative radiotherapy (34.3 vs. 67.2%, P < 0.001). The relative survival rate at five years for all patients treated with curative intent was 73% (70-75%) for patients > or = 75 years and 78% (77-79%) for patients < 75 years of age. Local recurrence rate was 9% (8-11%) for older and 8% (7-9%) for younger patients. CONCLUSION: Treatment of rectal cancer is influenced by patient's age. Future studies should include younger and older patients alike to reveal whether or not age-related differences are purposive. Local recurrence following surgery for low tumors and quality of life aspects deserve particular attention.

  • 6.
    Jung, Bärbel
    et al.
    Kirurgi.
    Påhlman, Lars
    Nyström, P-O
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Kirurgi.
    Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 6, p. 689-695Article in journal (Refereed)
    Abstract [en]

    Background: Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery. This randomized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery.

    Methods: A total of 1505 patients, aged 18-85 years with American Society of Anesthesiologists grades I-III, were randomized to MBP or no MBP before open elective surgery for cancer, adenoma or diverticular disease of the colon. Primary endpoints were cardiovascular, general infectious and surgical-site complications within 30 days, and secondary endpoints were death and reoperations within 30 days.

    Results: A total of 1343 patients were evaluated, 686 randomized to MBP and 657 to no MBP. There were no significant differences in overall complications between the two groups: cardiovascular complications occurred in 5.1 and 4.6 per cent respectively, general infectious complications in 7.9 and 6.8 per cent, and surgical-site complications in 15.1 and 16.1 per cent. At least one complication was recorded in 24.5 per cent of patients who had MBP and 23.7 per cent who did not.

    Conclusion: MBP does not lower the complication rate and can be omitted before elective colonic resection.

  • 7.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Invited commentary by E. Nilsson to the use of hernia registers for improving patient outcome (manuscripts by Stechemesser et al. and Muysoms et al.)2012In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 16, no 3, p. 237-238Article in journal (Other academic)
  • 8.
    Nilsson, Hanna
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery, Sahlgrenska University Hospitalt, Göteborg, Sweden.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Angerås, U
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Mortality after groin hernia surgery: delay of treatment and cause of death2011In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 3, p. 301-307Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Emergency hernia surgery, in contrast to elective hernia surgery, is associated with appreciable mortality. Incarcerated hernia is the second most common cause of small bowel obstruction after adhesions, and the leading cause of bowel strangulation.

    METHODS: Information on patients who died within 30 days of groin hernia surgery was retrieved from the Swedish Hernia Register, from the Cause-of-Death Register, and from hospital notes.

    RESULTS: Of 103,710 groin hernia operations between 1992 and 2004, 292 patients died within 30 days of surgery. Hospital notes and cause of death were retrieved for 242 cases (82%). In 5 of these patients, the hernia operation was done in addition to more urgent surgery and therefore excluded from further analyses; 152 patients were admitted as emergency cases and 55 of these patients underwent bowel resection. A total of 107 patients had signs of bowel obstruction when admitted. For 37% of these patients, physical examination of the groin was not documented. Patients with bowel obstruction without a note on a palpable groin lump were more likely to undergo imaging investigation preoperatively (P < 0.001) and they had an increased time to surgery compared to patients with a palpable lump. Women and patients with femoral hernia were significantly less likely to undergo a groin examination compared to other patients. Local anaesthesia was used in 7% of all patients who died postoperatively, and in 3% of emergency cases. Pulmonary disease, sepsis and malignant disease were more common as causes of death after emergency surgery than after elective surgery.

    CONCLUSIONS: Groin examination of patients presenting with bowel obstruction is of utmost importance in order to minimise delay to hernia surgery.

  • 9.
    Nilsson, Hanna
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery, Sahlgrenska University Hospitalt, Göteborg, Sweden.
    Stylianidis, Georgios
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Mortality after groin hernia surgery2007In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 245, no 4, p. 656-660Article in journal (Refereed)
    Abstract [en]

    Objective: To analyze mortality following groin hernia operations.

    Summary Background Data: It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail.

    Methods: The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden.

    Results: A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%.

    Conclusions: Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.

  • 10.
    Nordin, Pär
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Zetterström, H
    Carlsson, P
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial2007In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 94, no 4, p. 500-505Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice.

    METHODS: Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates.

    RESULTS: Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0.001). The advantage was also significant for total hospital and total healthcare costs (P < 0.001), whereas there was no significant difference between regional and general anaesthesia.

    CONCLUSION: The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.

  • 11.
    Rosenmuller, Mats H
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Authors' reply: Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy (Br J Surg 2013; 100: 886-894)2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 3, p. 288-289Article in journal (Refereed)
  • 12.
    Rosenmuller, Mats H.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ornberg, M. Thoren
    Myrnäs, Torbjörn
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lundberg, Owe
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy2013In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 100, no 7, p. 886-894Article in journal (Refereed)
    Abstract [en]

    Background: Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC. Methods: Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents. Results: Some 74.9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0.030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P < 0.001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions. Conclusion: SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. Registration number: NCT00370344 (http://www.clinicaltrials.gov).

  • 13.
    Rosenmüller, Mats H
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Authors' reply: Expertise-based randomized clinical trial of laparoscopic versus small-incision open cholecystectomy (Br J Surg 2013; 100: 886–894)2014In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 101, no 3, p. 288-289Article in journal (Other academic)
  • 14.
    Rosenmüller, Mats H.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindberg, Fredrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Åberg, Sten-Olof
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamaki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Costs and quality of life of small-incision open cholecystectomy and laparoscopic cholecystectomy: an expertise-based randomised controlled trial2017In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 17, article id 48Article in journal (Refereed)
    Abstract [en]

    Background: Health care providers need solid evidence based data on cost differences between alternative surgical procedures for common surgical disorders. We aimed to compare small-incision open cholecystectomy (SIOC) and laparoscopic cholecystectomy (LC) concerning costs and health-related quality of life using data from an expertise-based randomised controlled trial. Methods: Patients scheduled for cholecystectomy were assigned to undergo LC or SIOC performed by surgeons in two different expert groups. Total costs were calculated in USD. Reusable instruments were assumed for the cost analysis. Quality of life was measured using the EuroQol 5-D 3-L (EQ 5-D-3L), at five postoperative time points and calculated to Area Under Curve (AUC) for 1 year postoperatively. Two hospitals participated in the trial, which included both emergency and elective surgery. Results: Of 477 patients that underwent a cholecystectomy during the study period, 355 (74.9%) were randomised and 323 analysed, 172 LC and 151 SIOC patients. Both direct and total costs were less for SIOC than for LC patients. The total costs were 5429 (4293-6932) USD for LC and 4636 (3905-5746) USD for SIOC, P = 0.001. The quality of life index did not differ between the LC and SIOC groups at any time. Median values (25th and 75th percentiles (p25-p75)) for AUC at 1 year were as follows: 349 (337-351) for LC and 349 (338-350) for SIOC. Conclusions: In this expertise-based randomised controlled trial LC was a more costly procedure and quality of life did not differ after SIOC and LC. (ClinicalTrials.gov Identifier: NCT00370344, August 30, 2006).

  • 15.
    Rosenmüller, Mats
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Surgery Östersunds Hospital, Östersund, Sweden .
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cholecystectomy in Sweden 2000 - 2003: a nationwide study on procedures, patient characteristics, and mortality2007In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 7, no 1, p. 35-Article in journal (Refereed)
    Abstract [en]

    Background: Epidemiological data on characteristics of patients undergoing open or laparoscopic cholecystectomy are limited. In this register study we examined characteristics and mortality of patients who underwent cholecystectomy during hospital stay in Sweden 2000 – 2003.

    Methods: Hospital discharge and death certificate data were linked for all patients undergoing cholecystectomy in Sweden from January 1st 2000 through December 31st 2003. Mortality risk was calculated as standardised mortality ratio (SMR) i.e. observed over expected deaths considering age and gender of the background population.

    Results: During the four years of the study 43072 patients underwent cholecystectomy for benign biliary disease, 31144 (72%) using a laparoscopic technique and 11928 patients (28%) an open procedure (including conversion from laparoscopy). Patients with open cholecystectomy were older than patients with laparoscopic cholecystectomy (59 vs 49 years, p < 0.001), they were more likely to have been admitted to hospital during the year preceding cholecystectomy, and they had more frequently been admitted acutely for cholecystectomy (57% Vs 21%, p < 0.001). The proportion of women was lower in the open cholecystectomy group compared to the laparoscopic group (57% vs 73%, p < 0.001). Hospital stay was 7.9 (8.9) days, mean (SD), for patients with open cholecystectomy and 2.6 (3.3) days for patients with laparoscopic cholecystectomy, p < 0.001. SMR within 90 days of index admission was 3.89 (3.41–4.41) (mean and 95% CI), for patients with open cholecystectomy and 0.73 (0.52–1.01) for patients with laparoscopic cholecystectomy. During this period biliary disease accounted for one third of all deaths in both groups. From 91 to 365 days after index admission, SMR for patients in the open group was 1.01 (0.87–1.16) and for patients in the laparoscopic group 0.56 (0.44–0.69).

    Conclusion: Laparoscopic cholecystectomy is performed on patients having a lower mortality risk than the general Swedish population. Patients with open cholecystectomy are more sick than patients with laparoscopic cholecystectomy, and they have a mortality risk within 90 days of admission for cholecystectomy, which is four times that of the general population. Further efforts to reduce surgical trauma in open biliary surgery are motivated.

  • 16.
    Rutegård, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gümüsçü, Rojda
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stylianidis, G.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Chronic pain, discomfort, quality of life and impact on sex life after open inguinal hernia mesh repair: an expertise-based randomized clinical trial comparing lightweight and heavyweight mesh2018In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 22, no 3, p. 411-418Article in journal (Refereed)
    Abstract [en]

    PURPOSE: There is a paucity of high-quality evidence concerning mesh choice in open inguinal hernia repair. Using an expertise-based randomized clinical trial design, we aimed to evaluate the postoperative impact of two different mesh types on pain and discomfort, quality of life and sex life.

    METHODS: , ULTRAPRO™, Ethicon). Follow-up data were collected by questionnaires and outpatient visits in the range of 1-3 years after surgery.

    RESULTS: Some 412 patients were randomized and 363 patients were analysed. There was no difference in pain between groups after surgery but a statistically significant difference concerning awareness of a groin lump and groin discomfort, favouring the lightweight group 1 year after surgery. No differences in quality of life between groups could be detected but both groups had a substantially better quality of life postoperatively, as compared to before surgery. In the analysis of impact on sex life, no differences between mesh groups were found.

    CONCLUSION: The Lichtenstein operation performed for primary inguinal hernia improves quality of life for most of the male patients, independently of the type of mesh used. The lightweight mesh group experienced less awareness of a groin lump and groin discomfort 1 year postoperatively. ClinicalTrials.gov Identifier: NCT00451893.

  • 17.
    Sandzén, Birger
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stenlund, Hans C
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Treatment of Common Bile Duct Stones in Sweden 1989-2006: An Observational Nationwide Study of a Paradigm Shift2012In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 36, no 9, p. 2146-2153Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden. METHODS: All patients with hospital care for benign biliary diagnoses 1988-2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis. RESULTS: Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n = 26,815), 60.0 % underwent cholecystectomy during the first hospital admission in 1989-1994, compared to 30.1 % in 2001-2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission. CONCLUSIONS: Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.

  • 18.
    Sandzén, Birger
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study2009In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 9, p. 80-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Gallstones represent the most common cause of acute pancreatitis in Sweden. Epidemiological data concerning timing of cholecystectomy and sphincterotomy in patients with first attack of mild acute biliary pancreatitis (MABP) are scarce. Our aim was to analyse readmissions for biliary disease, cholecystectomy within one year, and mortality within 90 days of index admission for MABP.

    METHODS: Hospital discharge and death certificate data were linked for patients with first attack acute pancreatitis in Sweden 1988-2003. Mortality was calculated as case fatality rate (CFR) and standardized mortality ratio (SMR). MABP was defined as acute pancreatitis of biliary aetiology without mortality during an index stay of 10 days or shorter. Patients were analysed according to four different treatment policies: Cholecystectomy during index stay (group 1), no cholecystectomy during index stay but within 30 days of index admission (group 2), sphincterotomy but not cholecystectomy within 30 days of index admission (group 3), and neither cholecystectomy nor sphincterotomy within 30 days of index admission (group 4).

    RESULTS: Of 11636 patients with acute biliary pancreatitis, 8631 patients (74%) met the criteria for MABP. After exclusion of those with cholecystectomy or sphincterotomy during the year before index admission (N = 212), 8419 patients with MABP remained for analysis. Patients in group 1 and 2 were significantly younger than patients in group 3 and 4. Length of index stay differed significantly between the groups, from 4 (3-6) days, (representing median, 25 and 75 percentiles) in group 2 to 7 (5-8) days in groups 1. In group 1, 4.9% of patients were readmitted at least once for biliary disease within one year after index admission, compared to 100% in group 2, 62.5% in group 3, and 76.3% in group 4. One year after index admission, 30.8% of patients in group 3 and 47.7% of patients in group 4 had undergone cholecystectomy. SMR did not differ between the four groups.

    CONCLUSION: Cholecystectomy during index stay slightly prolongs this stay, but drastically reduces readmissions for biliary indications.

  • 19.
    Sandzén, Birger
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Surgery for acute gallbladder disease in Sweden 1989-2006: A register study2013In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 48, no 4, p. 480-486Article in journal (Refereed)
    Abstract [en]

    Objective. Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure. Material and methods. Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality. Results. Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years. Conclusions. Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.

  • 20.
    Sandzén, Birger
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Rosenmüller, Mats
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku M
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stenlund, Hans C
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öman, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    First attack of acute pancreatitis in Sweden 1988 - 2003: incidence, aetiological classification, procedures and mortality - a register study2009In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 9, p. 18-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Population-based studies suggest that the incidence of first attack of acute pancreatitis (FAAP) is increasing and that old age is associated with increased mortality. Because nationwide data are limited and information on standardized mortality ratio (SMR) versus age is lacking, we wanted to describe incidence and mortality of first attack acute pancreatitis (FAAP) in Sweden.

    METHODS: Hospital discharge data concerning diagnoses and surgical procedures and death certificate data were linked for patients with FAAP in Sweden. Mortality was calculated as case fatality rate (CFR), i.e. deaths per 1000 patients and SMR using age-, gender- and calendar year-specific expected survival estimates, and is given as mean with 95% confidence intervals. Data are presented as median values with 25% and 75% percentiles, means and standard deviations, or proportions. Proportions have been compared using the chi square test, Poisson-regression test or Fisher exact test. Location of two groups of ratio scale variables were compared using independent samples t-test or Mann-Whitney U-test.

    RESULTS: From 1988 through 2003, 43415 patients (23801 men and 19614 women) were admitted for FAAP. Age adjusted incidence rose from 27.0 to 32.0 per 100000 individuals and year. Incidence increased with age for both men and women. At index stay 19.7% of men and 35.4% of women had biliary diagnoses, and 7.1% of men and 2.1% of women alcohol-related diagnoses. Of 10072 patients who underwent cholecystectomy, 7521 (74.7%) did so after index stay within the audit period. With increasing age CFR increased and SMR decreased. For the whole period studied SMR was 11.75 (11.34-12.17) within 90 days of index admission and 2.03 (1.93-2.13) from 91 to 365 days. Alcohol-related diagnoses and young age was associated with increased SMR. Length of stay and SMR decreased significantly during the audit period.

    CONCLUSION: Incidence of FAAP increased slightly from 1988 to 2003. Incidence increased and SMR declined with increasing patient age. Although the prognosis for patients with FAAP has improved it remains an important health problem. Aetiological classification at index stay and timing of cholecystectomy should be improved.

  • 21.
    Sevonius, D
    et al.
    Department of Surgery, Lund University Hospital, Lund, Sweden.
    Gunnarsson, Ulf
    CLINTEC, Karolinska Institute, Stockholm, Sweden.
    Nordin, Pär
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, G
    CLINTEC, Karolinska Institute, Stockholm, Sweden.
    Recurrent groin hernia surgery2011In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 98, no 10, p. 1489-1494Article in journal (Refereed)
    Abstract [en]

    Background: The reoperation rate after recurrent groin hernia surgery is more than twice that recorded for primary groin hernia procedures. The aim was to define the outcome from routine redo hernia surgery by analysing a large population-based cohort from a national hernia register.

    Methods: All recurrent groin hernia operations registered in the Swedish Hernia Register from 1992 to 2008 were analysed using multivariable analysis with stratification for preceding repair.

    Results: Altogether 174 527 hernia operations were recorded in the Swedish Hernia Register between 1992 and 2008, including 19 582 reoperations. The preceding repair was included in the register for 5565 of these recurrent repairs. With laparoscopic repair as reference standard, the hazard ratio for recurrence was 2.55 (95 per cent confidence interval 1.66 to 3.93) after sutured repair, 1.53 (1.20 to 1.95) after Lichtenstein repair, 2.31 (1.76 to 3.03) after plug repair, 1.36 (0.95 to 1.94) after open preperitoneal mesh and 3.08 (2.22 to 4.29) after other repairs. Laparoscopic and open preperitoneal repair were associated with a lower risk of reoperation following a preceding open repair (P < 0.001), but no technique differed significantly from the others following a preceding preperitoneal repair.

    Conclusion: The laparoscopic and the open preperitoneal mesh methods of repair for recurrent groin hernias were associated with the lowest risk of reoperation. Although the method of repair in previous surgery must be considered, these techniques are the preferred methods for recurrent groin hernia surgery.

  • 22.
    Sevonius, Dan
    et al.
    Department of Surgery, University Hospital of Lund, Lund, Sweden.
    Gunnarsson, Ulf
    CLINTEC, Division of Surgery, Karolinska Institute, Stockholm, Sweden.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, Gabriel
    Department of Surgery, University Hospital of Lund, Lund, Sweden.
    Repeated groin hernia recurrences.2009In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 249, no 3, p. 516-518Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the characteristics of patients undergoing multiple groin hernia repairs and to identify strategies that prevent further recurrence. SUMMARY BACKGROUND DATA: Although relatively infrequent, recurrent groin hernias where several repairs have previously been undertaken constitutes a major problem in hernia surgery. Low numbers and heterogeneity have made it difficult to perform large prospective studies on this group. METHODS: The study was designed as an observational population-based register study. All repairs for recurrent hernia recorded in the Swedish Hernia Register (SHR) 1992-2006 were identified. Risk for reoperation by number of previous repairs, with adjustment for gender and age, and risk for reoperation by unit responsible for previous repair were determined using Cox proportional hazard analysis. RESULTS: There were 12,104 cases of hernia repaired once, 2 repairs in 4199 cases, 3 repairs in 310 cases, 4 repairs in 32 cases, and 5 repairs in 3 cases. The risk for further reoperation increased with the number of previous repairs (P < 0.001). The hazard ratios for reoperation following open preperitoneal mesh repair and laparoscopic repair decreased; whereas, the hazard ratio for sutured repair increased with the number of previous repairs. The difference between Lichtenstein repair and laparoscopic repair was significant for the first 2 repairs (P < 0.05). CONCLUSION: Laparoscopic preperitoneal repair provides the best surgical outcome in repeated groin hernia recurrence.

  • 23.
    Stylianidis, Giorgios
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Haapamäki, Markku
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nilsson, Erik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Management of the hernial sac in inguinal hernia repair.2010In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 97, no 3, p. 415-419Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is no consensus on the best management of the indirect hernial sac in groin hernia surgery. The aim of this study was to investigate to what extent different management options are associated with reoperation for recurrence. METHODS: This study used data from the Swedish Hernia Register. Surgeons registered whether the indirect hernial sac was managed by division (leaving the distal part in place), excision or invagination. RESULTS: An indirect hernia was found in 48 433 operations; the sac was excised in 49.5 per cent, invaginated in 37.6 per cent and divided in 12.9 per cent of operations. The 5-year cumulative reoperation incidence was 1.7 per cent for hernial sac excision, 1.7 per cent for division and 2.7 per cent for invagination. For indirect hernia repair, the relative risk of reoperation for recurrence was 0.63 (95 per cent confidence interval 0.51 to 0.79) for excision of the sac and 0.72 (0.53 to 0.99) for division compared with invagination. Lichtenstein repair combined with hernial sac excision had a 5-year cumulative reoperation incidence of only 1.0 per cent. CONCLUSION: Excision of the indirect hernial sac in inguinal hernia repair is associated with a lower risk of hernia recurrence than division or invagination.

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