umu.sePublications
Change search
Refine search result
1 - 31 of 31
CiteExportLink to result list
Permanent link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Rows per page
  • 5
  • 10
  • 20
  • 50
  • 100
  • 250
Sort
  • Standard (Relevance)
  • Author A-Ö
  • Author Ö-A
  • Title A-Ö
  • Title Ö-A
  • Publication type A-Ö
  • Publication type Ö-A
  • Issued (Oldest first)
  • Issued (Newest first)
  • Created (Oldest first)
  • Created (Newest first)
  • Last updated (Oldest first)
  • Last updated (Newest first)
  • Disputation date (earliest first)
  • Disputation date (latest first)
  • Standard (Relevance)
  • Author A-Ö
  • Author Ö-A
  • Title A-Ö
  • Title Ö-A
  • Publication type A-Ö
  • Publication type Ö-A
  • Issued (Oldest first)
  • Issued (Newest first)
  • Created (Oldest first)
  • Created (Newest first)
  • Last updated (Oldest first)
  • Last updated (Newest first)
  • Disputation date (earliest first)
  • Disputation date (latest first)
Select
The maximal number of hits you can export is 250. When you want to export more records please use the Create feeds function.
  • 1. Ahlborg, Liv
    et al.
    Hedman, Leif
    Nisell, Henry
    Felländer-Tsai, Li
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; Center for Advanced Medical Simulation and Training (CAMST), Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Simulator training and non-technical factors improve laparoscopic performance among OBGYN trainees2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 10, p. 1194-1201Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate how simulator training and non-technical factors affect laparoscopic performance among residents in obstetrics and gynecology. DESIGN: In this prospective study, trainees were randomized into three groups. The first group was allocated to proficiency-based training in the LapSimGyn(®) virtual reality simulator. The second group received additional structured mentorship during subsequent laparoscopies. The third group served as control group. At baseline an operation was performed and visuospatial ability, flow and self-efficacy were assessed. All groups subsequently performed three tubal occlusions. Self-efficacy and flow were assessed before and/or after each operation. SETTING: Simulator training was conducted at the Center for Advanced Medical Simulation and Training, Karolinska University Hospital. Sterilizations were performed at each trainee's home clinic. POPULATION: Twenty-eight trainees/residents from 21 hospitals in Sweden were included. METHODS/MAIN OUTCOME MEASURES: Visuospatial ability was tested by the Mental Rotation Test-A. Flow and self-efficacy were assessed by validated scales and questionnaires. Laparoscopic performance was measured as the duration of surgery. Visuospatial ability, self-efficacy and flow were correlated to the laparoscopic performance using Spearman's correlations. Differences between groups were analyzed by the Mann-Whitney U-test. RESULTS: No differences across groups were detected at baseline. Self-efficacy scores before and flow scores after the third operation were significantly higher in the trained groups. Duration of surgery was significantly shorter in the trained groups. Flow and self-efficacy correlate positively with laparoscopic performance. CONCLUSIONS: Simulator training and non-technical factors appear to improve the laparoscopic performance among trainees/residents in obstetrics and gynecology.

  • 2. Ahlborg, Liv
    et al.
    Weurlander, Maria
    Hedman, Leif
    Nisel, Henry
    Lindqvist, Pelle G
    Felländer-Tsai, Li
    Enochsson, Lars
    Individualized feedback during simulated laparoscopic training: a mixed methods study.2015In: International Journal of Medical Education, ISSN 2042-6372, E-ISSN 2042-6372, Vol. 6, p. 93-100Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: This study aimed to explore the value of individualized feedback on performance, flow and self-efficacy during simulated laparoscopy. Furthermore, we wished to explore attitudes towards feedback and simulator training among medical students.

    METHODS: Sixteen medical students were included in the study and randomized to laparoscopic simulator training with or without feedback. A teacher provided individualized feedback continuously throughout the procedures to the target group. Validated questionnaires and scales were used to evaluate self-efficacy and flow. The Mann-Whitney U test was used to evaluate differences between groups regarding laparoscopic performance (instrument path length), self-efficacy and flow. Qualitative data was collected by group interviews and interpreted using inductive thematic analyses.

    RESULTS: Sixteen students completed the simulator training and questionnaires. Instrument path length was shorter in the feedback group (median 3.9 m; IQR: 3.3-4.9) as compared to the control group (median 5.9 m; IQR: 5.0-8.1), p<0.05. Self-efficacy improved in both groups. Eleven students participated in the focus interviews. Participants in the control group expressed that they had fun, whereas participants in the feedback group were more concentrated on the task and also more anxious. Both groups had high ambitions to succeed and also expressed the importance of getting feedback. The authenticity of the training scenario was important for the learning process.

    CONCLUSIONS: This study highlights the importance of individualized feedback during simulated laparoscopy training. The next step is to further optimize feedback and to transfer standardized and individualized feedback from the simulated setting to the operating room.

  • 3. Arnelo, Urban
    et al.
    Siiki, Antti
    Swahn, Fredrik
    Segersvärd, Ralf
    Enochsson, Lars
    del Chiaro, Marco
    Lundell, Lars
    Verbeke, Caroline S
    Löhr, J-Matthias
    Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN)2014In: Pancreatology (Print), ISSN 1424-3903, E-ISSN 1424-3911, Vol. 14, no 6, p. 510-514Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVE: Even when advanced cross-sectional imaging modalities have been employed, endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMN) is often required in order to assess the final character and extent of lesions. The current study addresses the use of SpyGlass single-operator peroral pancreatoscopy in suspected IPMN.

    DESIGN: A prospective, non-randomized exploratory cohort study.

    SETTING: Single-center.

    PATIENTS AND INTERVENTION: A prospective study-cohort of 44 consecutive patients in a single tertiary referral center who underwent ERCP and peroral pancreatoscopy, was prospectively collected between July 2007 and March 2013 because of a radiological signs of IPMN. These IPMN-findings were discovered incidentally in 44% of the cases.

    MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy (specificity & sensitivity) and complications.

    RESULTS: The targeted region of the pancreatic duct was reached with the SpyGlass system in 41 patients (median age 65 years, 41% female). Three patients were excluded from analysis because of failed deep cannulation of the pancreatic duct. Brush cytology was taken in 88% and direct biopsies in 41%. IPMN with intermediate or high-grade dysplasia was the main final diagnosis (76%) in 22 patients who had surgery. Out of the 17 patients with a final diagnosis of MD-IPMN, 76% were correctly identified by pancreatoscopy. Of the 9 patients with a final diagnosis of BD-IPMN, the pancreatoscopy identified 78% of the cases correctly.The incidence of post-ERCP pancreatitis was 17%. Pancreatoscopy was found to have provided additional diagnostic information in the vast majority of the cases and to affect clinical decision-making in 76%.

    LIMITATIONS: Single-center study.

    CONCLUSIONS: Single-operator peroral pancreatoscopy contributed to the clinical evaluation of IPMN lesions and influenced decision-making concerning their clinical management. The problem of post-procedural pancreatitis needs further attention.

  • 4. Blohm, My
    et al.
    Österberg, Johanna
    Sandblom, Gabriel
    Lundell, Lars
    Hedberg, Mats
    Enochsson, Lars
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden.
    The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks2017In: Journal of Gastrointestinal Surgery, ISSN 1091-255X, E-ISSN 1873-4626, Vol. 21, no 1, p. 33-40Article in journal (Refereed)
    Abstract [en]

    Up-front cholecystectomy is the recommended therapy for acute cholecystitis (AC). However, the scientific basis for the definition of the optimal timing for surgery is scarce. The aim of this study was to analyze how the timing of surgery, after the admission to hospital for AC, affects the intra- and postoperative outcomes. Within the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), all patients undergoing cholecystectomy for acute cholecystitis between January 2006 and December 2014 were identified. Data regarding patient characteristics, intra- and postoperative adverse events (AEs), bile duct injuries, and 30- and 90-day mortality risk were captured, and the correlation between the surgical timing and these parameters was analyzed. In total, data on 87,108 cholecystectomies were analyzed of which 15,760 (18.1 %) were performed due to AC. Bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The time course between surgery and complication risks seemed to be optimal if surgery was done within 2 days after hospital admission. Although AC patients operated on the day of hospital admission had a slightly increased AE rate as well as 30- and 90-day mortality rates than those operated during the interval of 1-2 days after admission, the bile duct injury and conversion rates were, in fact, significantly lower. The optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission. However, the somewhat higher frequency of AE on admission day may emphasize the importance of optimizing the patient before surgery as well as ensuring that adequate surgical resources are available.

  • 5. D'souza, Melroy A.
    et al.
    Isaksson, Bengt
    Löhr, Matthias
    Enochsson, Lars
    Department of Clinical Science, Intervention, and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Swahn, Fredrik
    Lundell, Lars
    Arnelo, Urban
    The clinicopathological spectrum and management of intraductal papillary mucinous neoplasm of the bile duct (IPMN-B)2013In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 48, no 4, p. 473-479Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) is a rare but increasingly diagnosed clinical entity. Typical cholangioscopic findings usually include intraductal protruding papillary tumors that secrete mucus.

    METHODS: Clinical, radiological and histopathological data of seven consecutive patients who were found to have IPMN-B were analyzed.

    RESULTS: Six of the seven patients presented with obstructive jaundice/cholangitis as the presenting complaint. ERCP and other imaging were equivocal in five of these patients and peroral cholangioscopy (POCS, single-operator cholangioscopy system) was performed. This revealed mucin-producing intraductal tumors with numerous frond-like papillary projections; a macroscopic appearance consistent with IPMN-B. Preoperative biopsy revealed adenoma, with low-grade dysplasia in two patients and high-grade dysplasia in three. Three patients underwent Whipple resection; one underwent total pancreatectomy with left hepatectomy, one patient a pancreas preserving duodenectomy with common bile duct reimplantation and one patient an extended right hepatectomy. These patients were found to have IPMN-B with adenomatous changes with varying grades of dysplasia and even cholangiocarcinoma on final histopathology. One patient first underwent endoscopic papillectomy and on follow-up was found to have cholangiocarcinoma with metastases to the liver.

    CONCLUSION: POCS can be a key diagnostic investigation in the evaluation of patients with papillary tumors of the bile duct. IPMN-B has a heterogenous pathology and varying grades of dysplasia and even carcinoma may exist in the same patient. Surgical management should be radical and based on tumor extent.

  • 6.
    Enochsson, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Sunderby Research Unit, Luleå.
    Blohm, My
    Sandblom, Gabriel
    Jonas, Eduard
    Hallerbäck, Bengt
    Lundell, Lars
    Österberg, Johanna
    Inversed relationship between completeness of follow-up and coverage of postoperative complications in gallstone surgery and ERCP: a potential source of bias in patient registers2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 1, article id e019551Article in journal (Refereed)
    Abstract [en]

    Objective: To analyse the completeness in GallRiks of the follow-up frequency in relation to the intraoperative and postoperative outcome.

    Design: Population-based register study.

    Setting: Data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP), GallRiks.

    Population: All cholecystectomies and ERCPs recorded in GallRiks between 1 January 2006 and 31 December 2014.

    Main outcome measures: Outcomes for intraprocedural as well as postprocedural adverse events between units with either a 30-day follow-up of AO% compared with those with a less frequent follow-up (<90%).

    Results: Between 2006 and 2014, 162 212 cholecystectomies and ERCP procedures were registered in GallRiks. After the exclusion of non-index procedures and those with incomplete data 152 827 procedures remained for final analyses. In patients having a cholecystectomy, there were no differences regarding the adverse event rates, irrespective of the follow-up frequency. However, in the more complicated endoscopic ERCP procedures, the postoperative adverse event rates were significantly higher in those with a more frequent and complete 30-day follow-up (OR 1.92; 95% Cl 1.76 to 2.11).

    Conclusions: Differences in the follow-up frequency in registries affect the reported outcomes as exemplified by the complicated endoscopic ERCP procedures. A high and complete follow-up rate shall serve as an additional quality indicator for surgical registries.

  • 7. Enochsson, Lars
    et al.
    Sandblom, Gabriel
    Österberg, Johanna
    Thulin, Anders
    Hallerbäck, Bengt
    Persson, Gunnar
    Kvalitetsregister för gallstenskirurgi har förbättrat vården2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, article id DCE6Article in journal (Refereed)
    Abstract [sv]

    The Swedish Registry for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks) is a validated register with high coverage. The registry started on May 1, 2005 and serves as a base for audit on gallstone disease treatment and also provides a database for clinical research. The aim of this study is to present an overview of the clinical consequences and implementations in patient care that GallRiks research may have contributed to during a 10-year period. Results from studies on GallRiks data have reduced the use of antibiotic and thromboembolic prophylaxis as well as showed the importance of intraoperative cholangiography. Furthermore, the studies on GallRiks data have most probably changed the treatment strategies in ERCP. Studies on GallRiks data have changed and improved the management of patients in Sweden who undergo gallstone surgery or ERCP.

  • 8. Enochsson, Lars
    et al.
    Thulin, Anders
    Osterberg, Johanna
    Sandblom, Gabriel
    Persson, Gunnar
    The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks): A nationwide registry for quality assurance of gallstone surgery.2013In: JAMA Surgery, ISSN 2168-6254, E-ISSN 2168-6262, Vol. 148, no 5, p. 471-8Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe the process of initiating and organizing a nationwide validated web-based quality registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (ERCP) and to present some clinical data and the impact the registry has had on the clinical treatment of gallstones.

    DESIGN: Observational, population-based registry study.

    SETTING: Data from the nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks).

    PATIENTS: From May 1, 2005, to December 31, 2011, 63 685 cholecystectomies (laparoscopic and open) and 37 860 ERCPs have been prospectively registered in GallRiks.

    INTERVENTIONS: Cholecystectomies, laparoscopic or conventional, as well as ERCP in a population-based setting.

    MAIN OUTCOME MEASURES: Registrations of all cholecystectomies and ERCPs are performed online by the surgeon or endoscopist. Thirty-day follow-up of both gallstone surgery and ERCP is mandatory, as is an additional 6-month follow-up of the cholecystectomies. Scores on the 36-Item Short Form Health Survey are registered preoperatively and 6 months postoperatively in elective cholecystectomies at selected units.

    RESULTS: The 30-day overall complication rate is 6.1% in elective cholecystectomy, 11.2% in urgent cholecystectomy, and 12.0% following ERCP. The use of antibiotic and thromboembolic prophylaxis in elective laparoscopic cholecystectomy in Sweden has decreased by 8.7% and 17.8% (2006-2011), respectively, mainly owing to presentation of GallRiks data both at meetings and published in peer-reviewed publications. The large database has also enabled several research projects, including one demonstrating that the intention to perform intraoperative cholangiography reduced the risk of death after cholecystectomy. The database has reached greater than 90% national coverage and is continuously validated.

    CONCLUSIONS: GallRiks is a validated national quality registry for gallstone surgery and ERCP, serving as a base for audit of gallstone disease treatment. It also provides a database for clinical research.

  • 9. Haraldsson, E
    et al.
    Lundell, L
    Swahn, F
    Enochsson, Lars
    Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
    Löhr, J M
    Arnelo, U
    Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study.2017In: United European Gastroenterology journal, ISSN 2050-6406, E-ISSN 2050-6414, Vol. 5, no 4, p. 504-510Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla.

    OBJECTIVE: The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience.

    METHODS: An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, 'classic appearance'; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists.

    RESULTS: Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58-0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59-0.72).

    CONCLUSION: The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.

  • 10. Haraldsson, Erik
    et al.
    Swahn, Fredrik
    Verbeke, Caroline
    Mattsson, Johanna S M
    Enochsson, Lars
    Ung, Kjell-Arne
    Lundell, Lars
    Heuchel, Rainer
    Löhr, J-Matthias
    Arnelo, Urban
    Endoscopic papillectomy and KRAS expression in the treatment of adenoma in the major duodenal papilla.2015In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 50, no 11, p. 1419-1427Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The use of endoscopic papillectomy for resecting adenomas in the major duodenal papilla is increasing. This study focuses on the following three issues: Can endoscopic papillectomy be performed as a safe diagnostic and/or therapeutic procedure in biopsy-verified or suspected ampullary adenoma? Does expression of mutated KRAS in resected adenomatous tissue predict long-term outcome? What other factors may affect long-term outcome and should, therefore, be considered in decision making prior to endoscopic papillectomy?

    MATERIAL AND METHODS: Thirty-six prospectively collected patients who underwent endoscopic papillectomy at Karolinska University Hospital between 2005 and 2014 were analyzed.

    RESULTS: The rate of exact agreement between the histomorphological grading of the endoscopic biopsies and the papillectomy specimens was low (48%). Obstructive jaundice at presentation increased the risk of undetected adenocarcinoma (RR = 3.98; 95% CI = 1.46-10.85, p = 0.007). Lesions with malignancies were significantly larger (mean 30.6 mm) than those where only adenomas were found (mean 14.4 mm, p = 0.001). Mutated KRAS was detected in 9 of the 36 post-papillectomy specimens, including 4 of the 5 cases of ampullary adenocarcinoma. Eighteen cases were endoscopically cured after a mean follow-up period of 47 months (range 16-92 months).

    CONCLUSIONS: Endoscopic papillectomy is a valuable staging tool because of the limitations of endoscopic biopsy. Endoscopic papillectomy concomitantly offers a curative treatment for most patients with adenoma in the major duodenal papilla. Jaundice at presentation and large adenomas may indicate the presence of more advanced disease. Determination of mutated KRAS seems to be of limited value in predicting long-term outcome.

  • 11. Jaafar, Gona
    et al.
    Hammarqvist, Folke
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, Gabriel
    Patient-Related Risk Factors for Postoperative Infection After Cholecystectomy2017In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 41, no 9, p. 2240-2244Article in journal (Refereed)
    Abstract [en]

    Background: The impact of patient-related risk factors on the incidence of postoperative infection after cholecystectomy is relatively unknown.

    Aim: The aim of this study was to explore potential patient-related risk factors for surgical site infection (SSI) and septicaemia following cholecystectomy.

    Materials and methods: All cholecystectomies registered in the Swedish national population-based register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006–2014 were identified. The study cohort was cross-matched with the Swedish National Patient Register in order to obtain data on patient history and postoperative infections. Simple and multiple logistic regression analyses were performed in order to assess the impact of various comorbidities on the risk for SSI and septicaemia.

    Results: A total of 94,557 procedures were registered. A SSI was seen following 5300 procedures (5.6%), and septicaemia following 661 procedures (0.7%). There was a significantly increased risk for SSI in patients with connective tissue disease (odds ratio [OR] 1.404, 95% confidence interval [CI] 1.208–1.633), complicated diabetes (OR 1.435, CI 1.205–1.708), uncomplicated diabetes (OR 1.391, CI 1.264–1.530), chronic kidney disease (OR 1.788, CI 1.458–2.192), cirrhosis (OR 1.764, CI 1.268–2.454) and obesity (OR 1.630, CI 1.475–1.802). There was a significantly higher risk for septicaemia in patients with chronic kidney disease (OR 3.065, CI 2.120–4.430) or cirrhosis (OR 5.016, CI 3.019–8.336).

    Conclusion and discussion: Certain comorbidities have an impact on the risk for postoperative infection after cholecystectomy, especially SSI. This should be taken into account when planning the procedure and when deciding on prophylactic antibiotic treatment.

  • 12. Löhr, J-Matthias
    et al.
    Haas, Stephen L
    Lindgren, Fredrik
    Enochsson, Lars
    Hedström, Aleksandra
    Swahn, Fredrik
    Segersvärd, Ralf
    Arnelo, Urban
    Conservative treatment of chronic pancreatitis.2013In: Digestive Diseases, ISSN 0257-2753, E-ISSN 1421-9875, Vol. 31, no 1, p. 43-50Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Chronic pancreatitis is a progressive inflammatory disease giving rise to several complications that need to be treated accordingly. Because pancreatic surgery has significant morbidity and mortality, less invasive therapy seems to be an attractive option.

    AIM: This paper reviews current state-of-the-art strategies to treat chronic pancreatitis without surgery and the current guidelines for the medical therapy of chronic pancreatitis.

    RESULTS: Endoscopic therapy of complications of chronic pancreatitis such as pain, main pancreatic duct strictures and stones as well as pseudocysts is technically feasible and safe. The long-term outcome, however, is inferior to definitive surgical procedures such as resection or drainage. On the other hand, the medical therapy of pancreatic endocrine and exocrine insufficiency is well established and evidence based.

    CONCLUSIONS: Endoscopic therapy may be an option to bridge for surgery and in children/young adolescents and those unfit for surgery. Pain in chronic pancreatitis as well as treatment of pancreatic exocrine insufficiency follows established guidelines.

  • 13. Löhr, Johannes-Matthias
    et al.
    Lönnebro, Ragnar
    Stigliano, Serena
    Haas, Stephan L
    Swahn, Fredrik
    Enochsson, Lars
    Noel, Rozh
    Segersvärd, Ralf
    Del Chiaro, Marco
    Verbeke, Caroline S
    Arnelo, Urban
    Outcome of probe-based confocal laser endomicroscopy (pCLE) during endoscopic retrograde cholangiopancreatography: a single-center prospective study in 45 patients.2015In: United European Gastroenterology journal, ISSN 2050-6406, E-ISSN 2050-6414, Vol. 3, no 6, p. 551-560Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Diagnosis of pre-malignant and malignant lesions in the bile duct and the pancreas is sometimes cumbersome. This applies in particular to intraductal papillary mucinous neoplasia (IPMN) and bile duct strictures in primary sclerosing cholangitis (PSC).

    AIMS: To evaluate in a prospective cohort study the sensitivity and specificity of probe-based confocal laser microscopy (pCLE) during endoscopic retrograde cholangiopancreatography (ERCP).

    METHODS: We performed pCLE together with mother-baby endoscopy (SpyGlass) during 50 ERCP sessions in 45 patients. The Miami and Paris criteria were applied. Clinical diagnosis via imaging was compared to pCLE and the final pathological diagnosis from surgically-resected, biopsy, or cytology specimens. Patients were followed up for at least 1 year.

    RESULTS: We were able to perform pCLE in all patients. Prior to endoscopy, the diagnosis was benign in 23 patients and undetermined (suspicious) in 16 patients, while six patients had an unequivocal diagnosis of malignancy. Sensitivity was 91% and specificity 52%. The positive (PPV) and negative predictive value (NPV) was 82% and 100%, respectively. Apart from mild post-ERCP pancreatitis in two patients, no complications occurred.

    CONCLUSIONS: Our study showed that pCLE is a safe, expert endoscopic method with high technical feasibility, high sensitivity and high NPV. It provided diagnostic information that can be helpful for decisions on patient management, especially in the case of IPMN and unclear pancreatic lesions, in individuals whom are at increased risk for pancreatic cancer.

  • 14. Lübbe, Jeanne
    et al.
    Arnelo, Urban
    Lundell, Lars
    Swahn, Fredrik
    Törnqvist, Björn
    Jonas, Eduard
    Löhr, J-Matthias
    Enochsson, Lars
    ERCP-guided cholangioscopy using a single-use system: nationwide register-based study of its use in clinical practice2015In: Endoscopy, ISSN 0013-726X, E-ISSN 1438-8812, Vol. 47, no 9, p. 802-807Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND STUDY AIMS: Single-operator peroral cholangioscopy enables direct visualization of duct lesions, biopsy, and therapeutic interventions in the biliary and pancreatic ductal systems. The aim of this study was to address the use and outcome of this technology in wider clinical practice.

    PATIENTS AND METHODS: A nationwide study of endoscopic retrograde cholangiopancreatography (ERCP) procedures, with or without cholangioscopy, was conducted. Procedures that were registered in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2012 were included. The primary outcome was ERCP-specific adverse events.

    RESULTS: Data from 36 352 ERCP procedures were analyzed, including 408 cholangioscopy procedures. Postprocedural adverse events were more prevalent when cholangioscopy was used (19.1 % vs. 14.0 %). Pancreatitis (7.4 % vs. 3.9 %) and cholangitis (4.4 % vs. 2.7 %) were ERCP-specific adverse events that were elevated in the cholangioscopy group. However, in multivariate analysis, the risks of intraprocedural and postprocedural adverse events were significantly increased in the cholangioscopy group whereas the risks of pancreatitis and cholangitis, when adjusted for confounders, were not.

    CONCLUSION: The single-operator peroral cholangioscopy technique is an advanced technique for intraluminal visual inspection, and for therapeutic intervention of the biliary and pancreatic ducts. However, there is a significantly increased risk of intra- and postprocedural adverse events. Thus, this method should preferably be performed at tertiary referral centers in carefully selected patients.

  • 15. Noel, Rozh
    et al.
    Arnelo, Urban
    Enochsson, Lars
    Center for Digestive Diseases, CLINTEC, Karolinska Institutet, Karolinska University Hospital and Division of Surgery, Stockholm, Sweden.
    Lundell, Lars
    Nilsson, Magnus
    Sandblom, Gabriel
    Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease2016In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 51, no 4, p. 464-470Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: There are considerable variations in cholecystectomy rates between countries, but it remains unsettled whether high cholecystectomy rates prevent future gallstone complications by reducing the gallstone prevalence. The aims of this study were to investigate the regional differences in cholecystectomy rates and their relation to the incidence of gallstone complications.

    MATERIAL AND METHODS: Nation-wide registry-based study of the total number of cholecystectomies in Sweden between 1998 and 2013. Data were obtained from the Swedish Inpatient Registry covering the entire population and subdivided for by the 21 different counties. Indications for the procedure were prospectively collected during the years 2006-2013 in the National Registry for Gallstone Surgery and ERCP. The detailed demography of the total number of patients undergoing cholecystectomy and its relation to the respective indications were analysed by linear regression.

    RESULTS: The annual rates of cholecystectomy in the Swedish counties ranged from 100 to 207 per 100,000 inhabitants, with a mean of 157 (95% CI 145-169). The majority of cholecystectomies were done in females based on the indication biliary colic, with a peak incidence in younger ages. Cholecystectomies performed due to gallstone complications, pancreatitis and cholecystitis, were mainly carried out in the older age groups. No significant relationship could be demonstrated between cholecystectomy rates in the different regions and the respective incidences of gallstone complications.

    CONCLUSIONS: There are wide regional variations in cholecystectomy rates in Sweden. The present study does not give support that frequent use of cholecystectomy in uncomplicated gallstone disease prevents future gallstone complications.

  • 16. Noel, Rozh
    et al.
    Arnelo, Urban
    Lundell, Lars
    Hammarqvist, Folke
    Jumaa, Hanaz
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Sunderby Research Unit, Luleå.
    Sandblom, Gabriel
    Index versus delayed cholecystectomy in mild gallstone pancreatitis: results of a randomized controlled trial2018In: HPB, ISSN 1365-182X, E-ISSN 1477-2574, Vol. 20, no 10, p. 932-938Article in journal (Refereed)
    Abstract [en]

    Background: Delayed cholecystectomy is associated with increased risk of biliary events. The objectives of the study were to confirm the superiority of index cholecystectomy over delayed operation in mild gallstone pancreatitis.

    Methods: Patients with mild gallstone pancreatitis were randomized into index-or delayed cholecystectomy (IC vs. DC). IC was performed within 48 h from randomization provided a stable or improved clinical condition. The primary outcome was gallstone-related events. Secondary outcomes were rates of cholecystectomy complications, common bile duct stones (CBDS) detected at cholecystectomy and patient reported quality-of-life and pain.

    Results: Sixty-six patients were randomized into IC (n = 32) or DC (n = 34) between May 2009 and July 2017. There were significantly higher rates of gallstone-related events in the DC compared with the IC group (nine patients vs. one patient, p = 0.013). No statistically significant differences could be demonstrated in cholecystectomy complications (p = 0.605) and CBDS discovered during cholecystectomy (p = 0.302) between the groups. Pain and emotional well-being measured by SF-36 were improved significantly in the IC group at follow-up.

    Conclusions: Delayed cholecystectomy in mild gallstone pancreatitis can no longer be recommended since it is associated with an increased risk for recurrent gallstone-related events and impaired patient's reported outcomes. Trial registration number: clinicaltrials.gov (ID: NCT02630433).

  • 17. Noel, Rozh
    et al.
    Enochsson, Lars
    Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
    Swahn, Fredrik
    Löhr, Matthias
    Nilsson, Magnus
    Permert, Johan
    Arnelo, Urban
    A 10-year study of rendezvous intraoperative endoscopic retrograde cholangiography during cholecystectomy and the risk of post-ERCP pancreatitis2013In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 27, no 7, p. 2498-2503Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Rendezvous intraoperative endoscopic retrograde cholangiography (RV-IOERC), also called guidewire-facilitated IOERC, is one of the single-stage options available for managing common bile duct stones (CBDS) during laparoscopic cholecystectomy. The objective of this study is to investigate procedure-related complications in IOERC patients and stone clearance.

    METHODS: All patients who underwent IOERC between January 2000 and December 2009 were identified from the local registry of Karolinska University Hospital in Huddinge. Medical charts and ERC reports were studied, and descriptive statistics were obtained. Outcomes were procedure-related complications, especially post-ERCP pancreatitis (PEP), stone clearance, and mortality.

    RESULTS: 307 patients were identified. In 264 of the patients, the rendezvous cannulation technique was successful (86 %); in the remaining 43 patients, conventional cannulation technique was necessary. In total, PEP occurred in seven patients (2.28 %). One of the PEP patients was in the rendezvous cannulated group (0.37 %), whereas six patients developed PEP in the nonrendezvous group (13.95 %, p < 0.001). The primary stone clearance rate was 88.27 % (271/307). There was no mortality within 90 days in the series.

    CONCLUSIONS: IOERC with RV cannulation technique for management of CBDS during laparoscopic cholecystectomy has a low PEP rate and a high stone clearance rate, making it a safe and feasible method for removing CBDS. However, the technique requires logistics to perform IOERC in the operating theater. The present data suggest that IOERC with RV cannulation is superior to conventional cannulation with respect to risk of PEP.

  • 18. Olsson, Greger
    et al.
    Arnelo, Urban
    Lundell, Lars
    Persson, Gunnar
    Törnqvist, Björn
    Enochsson, Lars
    The role of antibiotic prophylaxis in routine endoscopic retrograde cholangiopancreatography investigations as assessed prospectively in a nationwide study cohort.2015In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 50, no 7, p. 924-931Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Risk factors for complications after endoscopic retrograde cholangiopancreatography (ERCP) with emphasis on the potential advantage of the use of prophylactic antibiotics were studied in a national population-based study cohort.

    MATERIALS AND METHODS: All ERCP procedures registered in the Swedish Registry of Gallstone Surgery and ERCP (GallRiks) between May 2005 and June 2013 were analyzed. Patients with ongoing antibiotic treatment, incomplete registration or those who had not undergone an index ERCP were excluded. Risk factors for adverse events were analyzed.

    RESULTS: Data from 47,950 ERCPs were collected, but after applying the exclusion criteria, 31,188 examinations were analyzed. In the group receiving prophylactic antibiotics, the postoperative adverse event rate was 11.6% compared with 14.2% in the group without antibiotics. The odds ratio (OR) for the risk of postoperative adverse events in patients receiving prophylactic antibiotics was 0.74 (95% confidence interval [CI]: 0.69-0.79). When analyzing a subgroup of 21,893 ERCPs for the three most common indications (common bile duct stones, malignancy, and obstructive jaundice), the beneficial effect of prophylactic antibiotics on adverse events remained (OR = 0.76; 95% CI: 0.70-0.82). Further, in the subgroup of patients with obstructive jaundice, the administration of prophylactic antibiotics had a beneficial effect on septic complications (OR = 0.76; 95% CI: 0.58-0.97).

    CONCLUSION: The risk of adverse events after ERCP is reduced 26% if antibiotics are given prophylactically during ERCP investigations, as suggested by data gained from this national population-based study. However, in absolute terms, the reduction in adverse events by prophylactic antibiotics is modest (2.6%).

  • 19. Olsson, Greger
    et al.
    Arnelo, Urban
    Swahn, Fredrik
    Törnqvist, Björn
    Lundell, Lars
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, CLINTEC, Karolinska Institutet; Center for Digestive Diseases, Karolinska University Hospital.
    The H.O.U.S.E. classification: a novel endoscopic retrograde cholangiopancreatography (ERCP) complexity grading scale2017In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 17, article id 38Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging endoscopic procedure, harboring a wide range of complexities within every single investigation. Classifications of the complexity of ERCP have been presented, but do not include modern endoscopic treatment modalities. In order to be able to target resources and compare the results of different endoscopic centers, a new complexity grading system for ERCP is warranted. This study launches a new complexity grading scale for ERCP-the H.O.U.S.E.-classification.

    METHODS: The medical record of every patient undergoing ERCP 2009-2011 at the Karolinska University Hospital was reviewed, regarding the complexity of the procedure, and categorized into one out of three-grades in the HOUSE classification system, and concomitantly graded according to the Cotton grading system. All ERCP-procedures were also registered in the Swedish registry for gallstone surgery and ERCP (GallRiks) and correlations between the grading systems and procedure related variables as well as outcomes were made.

    RESULTS: Between 2009 and 2011, 2185 ERCPs were performed at the Karolinska University Hospital, Huddinge. One thousand nine hundred fifty-four of those were index-ERCPs. Another 23 patients were excluded due to lack of postoperative complication registrations, leaving 1931 ERCP procedures to be analyzed. The procedure times were 40 ± 0.7, 65 ± 1.5 and 106 ± 3.2 min, respectively (HOUSE 1-3). The corresponding pancreatitis rates were 3.4, 7.0 and 6.8% and the postoperative complication rates 11.1, 15.7 and 12.8%, respectively.

    CONCLUSIONS: The HOUSE-classification is a novel grading scale for ERCP-complexity. The system can be implemented in clinical practice to allocate resources and allow the comparisons of results between different endoscopic centers. Further studies are warranted to further sharpen this instruments validitity and general clinical relevance.

  • 20. Olsson, Greger
    et al.
    Lübbe, Jeanne
    Arnelo, Urban
    Jonas, Eduard
    Törnqvist, Björn
    Lundell, Lars
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
    The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: a nationwide, register-based study2017In: United European Gastroenterology journal, ISSN 2050-6406, E-ISSN 2050-6414, Vol. 5, no 1, p. 111-118Article in journal (Refereed)
    Abstract [en]

    Background and objectives: The role of prophylactic pancreatic stenting (PS) in preventing post-endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis (PEP) has yet to be determined. Most previous studies show beneficial effects in reducing PEP when prophylactic pancreatic stents are used, especially in high-risk ERCP procedures. The present study aimed to address the use of PS in a nationwide register-based study in which the primary outcome was the prophylactic effect of PS in reducing PEP.

    Methods: All ERCP-procedures registered in the nationwide Swedish Registry for Gallstone Surgery and ERCP (GallRiks) between 2006 and 2014 were studied. The primary outcome was PEP but we also studied other peri- and postoperative complication rates.

    Results: Data from 43,595 ERCP procedures were analyzed. In the subgroup of patients who received PS with a total diameter ≤ 5 Fr, the risk of PEP increased nearly four times compared to those who received PS with a total diameter of >5 Fr (OR 3.58; 95% CI 1.40–11.07). Furthermore, patients who received PS of >5 Fr and >5 cm had a significantly lower pancreatitis frequency compared to those with shorter stents of the same diameter (1.39% vs 15.79%; p = 0.0033).

    Conclusions: PS with a diameter of >5 Fr and a length of >5 cm seems to have a better protective effect against PEP, compared to shorter and thinner stents. However, in the present version of GallRiks it is not possible to differentiate the exact type of pancreatic stent (apart from material, length and diameter) that has been introduced, so our conclusion must be interpreted with caution.

  • 21. Oussi, Ninos
    et al.
    Loukas, Constantinos
    Kjellin, Ann
    Lahanas, Vasileios
    Georgiou, Konstantinos
    Henningsohn, Lars
    Felländer-Tsai, Li
    Georgiou, Evangelos
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Video analysis in basic skills training: a way to expand the value and use of BlackBox training?2018In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 32, no 1, p. 87-95Article in journal (Refereed)
    Abstract [en]

    Background: Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

    Methods: Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

    Results: 31 students (19 females and 12 males), mean age of 26.2 +/- 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

    Conclusion: Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

  • 22. Påhlsson, H. I.
    et al.
    Groth, K.
    Permert, J.
    Swahn, F.
    Löhr, M.
    Enochsson, Lars
    Karolinska Institutet, CLINTEC, Stockholm, Sweden Department of Surgery, Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden.
    Lundell, L.
    Arnelo, U.
    Telemedicine: an important aid to perform high-quality endoscopic retrograde cholangiopancreatography in low-volume centers2013In: Endoscopy, ISSN 0013-726X, E-ISSN 1438-8812, Vol. 45, no 5, p. 357-361Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND STUDY AIMS: The aim of this study was to investigate whether telemedicine can help to ensure high-quality endoscopic retrograde cholangiopancreatography (ERCP) in patients living in rural areas. The study was conducted by investigators from two centers: the Karolinska University Hospital, a high-volume center which provided the teleguided support, and the Visby District Hospital, a low-volume center.

    PATIENTS AND METHODS: From September 2010 to August 2011, 26 ERCP procedures performed at a district hospital were teleguided by an experienced endoscopist at the Karolinska University Hospital. To ensure patient data protection, all communication went through a network (Sjunet) that was separate from the Internet and open only to accredited users. The indications for ERCP were common bile duct stones (n = 12), malignant strictures (n = 12), and benign biliary strictures (n = 2). In 15 cases, this was the patient's first ERCP procedure.

    RESULTS: The common bile duct was successfully cannulated in all 26 teleguided procedures. The local endoscopist scored the teleguided support as crucial for the successful outcome in 8 /26 cases, as an important factor in 8, and as being of less importance in the remaining 10. In the eight cases where the teleguided support was judged to be crucial, six subsequent percutaneous transhepatic cholangiography procedures and two repeat ERCPs were avoided. The overall cannulation rate at the district hospital improved from 85 % to 99 % after teleguided support was introduced. No procedure-related complications occurred.

    CONCLUSION: Distant guidance of advanced ERCP procedures in a low-volume center, through teleguided support from a high-volume center, has the potential to improve the quality of care, as reflected in high cannulation rates and the ability to complete the scheduled interventions.

  • 23. Soreide, Jon Arne
    et al.
    Karlsen, Lars Normann
    Sandblom, Gabriel
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review2019In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 33, no 6, p. 1731-1748Article, review/survey (Refereed)
    Abstract [en]

    Background: Endoscopic retrograde cholangiopancreatography (ERCP) was introduced more than four decades ago as a diagnostic tool for biliary and pancreatic diseases. Currently, ERCP is mainly used as a therapeutic approach to relieve biliary or pancreatic duct obstruction. Clinical practice has been based on a few large reports and some randomized controlled trials. These data are valuable and important, but the external validity of these reports is limited. Implementation into routine practice should be balanced with the knowledge that these studies were conducted under very specific circumstances. This review was undertaken to describe ERCP results from population-based national registries recorded during routine clinical practice.

    Methods: A systematic literature search of the electronic databases Medline Ovid and Embase was conducted. Eligible papers were selected and data were recorded according to the PRISMA criteria.

    Results: Thirty-one studies were included: 15 true national population-based and 16 population-level studies. Most studies originated from countries with a governmental public health care system. At least three-quarters of the ERCP procedures are currently therapeutic, and the technical success rate is high (>90%). The postprocedure 30-day mortality rate ranged between 1 and 5% and was strongly correlated with older age, male sex, emergency admission, and noncancer comorbidities, but exhibited a lower correlation with the annual ERCP volume. Patients with primary sclerosing cholangitis or liver cirrhosis should receive particular attention. The risk of developing a bile duct, liver, or pancreas malignancy after ERCP tended to increase, but endoscopic sphincterotomy did not affect this risk.

    Conclusion: ERCP is currently mainly used as a therapeutic approach, and the results are generally likely to improve patients' conditions. A nationwide registry enables better monitoring of routine clinical practice. The collection of valuable information from routine clinical practice in population-based databases may help to improve patient care from best evidence to best practice.

  • 24. Strömberg, Cecilia
    et al.
    Arnelo, Urban
    Enochsson, Lars
    Löhr, Matthias
    Nilsson, Magnus
    Possible mortality reduction by endoscopic sphincterotomy during endoscopic retrograde cholangiopancreatography: a population-based case-control study.2012In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 26, no 5, p. 1369-76Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for young patients, but ERCP and endoscopic sphincterotomy in particular are reported to be associated with increased complication and mortality rates. This study aimed to calculate mortality and to identify risk factors for death within 90 days after ERCP for nonmalignant disease.

    METHODS: From the Swedish Hospital Discharge Registry, the authors identified all individuals in Stockholm County who had undergone in-patient ERCP during 1990-2003. Among these individuals, they excluded those recorded in the Swedish Cancer Registry as having a diagnosis of malignancy in the liver, pancreas, or bile ducts. Cases, defined as patients who had died within 90 days after the procedure, were identified by cross-linkage to the causes of death registry. Control subjects were randomly sampled from the same cohort. The medical records were studied to discern risk factors for death after ERCP.

    RESULTS: The mortality rate was 1.6%. Advanced age, severe comorbidity, high complexity of the procedure, and occurrence of a complication were associated with death within 90 days, whereas a previous cholecystectomy or the simultaneous performance of an endoscopic sphincterotomy reduced the risk.

    CONCLUSIONS: Old age and comorbidity are the main risk factors for death after ERCP, but a complex procedure or the occurrence of a complication also seems to increase short-term mortality. The performance of a sphincterotomy may reduce the risk of death, possibly by facilitating adequate drainage. A previous cholecystectomy also may decrease the risk of death after ERCP.

  • 25. Swahn, Fredrik
    et al.
    Nilsson, Magnus
    Arnelo, Urban
    Löhr, Matthias
    Persson, Gunnar
    Enochsson, Lars
    Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
    Rendezvous cannulation technique reduces post-ERCP pancreatitis: a prospective nationwide study of 12,718 ERCP procedures2013In: American Journal of Gastroenterology, ISSN 0002-9270, E-ISSN 1572-0241, Vol. 108, no 4, p. 552-9Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim of this study was to investigate if intraoperative rendezvous cannulation reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) because there is no universal consensus on the optimal treatment of common bile duct stones.

    METHODS: We performed a nationwide case-control study, nested within the cohort of ERCP procedures reported to the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2009. Data were collected prospectively from a web-based registry of ERCP procedures that includes variables such as patient characteristics, indication, cannulation technique, diagnostic findings, therapeutic measures, and complications. The primary outcome was PEP.

    RESULTS: The registry included 12,718 ERCP procedures performed on patients without a history of previous ERCP. The risk of PEP when using the rendezvous technique compared with those who were cannulated by conventional means was reduced from 3.6 to 2.2% (odds ratio (OR) 0.5, 95% confidence interval 0.2-0.9, P=0.02). Although a significant reduction there are overall relatively few cases with PEP and the calculated numbers needed to treat to avoid one case of PEP is as high as 71. Other factors associated with increased risk of PEP were young age, prolonged procedure time, and elective ERCP.

    CONCLUSIONS: Rendezvous bile duct cannulation during ERCP reduces the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.

  • 26. Swahn, Fredrik
    et al.
    Regnér, Sara
    Enochsson, Lars
    Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden .
    Lundell, Lars
    Permert, Johan
    Nilsson, Magnus
    Thorlacius, Henrik
    Arnelo, Urban
    Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury2013In: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 19, no 36, p. 6026-6034Article in journal (Refereed)
    Abstract [en]

    AIM: To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP.

    METHODS: Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer's reagents. All samples were blinded at analysis.

    RESULTS: Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification.

    CONCLUSION: Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.

  • 27. Törnqvist, B
    et al.
    Strömberg, C
    Akre, O
    Enochsson, Lars
    Nilsson, M
    Original articleSelective intraoperative cholangiography and risk of bile ductinjury during cholecystectomy2015In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 102, no 8, p. 952-958Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Whether intraoperative cholangiography can prevent iatrogenic bile duct injury during cholecystectomy remains controversial.

    METHODS: Data from the national Swedish Registry for Gallstone Surgery, GallRiks (May 2005 to December 2010), were analysed for evidence of iatrogenic bile duct injury during cholecystectomy. Patient- and procedure-related risk factors for bile duct injury with a focus on the rate of intended intraoperative cholangiography were analysed using multivariable logistic regression.

    RESULTS: A total of 51 041 cholecystectomies and 747 bile duct injuries (1·5 per cent) were identified; 9008 patients (17·6 per cent) were diagnosed with acute cholecystitis. No preventive effect of intraoperative cholangiography was seen in uncomplicated gallstone disease (odds ratio (OR) 0·97, 95 per cent c.i. 0·74 to 1·25). Operating in the presence (OR 1·23, 1·03 to 1·47) or a history (OR 1·34, 1·10 to 1·64) of acute cholecystitis, and open surgery (OR 1·56, 1·26 to 1·94), were identified as significant risk factors for bile duct injury. The intention to perform intraoperative cholangiography was associated with a reduced risk of bile duct injury in patients with concurrent (OR 0·44, 0·30 to 0·63) or a history of (OR 0·59, 0·35 to 1·00) acute cholecystitis.

    CONCLUSION: Any proposed protective effect of intraoperative cholangiography was restricted to patients with (or a history of) acute cholecystitis.

  • 28. von Seth, Erik
    et al.
    Arnelo, Urban
    Enochsson, Lars
    Bergquist, Annika
    Primary sclerosing cholangitis increases the risk for pancreatitis after endoscopic retrograde cholangiopancreatography2015In: Liver international (Print), ISSN 1478-3223, E-ISSN 1478-3231, Vol. 35, no 1, p. 254-262Article in journal (Refereed)
    Abstract [en]

    BACKGROUND & AIMS: Patients with primary sclerosing cholangitis (PSC) have an increased risk for adverse events following endoscopic retrograde cholangiopancreatography (ERCP), mainly caused by bacterial cholangitis. The risk of pancreatitis is less examined. Therefore, our aim was to study adverse events following ERCP and to evaluate if PSC is a risk factor for pancreatitis.

    METHODS: Data were collected through a Swedish nationwide quality registry comprising fifty-one Swedish ERCP centres. The final study cohort consisted of 8932 adults who had undergone ERCP from 1 January 2007 to 31 December 2009. A total of 141 patients had PSC. Variables of importance for adverse events were entered into a multivariate logistic regression model for risk factor analysis.

    RESULTS: The following adverse events were increased in PSC as compared with non-PSC patients: overall (18.4% vs. 7.3%), pancreatitis (7.8% vs. 3.2%, P = 0.002), cholangitis (7.1% vs. 2.1%, P < 0.001) and per-operative extravasation of contrast (5.7% vs. 0.7%, P < 0.001). PSC was shown to be an independent risk factor for all of these adverse events: pancreatitis, OR 2.02 (95% CI, 1.04-3.92), cholangitis, OR 2.88 (95% CI, 1.47-5.65), and extravasation of contrast, OR 5.84 (95% CI, 2.24-15.23).

    CONCLUSION: The rate of adverse events overall following ERCP in PSC is 18% and PEP occurs in 8%. PSC is an independent risk factor for PEP and the risk is doubled. These findings underline the importance of a careful selection of PSC patients eligible for ERCP as well as a need for high competence of the treating team.

  • 29. Wanjura, V.
    et al.
    Szabo, E.
    Österberg, J.
    Ottosson, J.
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Sandblom, G.
    Morbidity of cholecystectomy and gastric bypass in a national database2018In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 105, no 1, p. 121-127Article in journal (Refereed)
    Abstract [en]

    Background: There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

    Methods: Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

    Results: There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1.35, 95 per cent c.i. 1.09 to 1.68; P=0.006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2.02, 1.44 to 2.85; P<0.001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1.72, 1.14 to 2.60; P=0.010). Simultaneous cholecystectomy added 61.7 (95 per cent c.i. 56.1 to 67.4) min (P<0.001) to the duration of surgery.

    Conclusion: Cholecystectomy should be performed before, not during or after, RYGB.

  • 30. Wanjura, Viktor
    et al.
    Sandblom, Gabriel
    Österberg, Johanna
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ottosson, Johan
    Szabo, Eva
    Cholecystectomy after gastric bypass: incidence and complications2017In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 13, no 6, p. 979-987Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although cholecystectomy incidence is known to be high after Roux-en-Y gastric bypass (RYGB) surgery, the actual increase in incidence is not known. Furthermore, the outcome of cholecystectomy after RYGB is not known.

    OBJECTIVES: To estimate cholecystectomy incidence before and after RYGB and to compare the outcome of post-RYGB cholecystectomy with the cholecystectomy outcome in the background population.

    SETTING: Nationwide Swedish multiregister study.

    METHODS: The Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (n = 79,386) and the Scandinavian Obesity Surgery Registry (n = 36,098) were cross-matched for the years 2007 through 2013 and compared with the National Patient Register.

    RESULTS: The standardized incidence ratio for cholecystectomy before RYGB was 3.42 (2.75-4.26, P<.001); the ratio peaked at 11.4 (10.2-12.6, P<.001) 6-12 months after RYGB, which was 3.54 times the baseline level (2.78-4.49, P<.001). After 36 months, the incidence ratio had returned to baseline. The post-RYGB group demonstrated an increased risk of 30-day postoperative complications after cholecystectomy (odds ratio 2.13, 1.78-2.56; P<.001), including reoperation (odds ratio 3.84, 2.76-5.36; P<.001), compared with the background population. The post-RYGB group also demonstrated a higher risk of conversion, acute cholecystectomy, and complicated gallstone disease and a slightly prolonged operative time, adjusted for age, sex, American Society of Anesthesiologists class, and previous open RYGB.

    CONCLUSION: Compared with the background population, the incidence of cholecystectomy was substantially elevated already before RYGB and increased further 6-36 months after RYGB. Previous RYGB doubled the risk of postoperative complications after cholecystectomy and almost quadrupled the risk of reoperation, even when intraoperative cholangiography was normal.

  • 31. Westfelt, Petter
    et al.
    Hedman, Leif
    Umeå University, Faculty of Social Sciences, Department of Psychology. Karolinska Institutet.
    Lindkvist, Mikael Axelsson
    Enochsson, Lars
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Fellander-Tsai, Li
    Schmidt, Peter Thelin
    Training nonanesthetist administration of propofol for gastrointestinal endoscopy in scenario-based full-scale hybrid simulation - a pilot study2013In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 48, no 11, p. 1354-1358Article in journal (Refereed)
    Abstract [en]

    Objective. The use of nonanesthetist-administered propofol (NAAP) in GI endoscopy has long been controversial. In the setting of NAAP, acute situations can develop during endoscopy and thus training before starting with NAAPs is considered crucial. The aim was to evaluate a pilot study on crew resource management (CRM)-based training of teams of endoscopists and endoscopy nurses in NAAP in a full-scale hybrid simulation consisting of a full-scale human patient simulator and an endoscopy simulator. Our hypothesis was that the training would increase the self-efficacy of the participants. Material and methods. Four scenarios were created, each with typical side effects of propofol administration. All scenarios included the need for prompt decision-making and treatment. Colonoscopy, gastroscopy or endoscopic retrograde cholangiopancreatography (ERCP) cases were assigned to the course participants in coherence with their main clinical expertise in order to facilitate situated and contextualized training. Twenty-one participants (ten doctors and eleven nurses) completed a questionnaire on self-efficacy before and after the course. A questionnaire regarding the quality and yield of the course was also completed. Results. For all participants, the self-efficacy score was 26.0 (24.0-28.0; interquartile range) before training and 30.0 (27.0-30.5) after training (p = 0.0003). The ten doctors had a self-efficacy score before training of 26.5 (25.0-29.5) and 30.0 (29.0-33.0) after (p = 0.0078). The eleven nurses scored 24.0 (22.0-26.0) before and 28.0 (27.0-30.0) after training (p = 0.0098). Conclusions. Systematic target focused scenario-based training with hybrid simulation of NAAP in endoscopy resulted in increased self-efficacy in both nurses and physicians.

1 - 31 of 31
CiteExportLink to result list
Permanent link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf