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Aims: To investigate predictive factors in patients with non-curable malignant hilar biliary obstruction (mHBO) and identify those with a life expectancy of 30 days or less, who would not benefit from palliative biliary drainage.

Materials and methods: A retrospective analysis of consecutive palliative patients undergoing percutaneous or endoscopic biliary drainage for mHBO at Groote Schuur and Tygerberg Hospitals, Cape Town, between 1 January 2015 and 1 January 2023. Demographic and baseline clinical parameters, laboratory test results, tumour characteristics and intervention type were compared in patients who survived ≤ 30 days to those who survived > 30 days after index intervention.

Results: A total of 294 patients were included in the study, of whom 135 survived ≤ 30 days and 159 > 30 days. Regression analysis using a Cox proportional hazard model showed that Eastern Cooperative Oncology Group performance status ≥ 2, strictures secondary to hepatocellular carcinoma, serum levels of albumin < 30 g/L and serum levels of total and conjugated bilirubin > 250 μmol/L predicted survival of ≤ 30 days.

Conclusions: These predictive factors should be considered by the multidisciplinary team regarding the decision to perform biliary drainage during end-of-life care or rather proceed to solely medical and symptomatic relief in patients with non-curable mHBO.

Background: Pancreatic ductal adenocarcinoma (PDAC) has a 5-year survival rate of less than 10%. Treatment with curative intent surgery still poses high rates of overall postoperative morbidity (68.7%) and mortality (5.4%). It is therefore essential to identify preoperative factors influencing early postoperative outcomes to provide better insight for improved patient selection and care.

Methods: Sixty patients diagnosed with PDAC who had undergone surgical resection at Groote Schuur Hospital, Cape Town, between 2016 and 2023 were included. The patient cohort was divided into two groups, postoperative survival ≤ 90 days vs > 90 days. The groups were compared regarding demographic and preoperative assessment tools using ASA, ECOG and Codman scores, baseline clinical and imaging data, preoperative treatment and surgical related parameters.

Results: Significant differences were found in patients, with patients presenting with pancreatic duct dilation (p < 0.05), tumour location in the pancreatic head (p < 0.05), elevated gamma-glutamyl transferase (GGT) (p < 0.01) and carbohydrate antigen 19-9 (CA19-9) (p < 0.05). Using regression analysis, GGT serum levels > 500 U/L were correlated with mortality ≤ 90 days, while pancreatic duct dilatation and CA19-9 levels > 200 U/L were associated with survival > 90 days.

Conclusions: The results of this study present important insights regarding risk factors influencing postoperative mortality and offer a potential roadmap for optimising preoperative care and judicious patient selection before pancreatic surgery.

BACKGROUND: Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis.

METHODS: A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment.

RESULTS: From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025).

CONCLUSIONS: Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis.

TRIAL REGISTRATION: The trial was registered prior to conducting the research on  http://clinical.trials.gov, NCT03014817.

Introduction: Upfront surgery is the standard of care for resectable pancreatic cancer, defined as the absence of or ≤180° tumour contact with the portal/superior mesenteric vein. We hypothesized that portomesenteric venous contact is prognostically unfavourable and aimed to assess whether it is associated with poorer outcomes compared with no venous contact in resectable head and body pancreatic cancer.

Methods: This single-centre retrospective study included patients undergoing upfront surgery for resectable head and body pancreatic cancer in 2010–2020 at Umeå University Hospital, Sweden. No venous contact was compared with portomesenteric venous contact of ≤180° based on preoperative imaging. Survival on an intention-to-treat basis was compared with Kaplan-Meier curves, a log-rank test and Cox proportional hazards models.

Results: The final study cohort included 39 patients with portomesenteric venous contact and 144 patients without venous contact. Patients with portomesenteric tumour contact had a median overall survival of 15.3 months compared to 23.0 months (log rank P = 0.059). Portomesenteric venous contact was an independent negative prognostic factor for survival in the multivariable Cox model (HR 1.68; 95% CI 1.11–2.55, P = 0.014) and was associated with higher rates of microscopically non-radical resections (R1) (50% vs 26.1%, P = 0.012) and pathological lymph node metastasis (76.7% vs 56.8%, P = 0.012). There was no difference in adjuvant chemotherapy receipt or postoperative complications between the groups.

Conclusions: Portomesenteric venous contact is associated with poorer overall survival and higher rates of R1 resections and lymph node metastasis in patients with resectable head and body pancreatic cancer treated with upfront surgery.

AIMS: To study the correlation between clinicopathological risk factors and the risk for intervention-requiring cancer recurrence in patients with small papillary thyroid cancers (sPTCs). MATERIALS AND METHODS: Records for 397 patients with sPTC (T1 ≤ 20mm) were obtained from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) between 2010 and 2016. Follow-up time was at least 5 years. Data regarding intervention-requiring cancer recurrence were obtained from patient medical records and analysed regarding lymph node (LN) status (N0, N1a and N1b) and recurrence. RESULTS: Age was significantly lower in the N1a and N1b groups compared to N0 (45 vs. 40.5 vs. 49 years, respectively; p = 0.002). Tumour size was smaller in the N1a group compared to N1b group (9 vs. 11.8 mm; p <0.01). The mean number of metastatic LNs at initial surgery was higher in the N1b compared to N1a group (6.6 vs. 3; p = 0.001), and in the recurrent compared to the non-recurrent group (7 versus 3.9; p <0.01). The recurrence rate was higher in the N1b group than the N1a and N0 groups (25% vs. 2.4% vs. 1.4%, respectively; p = 0.001). CONCLUSIONS: Lymph node stage N1b at diagnosis, and having five or more metastatic nodes, are strong risk factors for cancer recurrence and decreased disease-free survival in sPTC. The management of patients with sPTC should include thorough lymph node mapping for optimal treatment and individual risk stratification.

A steep increase of small papillary thyroid cancers (sPTCs) has been observed globally. A major risk factor for developing PTC is ionizing radiation. The aim of this study is to investigate the spatial distribution of sPTC in Sweden and the extent to which prevalence is correlated to gamma radiation levels (Caesium-137 (Cs-137), Thorium-232 (Th-232), Uranium-238 (U-238) and Potassium-40 (K-40)) using multiple geospatial and geostatistical methods. The prevalence of metastatic sPTC was associated with significantly higher levels of Gamma radiation from Th-232, U-238 and K-40. The association is, however, inconsistent and the prevalence is higher in densely populated areas. The results clearly indicate that sPTC has causative factors that are neither evenly distributed among the population, nor geographically, calling for further studies with bigger cohorts. Environmental factors are believed to play a major role in the pathogenesis of the disease.

Background: The incidence of papillary thyroid cancer (PTC) has been increasing over the recent decades, especially that of small papillary thyroid cancers (sPTCs) (≤ 20mm in size). sPTCs are generally classified as low risk cancers with a very favourable diagnosis, yet some of these cancers still cause locoregional and distant metastasis, recurrence and even death.

Aims: To investigate the role of tumour stromal, environmental and demographical factors affecting the metastatic aggressiveness of sPTCs in Sweden.

Material & Methods: Selected tumour stromal proteins (Types I (Col1) and IV (Col4) collagens, alpha smooth muscle actin (a-SMA) and matrix metallopeptidase 9 (MMP-9)) were analysed for their role in metastatic disease (Paper I). Demographic and clinicopathological differences regarding recurrence between metastasized vs. non-metastasized sPTCs in Sweden were studied in 2 registry-based retrospective observational cohort studies (Papers II & III). The geographic distribution of patients with sPTC in Sweden was pinpointed and layered with maps of gamma radiation deposits of radionuclides Caesium-137 (Cs-137), Thorium-232 (Th-232), Uranium-238 (U-238) and Potassium-40 (K-40) using different spatial analysis methods (Paper IV).

Results: Col1 and Col4 were significantly more expressed in the non-metastatic tumours compared with metastatic ones. Patients with N1b disease were younger, had a smaller tumour size and higher recurrence rates compared to patients with N0 and N1a disease. The mean number of metastatic LNs at initial surgery was higher in the N1b group than the N1a group and correlated with more recurrent disease. The prevalence of metastatic sPTC was associated with significantly higher levels of gamma radiation from Th-232, U-238 and K-40.

Conclusions: The higher expression of Col1 and Col4 in the non-metastasized tumours indicates a potential protective role in tumour progression. LN stage N1b at diagnosis, and having five or more metastatic nodes, are strong risk factors for cancer recurrence and decreased disease-free survival in sPTC. Environmental factors such as gamma radiation are believed to play a major role in the pathogenesis of the PTC. These findings altogether underscore the importance of LN evaluation, tumour biological as well as environmental factors in sPTC patients, suggesting that the management of these patients should be based on an individual risk stratification instead of a “one size fits all” approach.

BACKGROUND: The importance of stroma for tumor progression is recognized for many cancer types. In this study, we aim to evaluate the expression of types I (Col1) and IV (Col4) collagens, alpha-smooth muscle actin (a-SMA), and matrix metallopeptidase 9 (MMP-9) in the tumor stroma of small papillary thyroid carcinoma (PTC).

MATERIAL AND METHODS: Twenty-five non-metastatic small PTCs (pT1N0) and nineteen metastatic small PTCs (pT1N1b) including corresponding metastatic lateral lymph nodes were selected and paraffinized tissue blocks retrieved. The samples were stained for Col1, COL4, a-SMA, and MMP-9 antibodies using immunohistochemistry. The expression of the stromal proteins was scored and analyzed based on the location, intensity, and distribution.

RESULTS: Col1 and Col4 expression were significantly higher in normal thyroid tissue compared to PTC tissue. On the contrary, expression of a-SMA and MMP-9 was higher in PTC tissue compared to normal thyroid tissue. Both Col1 and Col4 were significantly more highly expressed in the non-metastatic tumors compared with metastatic tumors. The expression of a-SMA and MMP9 was slightly, but not significantly, higher in the metastasized tumors and their respective lymph nodes. There was a significant correlation between the metastasized tumors and their respective lymph nodes in Col1 and MMP-9 expression.

CONCLUSIONS: Col1, Col4, a-SMA, and MMP-9 expression in PTCs differs significantly from that of normal thyroid tissue. The higher expression of Col1 and Col4 in normal thyroid tissue and in the non-metastasized tumors indicates that Col1 and 4 might have a potential protective role in tumor progression. The higher expression of a-SMA and MMP9 in PTCs indicates that these proteins might have a role in promoting PTC progression and aggressiveness.

Background: The western world is seeing a rising incidence of thyroid cancer. Improved diagnostic methods do not entirely explain this increase. Papillary thyroid carcinoma (PTC) is the most common subtype of thyroid cancer. Small PTC (<= 20 mm) and especially papillary thyroid microcarcinomas (PTMC <= 10 mm) are considered to be low-risk tumors but some cases are considerably more aggressive. Sufficient understanding of these mechanisms is a long-term goal for more efficient and safer treatment of these tumors.

Methods: We identified 959 cases of small PTCs in the validated Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery, grouped according to lymph node metastasis. These were analyzed according to age, gender, tumor size and geographic region.

Results: Patients with N1b disease (lateral lymph nodes metastases) had a smaller tumor size compared to patients with N1a disease (8.6 mm vs 10.1 mm respectively, p < 0.05). Patients and specifically females with N1b disease were younger than those with N0 or N1a disease. Patients with N1b disease had a lower proportion of females (60%) compared to N0 and N1a groups (81% and 78%, respectively). The incidence of operated small PTCs and of lymph node engagement differs between geographic regions in Sweden.

Conclusions: Small PTC and especially PTMC seem to show different patterns of aggressiveness and demography regarding lateral lymph node metastases and 7% had N1b disease and tumor <1 cm, underscoring the importance of lymph node evaluation in PTMC patients. More understanding of predictive factors, mechanisms for metastatic disease and causes of regional differences, is needed.

To evaluate whether patients presenting with laboratory results consistent with primary hyperparathyroidism (pHPT) are managed in accordance with guidelines. The laboratory database at a hospital in Sweden, serving 127,000 inhabitants, was searched for patients with biochemically determined pHPT. During 2014, a total of 365 patients with biochemical laboratory tests consistent with pHPT were identified. Patients with possible differential diagnoses or other reasons for not being investigated according to international guidelines were excluded after scrutinizing records, after new blood tests, and clinical assessments by endocrine surgeons. Altogether, 92 patients had been referred to specialists and 82 had not. The latter group had lower serum calcium (median 2.54 mmol/L) and PTH (5.7 pmol/L). Out of these 82 cases, 9 patients were diagnosed with pHPT or had some sort of long-term follow-up planned as outpatients. Primary hyperparathyroidism is overlooked and underdiagnosed in a number of patients in the clinical setting. It is important to provide local guidelines for the management of patients presenting with mild pHPT to ensure that these patients receive proper evaluation and follow-up according to current research.