Scandinavian Journal of Surgery最新文献

Introduction: Implementing new treatment regimens entails a learning phase with a concomitant risk of suboptimal results. High caseload has generally been shown to improve results in complex surgical procedures. This study aimed to evaluate results of Cytoreductive Surgery (CRS) and Intraperitoneal Chemotherapy (IP), given as Early Postoperative Intraperitoneal Chemotherapy (EPIC) or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in a mid-size volume center, stratified by time periods.

Method: This retrospective single-center cohort study included all CRS-IP procedures in Malmö, Sweden. All data were retrieved from a prospective quality control registry. Primary outcomes were: 5-year overall survival (5-Yr OS) and 30-day severe and total postoperative complication rates. Secondary outcomes were: recurrence rate, 3-year disease-free survival (DFS), and 90-day mortality rate. Outcomes were analyzed by time periods divided into initiating phase (n = 56) and established phase (n = 208).

Results: In total 264 CRS-IP in 240 patients were performed from 2004 to 2021 (35 EPIC, 229 HIPEC). The 5-Yr OS after primary CRS-IP was 43% in colorectal cancer (n = 169) and 87% in pseudomyxoma (n = 53). In pmCRC, the 5-year OS was significantly lower in the initiation phase (29%) compared to the established phase (48%), verified in an adjusted multivariable analysis showing a hazard ratio of 0.51 for mortality in the established phase. The risk of recurrence did however not differ. Total 30-day complication rate was 67%, severe complication rate 15% and 90-day mortality was 1%. None of which differed depending on time period in multivariable analysis.

Conclusion: Our results for both pseudomyxoma peritonei (PMP) and pmCRC are in line with previously published results, implying that high volume is not a prerequisite for high-quality CRS-IP. Although long-term survival in pmCRC was significantly better in the established phase, recurrence rates remained unchanged. Further, postoperative mortality and risk of complications did not differ between time periods, suggesting that the impact of the learning curve was limited.

Background and aims: Psoas muscle surface area (PMA) can estimate sarcopenia related long-term mortality risk. This study explored whether this association is linear or non-linear and if a meaningful threshold defines patients at high risk.

Methods: This retrospective individual participant-level meta-analysis included four different cohorts of 3893 patients undergoing cardiovascular interventions: 1302 abdominal aortic aneurysm repairs (AAA), 1099 transcatheter aortic valve insertions (TAVI), 593 surgeries for thoracic aortic and aortic valve pathology (TA) and 899 procedures for peripheral artery disease (PAD). The association between PMA and mortality was visualized using pooled spline curves. Cox models were fitted separately within each cohort with three levels of adjustment, and hazard ratios were combined using inverse-variance meta-analysis. Results were replicated in a retrospective dataset of 561 patients undergoing carotid endarterectomy or thrombectomy for ischemic stroke, where sarcopenia status was estimated using masseter muscle surface area.

Results: Age and sex were the most important features associating with PMA (p < 0.001), but significant variation between the cohorts was also observed (p < 0.001). The association between PMA and long-term mortality was inverse and linear (p < 0.001). Patients with poor muscle status (Z-values -1.5 or less for PMA) had significantly higher adjusted risk of death (hazard ratio (HR) of 1.6 with 95% confidence interval (CI) 1.3-2.0, p < 0.001) when compared to all other patients. Similar results were observed in the replication cohort (HR 1.7, 95% CI 1.0-2.82, p = 0.04).

Conclusions: Long-term mortality after a cardiovascular intervention increases linearly as the PMA value decreases. Patients with poor muscle status (Z-values below -1.5) seem to have consistently elevated mortality risk independent of other risk factors.

Background and aims: The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is widely used to treat pseudomyxoma peritonei (PMP), peritoneally metastasized colorectal or appendiceal cancer (pmCRC or pmAppCa) and peritoneal mesothelioma, although the specific efficacy of HIPEC remains inadequately proven. The aim of this retrospective study was to evaluate the outcomes of our CRS-HIPEC procedures and compare them with prior reports.

Materials and methods: All patients operated with the intent of CRS-HIPEC at Oulu University Hospital (OUH) between September 2013 and August 2023 were prospectively registered in a CRS-specific quality control registry that included preoperative, intraoperative, and pathological data, as well as 30-day postoperative complications. The follow-up included thoracoabdominal computed tomography (CT) every 6 months for 3 years and after this yearly until 6 years postoperatively. Survival data were retrieved both from hospital records and from a national registry to analyze both short- and long-term outcomes of CRS-HIPEC.

Results: Since its introduction at OUH in 2013, CRS-HIPEC was performed with curative intent in 272 patients. Peritoneal disease was confirmed in 223 (82%) cases. Among 171 resectable patients operated with CRS, 162 (95%) received HIPEC. Indications included pmCRC in 67 patients (41%), PMP in 61 (37%), pmAppCa in 23 (14%), and peritoneal mesothelioma in 7 (4%, other histology 4). Severe complications within 30 days (Clavien-Dindo class III-V) occurred in 68 patients (40%) of the CRS patients with a postoperative mortality of 0.6% (n = 1). The mean follow-up was 39 months (range 1-138). The estimated 5-year overall survival after CRS-HIPEC was 87% for PMP, 41% for pmCRC and 58% for pmAppCa. Estimated 5-year disease-free survival was 70%, 24%, and 36%, respectively.

Conclusion: CRS-HIPEC is associated with good OS and DFS in PMP, whereas survival after both pmCRC and pmAppCa is considerably lower. The procedure is associated with a considerable risk of severe complications and should therefore be performed in specialized centers only.

Background and aims: Acute appendicitis is the most common surgical emergency worldwide. Obtaining a correct diagnosis and timely management can be challenging even in modern medicine. Hence, appendicitis is still considered a "high-risk" diagnosis for litigation and claims of malpractice. Few studies have investigated the pattern and outcome of claims for appendicitis in a contemporary universal health care system. The aim of this study is to analyze compensation claims related to the investigation and treatment of appendicitis in Norway.

Methods: An observational study based on claims from the Norwegian System of Patient Injury Compensation (NPE) from 2005 to 2023. Population rates of appendicitis treatment were obtained from the Norwegian Patient Registry (NPR; data from 2016 to 2023) and Statistics Norway (SSB).

Results: Altogether 207 compensation claims were filed for appendicitis and 56 (27%) received compensation. The probability of receiving compensation was not influenced by age, gender, or geographical location. The most common reasons for compensation granted were delayed diagnosis (n = 25, 45%) and delayed treatment (n = 5, 9%). The most common reasons for the 151 (73%) denied claims were predictable complication (n = 48, 32%) and condition caused by an unrelated disease (n = 40, 26%). Out of the 59,450 appendectomies performed, 96 claims were filed to NPE, giving a claim rate of 0.16% or 1 claim for every 620 appendectomies. For the entire study period, there was a total payout of 27.2 mill NOK (approximately 2.4 mill EUR) with a mean of 460,000 NOK (approximately 40,000 EUR) and a median of 75,000 NOK (approximately 6,600 EUR) per claim.

Conclusion: In acute appendicitis, about a quarter of claims are compensated due to malpractice. More than half of the approved claims involved delays in diagnosis or treatment, which can be related to the clinical challenges of diagnosing appendicitis.

Scientific integrity relies on reproducibility. Reproducible scientific results are essential for advancing clinical practice and improving patient outcomes. However, despite the importance, reproducibility issues are widespread, often arising from inadequate methodologies and a lack of expertise in research design. Methodological shortcomings can lead to unreliable and biased findings, wasted resources, and thus compromised clinical decisions. Recent studies indicate that researchers frequently struggle to replicate findings, emphasizing the need for improvements in quality and transparency.This review aimed to enhance the understanding of common pitfalls in research methodologies by identifying and describing the common limitations. Ultimately, this review aims to strengthen the quality of surgical research and improve patient care through more reliable and clinically applicable research findings.

Background: Gynecomastia is a benign, excessive development of the male breast that occurs at an overall incidence of 32% to 36%. The goals of surgical treatment are to restore the breast contour with minimal scarring and protect the areolar anatomy and sensation. Here, a new single stage technique is described where peripheral fat tissue is effectively removed using ultrasound-assisted liposuction (UAL) followed by a Dome breast lifting from the superior parabolic periareolar incision without touching the complex inferior pedicle.

Methods: A retrospective review of outcomes for 29 patients aged between 18 and 49 years with grade IIB or grade III gynecomastia who were treated with UAL and the Dome technique. Health-related quality-of-life and aesthetic outcomes were evaluated using a modified version of the Breast Evaluation Questionnaire (BEQ).

Results: The mean Likert-type score (LS) increased from 1.82 (18%) preoperatively to 4.10 (81%) months postoperatively (p < 0.05). No infection, nipple-areola complex necrosis, nipple retraction, or saucer deformity was encountered.

Conclusion: The use of UAL and Dome technique for the treatment of severe gynecomastia allows for the effective removal of both the fat and glandular tissue of the breast through a minimal periareolar parabolic incision. This technique can achieve excellent aesthetic results with inconspicuous scarring in a single session.

Background and aims: To provide a register-based analysis of the incidence, anatomical distribution, and associated operative care of all burn injuries treated in specialist care in Finland.

Methods: This is a register-based epidemiological study covering the entire population of Finland from 2011 to 2015. Our data include all burn patients registered in the Care Register for Health Care. We used the International Classification of Diseases, 10th Revision code for burn injuries and the Nordic Medico-Statistical Committee Classifications of Surgical Procedures for procedure codes. We calculated the mean crude and adjusted (to European Standard Population 2013) incidence rates of burns as cases per 100,000 person-years assuming Poisson distribution of cases for calculating 95% confidence intervals.

Results: The study included 16,575 patients with burn injuries (male 63%). The mean standardized annual incidence rate per 100,000 person-years of any burn injury during the study period was 60.8 (95% CI 59.9-61.7). The corresponding values were 76.3 (95% CI 74.9-77.8) and 45.2 (95% CI 44.1-46.3) for male and female. Among patients admitted for ⩾2 days, the incidence rate per 100,000 was 10.9 (male 15.5 and female 6.5). The mean (SD) age was 32 (23) years. Hand injuries were the most common burns. The most frequently operated regions were the upper limb injuries. A total of 8.8% of patients were admitted for ⩾2 days, with a mean inpatient time of 12 (SD 29) days for females and 11 (19) days for. No male patient had inpatient time > 100 days.

Conclusions: Male patients had more burn injuries and were admitted to specialist care more often than females. Hand and wrist injuries were common but rarely operated. Limb and torso injuries were operated on most often. Females had a longer mean length of stay (LOS) than males in the age group 11-30 years. The reasons for this is unknown.

Background and aims: The aim of this study was to compare the safety and efficacy of establishing a robotic-assisted thoracoscopic surgery (RATS) program in a low-volume center with mixed cardiothoracic practice and surgeons with different background experiences-video-assisted (VA) versus open thoracotomy (OT).

Methods: Between January 2015 and June 2023, the center performed 460 anatomical lung resections. The RATS program was established in October 2021, and two surgeons, OT and VA, were selected as RATS surgeons. Before this, surgeon OT performed mostly open thoracic surgery, and surgeon VA had notably more thoracoscopic experience. The primary outcomes were the learning curves of surgeon OT and VA for lymph node yield, operative time, blood loss, and complications after starting the RATS program. A Risk-Adjusted Cumulative Sum (RA-CUSUM) method was used to determine learning curves.

Results: Surgeons OT and VA showed similar learning curves in lymph node yield with surgeon OT having a peak at case number 23 and surgeon VA at 19. Operative time improved with surgeon VA after 15 cases and with surgeon OT after 30 cases. RA-CUSUM analysis showed no increased bleeding cases when comparing the baseline risk and the median bleeding values of the center. With both surgeons, there were significantly fewer overall complications when using RATS than with other surgical techniques.

Conclusion: According to this study, training surgeons with either open or thoracoscopic background experience to perform robotic-assisted lung cancer surgery is safe and does not compromise short-term operative outcomes. This study is a retrospective registry study and has been approved by the Northern Ostrobothnia Research Ethics Committee with license number EETTMK 5/2019; hence, no clinical trial registry number is associated with this study.