Scandinavian Journal of Surgery最新文献

Background and aims: Arteriovenous access ischemic steal (AVAIS) is a rare complication that causes morbidity and threatens hemodialysis access usability in patients with end-stage kidney disease (ESKD). This study aimed to determine the incidence of AVAIS over a 15-year period and assess the access usability after surgical correction.

Methods: Access operations between January 2007 and August 2022 at Helsinki University Hospital were reviewed. Demographics, clinical, duplex, and contrast examinations with brachial artery volume flows, finger pressures, and delays to surgery were evaluated. Symptom relief, complications, access closures/re-interventions, primary, secondary, and functional patencies were assessed. Endpoints were permanent cessation of access use due to complication(s), transplantation, closure, definitive occlusion, or death.

Results: Among 2914 access-related operations, the overall incidence of AVAIS was 2.2%. At the first vascular consultation 52% had ulcer(s) or gangrene(s) resulting in 28 direct closures, and 30 corrections as follows: 20 proximalization of arterial inflow (PAI), 6 flow reduction procedures, 2 distal revascularization with interval ligation (DRIL), 1 distal radial artery ligation (DRAL), and 1 venous bypass. The median time from consultation to surgery was 18 days (range: 0-348 days) for direct closures and 43 days (0-170 days) for corrective surgery. The functional patencies after correction were 60% at 1 year and 55% at 2 years; the primary patencies were 45% and 28% and secondary patencies 61% and 57%, respectively. The functional patencies after PAI were 41% and 31%, respectively.

Conclusion: In AVAIS, access preservation is challenging in ESKD patients with multiple diseases. Attention should be paid to the original choice of vascular access by considering each patient's risks. Delay to vascular consultation and intervention should be minimized. PAI should be reserved for selected patients when no other option is preferable.

Background and aims: This study investigated patients with type B aortic dissection (TBAD) who were treated with thoracic endovascular aortic repair (TEVAR). The aim was to study whether patients who needed secondary aortic intervention (SAI) had worse survival than patients who did not require SAI after the initial TEVAR.

Methods: Data were collected from the National Care Register for Health Care (CRHC) at the Finnish National Institute for Health and Welfare. All Patients over 15 years of age with TBAD (ICD-10; I71.01) treated with TEVAR during the years 2000-2019 were included in the study. Data were collected retrospectively. A data search of the Official Statistics of Finland Cause of Death registry was carried out to identify the date and cause of death in patients with TBAD.

Results: 236 patients with TBAD received TEVAR as primary operative treatment from year 2000 to 2019. SAI after initial TEVAR was performed in 45 (17%) patients during median follow-up time of 5.1 years. There was no significant difference in survival between the patients who underwent primary TEVAR alone and those who required additional SAI (p = 0.063). Age-adjusted survival did not differ between the groups either. Median follow-up time was significantly longer in the SAI group compared to patients with no SAI (5.9 vs 4.9 years, p = 0.047). The most common cause of death in both groups was an aortic-related event (47%).

Conclusions: Based on this study, SAIs may not impair the overall survival of patients previously treated with TEVAR for TBAD. Systematic follow-up after the initial TEVAR may be beneficial in identifying patients with TBAD who may require secondary operation.

Background and objectives: Long-term studies exploring factors associated with glycemic control of type 2 diabetes mellitus (T2DM) after bariatric surgery are being requested. This prospective cohort study aimed to evaluate potential predictors of long-term glycemic control 5 years after surgery.

Methods: Patients were operated between 2002 and 2014. Data were collected prospectively in a database after obtaining written informed consent from the patients. Surgical methods were sleeve gastrectomy (SG) or biliopancreatic diversion with duodenal switch (BPDDS). Possible predictors of postoperative long-term glycemic control (HbA1c) were investigated using multiple path regression analysis, which handles missing data.

Results: A total of 181 patients were included consecutively, 87 after SG and 94 after BPDDS. The follow-up rate was 124/181 (69%), 57 (66%) after SG and 67 (71%) after BPDDS. We found that 39/57 (68%) of the patients who underwent SG and 54/67 (81%) of the patients who underwent BPDDS had remission of T2DM at 5 years. Lower preoperative HbA1c (P < 0.010), higher preoperative C-peptide (P = 0.004), greater percent total weight loss (P < 0.005), and the BPDDS procedure (P < 0.001) were associated with better postoperative long-term glycemic control (explained variance = 39.4%).

Conclusions: Both procedures, especially BPDDS, were effective in achieving long-term glycemic control. Lower preoperative HbA1c, higher C-peptide levels, greater weight loss, and the BPDDS procedure were key predictors of better long-term glycemic control.

Background: Indeterminate biliary strictures, that is, a stricture with benign brush cytology but without clear etiology in clinical or radiological assessment, pose a challenge for clinicians. This study aimed to assess the incidence and risk factors for malignant disease in patients with indeterminate biliary strictures.

Methods: This is a single-center retrospective study of patients with indeterminate biliary stricture undergoing first endoscopic retrograde cholangiopancreatography (ERCP) and biliary brushing between March 2011 and March 2020. The study included patients with atypical cytology in the first ERCP biliary brushing samples. Main exclusion criteria were primary sclerosing cholangitis, apparent malignancy or tumor in imaging studies, postoperative strictures, chronic pancreatitis, biliary tract stone, and no ≥12-month follow-up or a final pathological diagnosis.

Results: A total of 2279 patients underwent first ERCP procedure because of a biliary tract stricture during the study period, of which 51 patients (2.2%) had an indeterminate biliary stricture and were included. A total of 30 patients (58.8%) had final diagnosis of malignant disease. The patients with final diagnosis of malignant disease were mostly men (n = 19, 63.3%), had jaundice (n = 25, 86.2%), and had significantly higher bilirubin and CA19-9 values than those with benign disease. A total of 25 patients were operated on, of which 21 patients (84%) had malignant disease. Twenty-six patients were followed up only, of whom nine patients (34.6%) had a malignant disease.

Conclusion: Indeterminate biliary strictures are uncommon, but two-thirds of the initially indeterminate biliary strictures are malignant. The presence of clinical jaundice and elevated bilirubin and CA19-9 values are associated with increased risk of malignancy.

Study design: Retrospective cohort study.

Objective: In orthopedic surgery, the use of antibiotic-impregnated spacers is a well-established method for treating periprosthetic joint infections with excellent outcomes. However, their application in head and neck surgery remains poorly documented, despite the high susceptibility of these patients to persistent infections. The objective of this study was to evaluate the 10-year outcomes of antibiotic spacers in the treatment of persistent mandibular infections unresponsive to conventional methods, prior to definitive reconstruction.

Methods: We retrospectively reviewed patients with persistent mandibular infections treated with antibiotic-impregnated spacers between 2014 and 2023. Patient characteristics, surgical details, infection type, and clinical outcomes were assessed. The two-stage surgical protocol was described.

Results: Seven patients (mean age 49 years, range 20-77) were included. Six had undergone complex mandibular reconstructions for malignant tumors (n = 3), benign tumors (n = 1), or congenital anomalies (n = 2). One patient had osteomyelitis of the jaw with extensive necrosis. Following spacer placement, complete resolution of infection occurred in 3/7 patients, a transition to non-suppurative infection in 3/7, and suppurative infection in 1/7. On average, infections recurred 5 months postoperatively. All infections resolved by the time of spacer removal, allowing definitive reconstruction.

Conclusion: Antibiotic-impregnated spacers appear to be a promising adjunct in managing persistent mandibular infections, facilitating successful permanent reconstruction in complex head and neck cases.

Background and aims: Neoadjuvant short-course radiotherapy (SCRT) prior to surgery has been used to reduce local recurrences in moderately advanced rectal cancer (RC). Total mesorectal excision (TME) surgery by itself can reduce the local recurrence rate in these patients. The objective was to assess whether discontinuing neoadjuvant SCRT had a negative impact on survival and local recurrence rates of moderately advanced RC.

Methods: This retrospective study examined 137 consecutive patients (67 neoadjuvant SCRT, 70 TME without neoadjuvant therapy) treated for rT1-3N1M0 RC without extramural venous invasion (EMVI) or a threatened surgical margin between January 2016 and March 2020 in a tertiary rectal surgery referral center. The primary objective was the impact of neoadjuvant therapy on overall, cancer-specific, and disease-free survival, and local recurrence rate. Secondary outcomes were risk factors affecting survival. The analyses were conducted on the total study cohort as well as a propensity score matched cohort of the same patient group, with the matching predicated upon age, gender, and histological T score.

Results: The oncological outcomes were similar between the two different treatment groups. The 5-year cumulative overall survival rate, calculated using the Kaplan-Meier method, was 89.6% in the neoadjuvant SCRT group and 83.5% in the surgery-only group (p = 0.570), with the corresponding cancer-specific survival rates at 97.0% and 98.4% (p = 0.219) and disease-free survival rates at 97.0% and 91.9% (p = 0.438). No local recurrencies were detected in either group during the 5-year follow-up period.

Conclusion: The omission of neoadjuvant SCRT in rT1-3N1M0 RC with no EMVI and no threatened resection margin caused no adverse effects on the survival of the patients. Based on this series, it appears that avoiding SCRT does not compromise the oncological outcome in these patients.

Background and aims: Gangrenous appendicitis, a type of complicated appendicitis, is an indication of emergency surgery due to a high risk of perforation. However, it can be challenging to diagnose preoperatively. This study aimed to validate the predictive factors of patients with gangrenous appendicitis and develop a novel scoring model based on objective parameters.

Methods: This retrospective single-center study included 171 of 302 consecutive patients undergoing appendectomy between April 2014 and December 2023. Patients with perforation, chronic appendicitis, and appendicitis presenting with an abscess were excluded from the analysis. In other words, the study targeted Grades 1 and 2 on the American Association for the Surgery of Trauma (AAST) severity assessment scale. Computed tomography (CT) scan value was defined as the average value of fluid in the appendix lumen on plain CT scan. Univariate and multivariate analyses were performed to identify the independent objective predictors of gangrenous appendicitis. A new scoring model was developed based on the logistic regression coefficients of the independent predictors. The scores were then classified into three categories, and the probability of gangrenous appendicitis for each category was evaluated.

Results: Overall, 46 (27%) and 125 (73%) patients presented with gangrenous appendicitis (=AAST Grade 2) and non-gangrenous (uncomplicated) appendicitis (=AAST Grade 1), respectively. The independent predictive factors of gangrenous appendicitis included a CT value of ≥24 HU, an appendiceal diameter of ≥12 mm, the presence of cecal mucosal edema, and a C-reactive protein level of ≥5.4 mg/dL. The scoring model, based on these four independent predictors, ranged from 0 to 4. The probability values of gangrenous appendicitis were 0%, 15%, and 97% in the low (0)-, moderate (1, 2)-, and high (3, 4)-risk categories, respectively.

Conclusion: Our scoring model may assist in decision-making concerning emergency surgery and appendicitis management.