Scandinavian Journal of Surgery最新文献

Colorectal cancer is the second most common cause of cancer-related death worldwide, and liver metastases are the leading cause of mortality in these patients. Surgical innovations combined with modern systemic chemotherapy have improved 5-year overall survival rates. This review aims to equip non-hepatobiliary surgeons with a comprehensive toolbox for the diagnosis and management of colorectal liver metastases. It covers the current landscape of diagnostic workup, including imaging modalities and biomarkers, and reviews the surgical and nonsurgical treatment options. This guide attempts to enhance multidisciplinary care for patients with colorectal liver metastases by integrating evidence-based practices with innovative strategies, which can improve outcomes and survival.

Background: The benefit of surgical resection for colorectal cancer (CRC) lung metastases is unclear. The aim was to investigate the incidence, treatment strategy, and 5-year overall survival (OS) in CRC patients with isolated lung metastases.

Methods: This registry-based retrospective cohort study included patients treated with curative resection of CRC within the county of Skåne during the period 2010-2016, who had synchrone or metachrone isolated lung metastases. Exclusion criteria were previous or concurrent metastases at other organ sites. Patients were identified in the Swedish Colorectal Cancer Registry (SCRCR) and data were retrieved from SCRCR and medical charts. Patients were divided into groups based on whether they had synchronous or metachronous lung metastases and curative or palliative treatment intent. The primary endpoint was 5-year OS. Multivariable Cox-regression and Kaplan-Meier survival analysis were performed.

Results: Of 8457 curatively resected CRC patients, 93 (1.1%) had isolated lung metastases (53 synchronous/40 metachronous). Of these, 53 were treated with curative intent, 51 (96%) of whom were managed surgically. The remaining 40 patients were treated palliatively and either with chemotherapy or with best supportive care. Five-year OS was 42% (39/93), median 50 months (IQR: 24-60) for the entire cohort, and 68% (36/53), median 60 months (IQR 55-60) and 7.5% (3/40), median 22 months (IQR: 12-33) for curative and palliative patients, respectively. In multivariable analysis, age (hazard ratio (HR): 1.04, confidence interval (CI): 1.01-1.07), multiple lung metastases (HR: 1.64, CI: 1.08-2.47), and unilateral distribution (HR: 0.41, CI: 0.20-0.84) were predictors of OS.

Conclusions: Isolated CRC lung metastases are rare. Curative treatment was associated with considerably better 5-year OS than palliative treatment (68% vs 8%). Age, solitary metastases, and unilateral distribution were predictors of survival.

Background and aims: The present study aimed to compare patients who underwent deep inferior epigastric perforator (DIEP) flap reconstruction with and without the implementation of the new optimized surgical recovery pathway. The new protocol aims to standardize and optimize perioperative management, shorten hospital stays, and lower complication rates for patients undergoing major surgical procedures.

Methods: Consecutive patients who underwent immediate or delayed DIEP flap breast reconstruction were included in this study. Data regarding patient demographics, timing, laterality of reconstruction, hospital length of stay (LOS), and drain management were collected and compared for the pre-protocol group and the post-protocol group.

Results: The pre-protocol group consisted of 65 patients, while the post-protocol group consisted of 68 patients. The two groups had similar total complication rates (pre-protocol 43.1% versus post-protocol 32.4%, p = 0.20). Between the two groups, there was a significantly lower rate of major surgical complications in the post-protocol group (pre-protocol 32.3% versus post-protocol 14.7%, p = 0.016). There were no significant differences between the groups regarding minor surgical complications (pre-protocol 7.7% versus post-protocol 17.6%, p = 0.086). In the pre-protocol group, the mean LOS was 6.1 days (range = 4-10, median = 6); in the post-protocol group, the mean LOS was 3.6 days (range = 3-10, median = 3; p < 0.00001). Majority of the post-protocol patients were discharged on postoperative day 3 (n = 47, 69.1%).

Conclusion: Patients undergoing DIEP flap reconstruction can be discharged earlier without risking their safety by following the new protocol.

Surgery has historically played a pivotal role in the management of metastatic melanoma, evolving significantly with the advances of systemic therapies. The advent of immune checkpoint inhibitors initially diminished the role of surgery in treatment paradigms; however, there has been a resurgence of interest in its application within this setting. Several retrospective studies show a survival benefit for patients treated with immune checkpoint inhibitors who are resected to no evidence of disease, especially in case of an objective response to modern therapies. This narrative review explores the role of surgery as a treatment modality in metastatic melanoma before and in the era of immune checkpoint inhibitors, highlighting indications, outcomes, and integration with systemic treatment approaches.

Background and aims: There is no consensus on which Lisfranc injuries can be treated non-operatively. The aim of the study was to compare non-operative treatment and open reduction and internal fixation (ORIF) in the treatment of non-displaced Lisfranc injuries.

Materials and methods: This study was a multicenter randomized controlled trial (RCT) conducted at two hospitals in Finland between 19 March 2012, and 20 December 2022, with a target sample size of 60 patients. The primary outcome was Visual Analogue Scale Foot and Ankle (VAS-FA) at 2 years. The secondary outcomes included VAS-FA pain, function, and other complaints subscales and the American Orthopedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6 months, 1 and 2 years.

Results: Altogether 27 patients with computed tomography (CT)-confirmed non-displaced Lisfranc injuries were enrolled in this trial resulting in an underpowered trial. In patients with non-displaced Lisfranc injuries, the mean VAS-FA overall score in the non-operative group was 96.1 [confidence interval (CI): 91.5-100] and 91.8 [86.9-96.7] in the ORIF group at 2 years with no statistically significant difference between the groups (mean between-group difference (MD) 4.3 [CI, -2.4 to 11], Cohen's d = 0.706) in this underpowered RCT.

Conclusion: There was no difference in VAS-FA between non-operative and ORIF in patients with non-displaced Lisfranc injuries, but the trial is underpowered to draw robust conclusions.

Background: Tailoring surgical treatment is mandatory to optimize outcomes in chronic pancreatitis. Total pancreatectomy (TP) offers pain relief in a subset of patients. TP with islet autotransplantation (IAT) has the potential to reduce the burden of postsurgical diabetes. We present the first Scandinavian prospective study assessing outcomes following total pancreatectomy and islet autotransplantation (TPIAT) in chronic pancreatitis. Our aim was to assess short- and long-term outcomes following implementation of a nationwide program of TPIAT at a tertiary reference center for pancreatic surgery in Norway.

Methods: A prospective, observational single-center study enrolling consecutive patients undergoing TPIAT for chronic pancreatitis at Oslo University Hospital. The selection of potential candidates for TPIAT was based on discussions at multidisciplinary team (MDT) meetings, focusing on tailored surgery in chronic pancreatitis. Patients were finally evaluated in a dedicated TPIAT team. The outcome measures included pain relief, quality of life (QoL) assessed by EORTC QLQ-C30, complications, and glycemic control.

Results: Between August 2017 and November 2022, 15 patients underwent TPIAT. The follow-up rate was 87% with a median follow-up of 26 months (range = 14-65). Pain relief was achieved in 92%. EORTC QLQ-C30 analysis revealed clinically significant improvements in 28 of 30 domains, particularly in pain and role- and social-functioning. The Clavien-Dindo ≥IIIa complications occurred in one patient. There was no 90 days mortality. All patients maintained C-peptide positivity, although none of the patients reached insulin independence.

Conclusion: TPIAT was as a safe and effective treatment for a selected group of patients with chronic pancreatitis, providing substantial pain relief and enhanced QoL. Islet autotransplantation prevented complete insulin deficiency, reducing diabetes severity postpancreatectomy. Dedicated chronic pancreatitis MDT meetings were key factor in the success of the program.

Background: The impact of surgical specialization on long-term survival in patients undergoing emergent colon cancer resections remains unclear.

Method: A retrospective analysis was conducted on all patients who underwent emergent colon cancer resections at a secondary care hospital between 2010 and 2020. The most senior surgeon performing the procedures was classified as colorectal surgeon (CS) or non-colorectal surgeon (NCS). NCS was further divided into acute care surgeons (ACSs) or general surgeons (GSs). Overall survival (OS) and cancer-free survival (CFS) were compared in patients operated by surgeons with different specializations.

Results: A total of 235 emergent resections were performed during the study period, of which 99 (42%) were performed by CS and 136 (58%) by NCS. In adjusted Cox regression analyses, OS and CFS were similar in patients operated on by CS and NCS (hazard ratio (HR) for OS: 1.02 (0.72-1.496), p = 0.899 and HR for CFS: 0.91 (0.61-1.397), p = 0.660). Similarly, OS and CFS were equivalent in patients operated by ACS and CS (HR for OS: 1.10 (0.75-1.62), p = 0.629 and HR for CFS: 1.24 (0.80-1.92), p = 0.343). However, patients operated by GS had significantly shorter OS and CFS (HR for OS: 1.78 (1.05-3.00), p = 0.031 and HR for CFS: 1.83 (1.02-3.26), p = 0.041) compared with those operated by ACS and CS.

Conclusion: Long-term survival after emergent colon cancer resections was similar in patients operated on by CS and NCS, and the subgroup of ACS, indicating equivalent comparable surgical quality. The less favorable poorer survival observed for patients operated on by GS may possibly be due to less frequent exposure to colorectal and emergent surgery.

Background and aims: The therapeutic management of fistulas presents significant challenges, often involving both conservative and surgical approaches. Despite these interventions, recurrence and postoperative mortality rates remain high. Endoscopic stent insertion into the fistula, along with the creation of a stent stoma, may offer a promising alternative for patients who fail surgical or conservative therapies. This study aimed to evaluate the feasibility, effectiveness, and safety of endoscopic stent insertion in the treatment of refractory small intestinal fistulas.

Methods: Patients with refractory small intestine fistulas who underwent endoscopic stent insertion were included. The primary endpoint was defined as successful fistula treatment, which included an improvement in clinical symptoms related to the fistula, successful bridging to subsequent surgical revision, and the restoration of enteral nutrition. Secondary endpoints comprised the feasibility of the endoscopic procedure, complications, procedure-related complications, and in-hospital mortality.

Results: Eight patients were included, with a median follow-up period of 2.7 months. The implantation of a self-expanding metal stent was successfully performed in all patients (technical success rate, 100%; n = 8/8). The clinical success rate was 87.5% (n = 7/8), indicating clinical improvement in fistula-related symptoms, wound care, and enteral nutrition. Procedure-related complications occurred in one patient (12.5%; n = 1/8), involving stent dislocation leading to small intestine perforation, which was managed endoscopically. No procedure-related mortality was observed.

Conclusions: Endoscopic stent insertion is a feasible, effective, and safe option for the management of therapy-refractory small intestinal fistulas. The creation of a stent stoma improves patient quality of life.

Background and objective: Assessing surgical outcomes, notably postoperative complications (PCs), is crucial for healthcare systems. However, reliance on International Classification of Diseases, 10th revision (ICD-10) codes, may be suboptimal. This study aims to compare the accuracy of ICD-10 codes against manual curation of electronic healthcare records (EHRs) for identifying 13 individual PCs and evaluate associated resource utilization.

Methods: EHR data from 11,827 surgical cases across 18 Danish hospitals in November 2021 were analyzed. PCs were identified and extracted through both manual curation and ICD-10 codes. Outcomes such as readmission, admission days, intensive care unit (ICU) stays, reoperations, and radiology procedures were assessed as proxies for resource consumption. Statistical and economic analyses quantified resource utilization and associated costs.

Results: In total, 1047 PCs were found through manual curation and 439 PCs were found through ICD-10 codings. Only 218 of the PCs found through ICD-10 codes were retrieved during manual curation-corresponding to a correct ICD-10 coding of 20.8% of PCs. Patients with PCs experienced significantly higher resource utilization, including a 6.6 times higher readmission rate, 6 additional admission days, 2 extra ICU days, 7.7 times more reoperations. PCs incurred substantial economic costs, with additional admission days alone accounting for €25.5 million annually, over four times higher than estimates from ICD-10 codes.

Conclusions: ICD-10 codes inadequately capture early PCs highlighting the need for improved detection strategies. The actual costs associated with PCs far exceed current estimates, emphasizing the necessity for enhanced monitoring for informed decision-making. In the Danish healthcare system, ICD-10 codes only capture approximately 21% of PCs, making it inadequate for surgical quality monitoring. The actual costs related to PCs, based on study assumptions, are more than four times higher than estimated from current standard. This calls for novel strategies for PC detection to improve healthcare as well as political and financial decision-making.