Björn Törnqvist

Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study.

Objectives To determine whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries. Design Population based cohort study. Setting Prospectively collected data from the Swedish national registry of gallstone surgery and endoscopic retrograde cholangiopancreatography, GallRiks. Multivariate analysis done by Cox regression. Population All cholecystectomies recorded in GallRiks between 1 May 2005 and 31 December 2010. Main outcome measures Evidence of bile duct injury, rate of intended use of intraoperative cholangiography, and rate of survival after cholecytectomy. Results During the study, 51 041 cholecystectomies were registered in GallRiks and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had an impaired survival compared with those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62% (hazard ratio 0.38 (95% confidence interval 0.31 to 0.46)). Conclusions The high incidence of bile duct injury recorded is probably from GallRiks’ ability to detect the entire range of injury severities, from minor ductal lesions to complete transections of major ducts. Patients with bile duct injury during cholecystectomy had impaired survival, and early detection of the injury improved survival. The intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy.

Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy

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

Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson’s disease in the Nordic region

Abstract Objective. Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson’s disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. Material and methods. A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson’s disease patients with the primary goal of providing guidance on best practice for the Nordic countries. Results. Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. Conclusions. LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson’s disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.

ERCP-guided cholangioscopy using a single-use system: nationwide register-based study of its use in clinical practice.

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.

The impact of prophylactic pancreatic stenting on post-ERCP pancreatitis: A nationwide, register-based study

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.

The role of antibiotic prophylaxis in routine endoscopic retrograde cholangiopancreatography investigations as assessed prospectively in a nationwide study cohort.

Abstract 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%).

Pattern of care for cancer of the oesophagus in a western population: Pattern of care for cancer of the oesophagus

Most oesophageal outcome research focuses on surgical treatment, despite most patients not undergoing surgery as they are unfit or have metastatic disease. Few studies have evaluated the patterns of care for all patients presenting with oesophageal cancer.

Anterior Partial Fundoplication

For more than five decades, the gold standard operation for gastro-esophageal reflux disease has been Nissen fundoplication. However, in some patients wrapping the gastric fundus fully around the esophagus is followed by troublesome new symptoms such as abdominal bloating, dysphagia, inability to belch and flatulence, and these problems are probably generated by an over-competent valve which results following Nissen fundoplication. To reduce the risk of these side effects, surgeons have evaluated various modifications to the Nissen procedure, including partial fundoplications in which the gastric fundus is wrapped only part way around the distal esophagus, thereby generating a more physiological gastro-esophageal valve mechanism. A partial fundoplication can be constructed using either an anterior or a posterior approach, with the lowest risk of side effects following anterior partial fundoplication variants. Long-term follow-up from randomized controlled trials demonstrate that anterior partial fundoplications are followed by a reduced risk of side effects, and the overall success rate, defined using measures of overall satisfaction with the surgical outcome, is at least as good as following Nissen fundoplication. However, there are trade-offs between the risks of recurrent reflux vs. side effects, and these balance somewhat, with differences in these risks correlating with the extent of the fundoplication constructed. This chapter describes the indications, critical technical aspects pertinent to the creation of a satisfactory anterior partial fundoplication, and outcomes.