Bo Anderberg

Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer.

There has been no randomized clinical trial of the costs of laparoscopic colonic resection (LCR) compared with those of open colonic resection (OCR) in the treatment of colonic cancer.

Value of routine intraoperative cholangiography in detecting aberrant bile ducts and bile duct injuries during laparoscopic cholecystectomy

A prospective study was performed to determine the frequency and type of bile duct abnormalities, and to determine whether routine use of intraoperative cholangiography during laparoscopic cholecystectomy might aid in the prevention of bile duct injuries. Overall, anatomical aberrations of the bile ducts were found in 98 (19 per cent) of 513 cholangiograms. The most common anomalies were at the hepatic confluence and constituted different types of right hepatic subsegmental ducts draining separately into the biliary tree (n=43, 8.4 per cent), either close to the cystic duct or directly into the cystic duct. Three bile duct injuries (0.5 per cent) occurred during the study period. These results show that routine intraoperative cholangiography is feasible and provides valuable information about the anatomy of the biliary tract, thereby improving the safety of laparoscopic cholecystectomy. If an injury to the biliary tract occurs early during operation, the cholangiogram allows the surgeon to detect the injury, to make a prompt repair and thereby reduce the morbidity associated with a delayed diagnosis. Routine use of intraoperative cholangiography is strongly recommended.

LAPPRO: A prospective multicentre comparative study of robot-assisted laparoscopic and retropubic radical prostatectomy for prostate cancer

Abstract Objective. This study describes the study design and procedures for a prospective, non-randomized trial comparing open retropubic and robot-assisted laparoscopic radical prostatectomy regarding functional and oncological outcomes. Material and methods. The aim was to achieve a detailed prospective registration of symptoms experienced by patients using validated questionnaires in addition to documentation of surgical details, clinical examinations, medical facts and resource use. Four patient questionnaires and six case-report forms were especially designed to collect data before, during and after surgery with a follow-up time of 2 years. The primary endpoint is urinary leakage 1 year after surgery. Secondary endpoints include erectile dysfunction, oncological outcome, quality of life and cost-effectiveness at 3, 12 and 24 months after surgery. Results. The study started in September 2008 with accrual continuing to October 2011. Twelve urological departments in Sweden well established in performing radical prostatectomy are participating. Personal contact with the participating departments and patients was established to ascertain a high response rate. To reach 80% statistical power to detect a difference of 5 absolute per cent in incidence of urinary leakage, 700 men in the retropubic group and 1400 in the robotic group are needed. Conclusions. The Swedish healthcare context is well suited to performing multicentre long-term prospective clinical trials. The similar care protocols and congruent specialist training are particularly favourable. The LAPPRO trial aims to compare the two surgical techniques in aspects of short- and long-term functional and oncological outcome, cost effectiveness and quality of life, supplying new knowledge to support future decisions in treatment strategies for prostate cancer.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study.

BackgroundLaparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation.MethodsA total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon.ResultsIn the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p=0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8).ConclusionThe use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Bacteremia following diagnostic and therapeutic ERCP.

The occurrence of bacteremia in association with diagnostic or therapeutic ERCP was studied in 180 patients undergoing a total of 194 examinations. Nineteen (15%) of 126 diagnostic procedures and 18 (27%) of 68 therapeutic procedures were associated with bacteremia (p less than 0.1). Nine patients had polymicrobial bacteremia and a total of 16 species were detected. Different streptococci, mainly alpha-hemolytic, were the most common bacteria which were identified in 38% of the bacteremic patients. There were no significant differences with regard to the occurrence of fever, pancreatitis, or septic complications between the diagnostic and therapeutic groups of patients. Neither did the complication rate in patients with bacteremia differ from that in patients without bacteremia, whether the procedure was diagnostic or therapeutic. Complication rates did not differ between patients with and patients without pancreaticobiliary obstruction. However, the majority of patients with biliary stasis had drainage with relief of the obstruction at the time of the diagnostic ERCP. We conclude that general routine antibiotic prophylaxis is not indicated in patients undergoing diagnostic or therapeutic ERCP. The question whether such prophylaxis should be given with certain diagnoses or treatments, or in patients with valvular heart disease, remains to be answered in controlled randomized studies.

Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an inaccessible polyp of the colon

AbstractBackground: The purpose of this report was to describe a simple technique suitable for polyps where circumstances of the bowel anatomy prevent complete access and control of the colonoscopic procedure. Methods: By combining laparoscopic mobilization of the bowel with colonoscopic polypectomy, previously inaccessible polyps could be snared in two patients. Results: Both patients had 3-cm large sessile adenomas in the sigmoid colon safely removed, and they returned home within a day. Conclusions: The described procedure increases the safety of the otherwise difficult polypectomy and also avoids laparotomy with enterotomy or bowel resection as the alternative.

Cost-minimisation analysis of laparoscopic and open appendicectomy.

OBJECTIVE To compare the direct and indirect costs of laparoscopic and open appendicectomy. DESIGN Randomised study. SETTING University hospital, Sweden. MAIN OUTCOME MEASURES Total costs for a defined period of time for each option. RESULTS 102 patients were randomised and 99 were included in the final analysis. All patients had completely recovered within two months of operation. Disposable extra material used for the laparoscopic operation and longer operating time raised its median cost by SEK 912 and 1785, respectively. The mean duration of hospital stay, period off work (indirect costs), and time to complete recovery did not differ between the groups. CONCLUSION Laparoscopic appendicectomy has higher direct costs than open operation and is not as cost-effective when the longterm outcome is the same in both groups.

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients.

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

Introduction of Herniorraphy with Mesh Plug and Patch

OBJECTIVE To evaluate the introduction of the Perfix mesh plug and patch system for inguinal hernia repair. DESIGN Prospective consecutive follow-up study. SETTING Teaching hospital, Sweden. SUBJECTS 139 patients with 145 hernias who were operated on for inguinal hernia with the Perfix mesh plug and patch technique during 1997. MAIN OUTCOME MEASURES Operating time, sick leave, time to full recovery, morbidity, recurrence rate. RESULTS The median operating time was 35 minutes (range 15-105) and the mean follow-up was 9 months (range 4-13). Office workers required a mean of 7 days off work (range 0-43) and manual workers 15 days (range 0-90). Retired patients took 21 days (0-30) to recover fully, office workers 22 days (7-70), manual workers 30 days (7-90), students 34 days (0-60) and unemployed patients 60 days (21-150). There were 17 minor complications within 30 days and 2 recurrences during the follow up period. CONCLUSION Herniorraphy with a mesh plug and patch can easily be introduced with good short-term results.