Gunilla Nilsson

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BackgroundMeasuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.MethodsAn expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.ResultsRandomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.ConclusionsLaparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux

The aim of this study was to compare the long‐term results of laparoscopic and open antireflux surgery in a randomized clinical trial by investigating subjective and objective outcomes.

Retention behaviour of amylopectins in asymmetrical flow field-flow fractionation studied by multi-angle light scattering detection

Asymmetrical flow field-flow fractionation (FFF) with multi-angle light scattering (MALS) detection was applied for the fractionation of amylopectins from four different sources. Samples originated from genetically modified potatoes and waxy maize. Amylopectins were dissolved in a 1 mol l(-1) sodium hydroxide solution or water. With an injected mass of 0.2 microg, well below overloading conditions, a decrease of the apparent hydrodynamic radius with increasing inlet flow-rate was observed. Moreover, a decrease of the radius of gyration with increasing elution volume was recorded by the MALS detector. Steric/hyperlayer effects are a feasible explanation for this behaviour. The observed radius of gyration at the steric inversion point was in the order of 0.3 microm, which is smaller than the theoretically calculated inversion point. Apparently, the amylopectin behave as macromolecules with a larger hydrodynamic radius than expected on basis of their radius of gyration and are subjected to significant lift forces. The results were confirmed by four fractionations with varying flow-rates but constant ratio of cross to outlet-flow. In contrast to the normal mode operation, the retention of the amylopectins depended strongly on the applied flow-rates and was close to that of a much smaller 10 kDa dextran. Apparent molar masses in the order of between 10(7) and 10(9) g mol(-1) were obtained. The results are contrasted with enzymatically degraded and oxidised starch samples that were fractionated in the normal mode.

Short-term outcome after laparoscopic and open 360 degrees fundoplication - A prospective randomized clinical trial

Background: Despite the lack of randomized trials supporting the laparoscopic approach, laparoscopic antireflux surgery has gained widespread acceptance during the last decade. The aim of this study was to compare the short-term symptomatic and objective outcome after laparoscopic and open 360° fundoplication in a prospective randomized clinical trial. Methods: Sixty patients with GERD were randomized to undergo either laparoscopic (LF) or open 360° fundoplication (OF). Endoscopy, esophageal manometry, 24-h pH monitoring, clinical symptom evaluation, and symptom scoring according to a validated questionnaire (the Gastrointestinal Symptom Rating Scale [GSRS]) was performed preoperatively and 6 months after surgery. Results: Five patients randomized to the laparoscopic group were converted to open surgery. Esophageal acid exposure was restored to normal in all patients. Lower esophageal sphincter length and resting pressure were significantly increased after both laparoscopic and open fundoplication (p <0.001); there were no differences between the groups. No significant differences were seen in symptomatic outcome, although there was a trend toward a higher rate of mild dysphagia (p = 0.051) after laparoscopic surgery. GSRS revealed a decrease in reflux score (p <0.001) and abdominal pain score (p <0.001) postoperatively. There were no significant differences in GSRS scores between the two groups. Conclusion: Laparoscopic 360° fundoplication is as effective in treating reflux disease as open fundoplication. Six months postoperatively, no significant differences were seen in symptomatic or objective outcome. Long-term evaluation is needed.

Development of asymmetrical flow field-flow fractionation-multi angle laser light scattering analysis for molecular mass characterization of cationic potato amylopectin

The goal of this study is to investigate the applicability of asymmetrical flow field-flow fractionation (AsFlFFF)-multi angle laser light scattering (MALLS), and to develop a method for analysis of cationic potato amylopectin (CPAP) having ultrahigh molecular mass (UHMr). Use of the aqueous carrier having low salt content (3 mM NaN3) resulted in a distortion in AsFlFFF fractograms of CPAP with a general pattern of a sharp rise at the beginning of the elution followed by a long tailing, probably due to combination of attractive and repulsive charge interactions (attractive interaction between CPAP molecules and the channel membrane, and repulsion among cationic CPAP molecules). As the cross flow-rate (Fc) increases, the tailing tends to increase, and the repeatability of the AsFlFFF retention data tends to decrease, which is an indication of the presence of the charge interactions. The tailing gradually decreased, and the repeatability of the AsFIFFF retention data increased, as the salt content of the carrier increased. The distortion of the fractogram finally disappeared at Fc of about 0.2 ml/min and the channel flow-rate (F(out)) of about 1 ml/min with the aqueous carrier having the salt content of 40 mM (3 mM NaN3 +37 mM NaNO3). The weight-average molecular mass (Mw) and the z-average radius of gyration ((rg),) determined by MALLS were 5.2 x 10(7) and 34 x 10(1) nm, respectively. With the flow-rate ratio, Fc/F(out) kept constant, the degree of the charge interactions (and thus the distortion of fractogram) seems to increase with the cross flow-rate (Fc) and with the sample injection mass. AsFIFFF-MALLS was applied for determination of molecular mass distributions (MrDs) and the sizes of CPAPs prepared by various cooking procedures.

Randomized clinical trial of laparoscopic versus open fundoplication: evaluation of psychological well-being and changes in everyday life from a patient perspective.

Background: The laparoscopic approach in antireflux surgery might have an impact on the patients daily activities and well-being. Methods: Sixty patients were randomized to laparoscopic or open 360° fundoplication. Data were collected by questionnaires and interviews preoperatively, 1 month and 6 months after operation. Results: Five patients in the laparoscopic group were converted to open surgery. Psychological general well-being increased after surgery and reached norm values in both study groups. No significant differences were found between the two types of surgery in the per protocol analysis, while the domain self-control was significantly better after open surgery in the intention-to-treat analysis. There was improvement of diet and sleep in both study groups; after 6 months, disturbed sleep was significantly more uncommon after open surgery. Dysphagia and flatulence were new symptoms that were reported after surgery. Overall perception of the results of the operation did not differ between the groups. Conclusions: Psychological general well-being, diet and sleep improved after both laparoscopic and open surgery. There were only small differences between the groups, but in some respects the results were better after open surgery.

Optimal membrane choice for microdialysis sampling of oligosaccharides

An analytical methodology based on microdialysis sampling, high-performance anion-exchange chromatography and integrated pulsed electrochemical detection for the monitoring of oligosaccharides in bioprocesses is presented. Amylopectin and model maltooligosaccharide standards; glucose, maltose, maltotriose, maltotetraose, maltopentaose, maltohexaose and maltoheptaose were used to demonstrate its versatility in view to sampling in enzymatic bioprocesses. The performance and characteristics of membranes with the same cut-off ranging between 3 and 100 kDa, were evaluated with respect to their extraction fraction (EF), permeability factors, temperature stability and protein (enzyme) interaction. All investigated membranes showed some non-specific interaction with enzymes. The EF and non-specific membrane-enzyme interactions were higher for the polysulfone membranes compared with the polyamide and polyethersulfone membranes. For all saccharides, the EF was independent of the concentration even for a 250-fold change in concentration. The EF and morphology of the membranes in their dehydrated state, as observed using scanning electron microscopy did not show any significant difference between membranes exposed to a 90 degrees C temperature for 3 and 24 h indicating their applicability to the study of high temperature bioprocesses.

Changing the amylopectin-sodium dodecyl sulphate interaction by modifying the exterior chain length

The retrogradation of amylopectin and its interaction with the surfactant sodium dodecyl sulphate (SDS) as a function of the exterior chain length (ECL) of the amylopectin molecules was investigated. Amylopectin was modified by partial beta-amylolysis, which decreased ECL without causing any other changes in the molecular structure. Retrogradation of amylopectin was studied with differential scanning calorimetry (DSC), in the presence and absence of SDS. The retrogradation enthalpy of amylopectin was significantly dependent on the ECL, whereas the melting temperature was only to some extent influenced by ECL. The ability of SDS to inhibit the retrogradation of amylopectin depended on ECL, which suggests that there was a specific binding of SIDS to amylopectin, The decrease in retrogradation when SDS was added to the amylopectin sample was less when ECL decreased. The overall effect was thus an increase in retrogradation in the presence of SIDS when the ECL decreased, Small changes in the molecular structure of amylopectin gave rise to sharp changes in both retrogradation and interaction with lipids, showing that the molecular structure is important for the crystallisation and interaction behaviour of amylopectin.

Microdialysis clean-up and sampling in enzyme-based methods for the characterisation of starch

Microdialysis was used for sampling enzyme hydrolysis products of starch hydrolysed with beta -amylase, pullulanase, and/or isoamylase, to obtain information about the molecular structure of starch. Starches from waxy, normal, and high amylose maize, and from normal and genetically modified potato (amylose deficient) were used, and also commercial potato amyloses. The hydrolysis products were analysed using high-performance anion-exchange chromatography with pulsed amperometric detection (HPAEC-PAD). Simultaneous sampling and sample clean-up were achieved with microdialysis, thus enabling on-line injection into the liquid chromatographic system. The molecular weight cut-off of the membrane allowed for diffusion of small molecules such as oligosaccharides through the membrane, but hindered large molecules, e.g. enzymes and large polysaccharides, from entering the chromatographic system. With microdialysis sampling, it was possible to investigate the short chain fractions of debranched starch in the presence of amylose without pre-fractionation. The microdialysis-HPAEC-PAD system was also used for determination of the A:B chain ratio and the P-limit value. After P-amylolysis, only liberated maltose diffused through the dialysis membrane, which resulted in on-line sample clean-up from branched P-limit dextrin as well as from the enzyme. The proposed method is fast and easy to handle since clean-up of the hydrolysate is achieved on-line with the chromatographic system

The Patients’ Perspective

“Our ability to imagine the illness experience and to emphasize with those who are ill is severely limited” [2]. Novels describing patients’ illness experiences have become invaluable sources for medical and health care professionals and students. An understanding of disease processes, treatments and outcomes is necessary for humane and effective care of patients [2]. Further, teaching of literature in medical schools has become widely accepted as a primary means to teach about the patients’ experiences [3]. Likewise narrative medicine suggests that several dimensions of medical research, teaching and practice are imbued with narrative considerations and can be made more effective with narrative competence [3]. Narrative competence is the ability to acknowledge, absorb, interpret and act on the stories and plights of others [3]. A literature review involving patients as teachers showed that meeting real patients with firsthand experience of a condition, who have knowledge and teaching skills, offers learners important educational benefits [4]. Patients offer unique qualities that can improve communication, enhance the acquisition of skills and change attitudes towards patients by perceiving patients’ experiences and expertise [4]. Patients’ experiences are also useful to fellow patients. From on-going conversations with GERDpatients, it is obvious that patients not only request honest and clear information from health professionals but they also seek information from peers i.e. patients who have previously undergone antireflux surgery, and who will be able to report their experiences and outcomes after operation versus living with the disease before surgery. Describing the symptoms, the operation and the outcomes, i.e., daily life with illness, before and after surgical treatment, and illuminated from a patient perspective would be of importance. This will increase the understanding of living with chronic reflux disease, enhance information about the outcome of different treatments, e.g., surgery, from a patient perspective and constitute a foundation for decision-making about advantages or disadvantages. GERD-patients’ experiences of illness and surgical treatment could promote an increase in information for future patients, next of kin and health professionals.