Hans-Olaf Johannessen

Survival and complications after insertion of self-expandable metal stents for malignant oesophageal stenosis

Objective. To report on survival and complications after insertion of self-expandable stents in patients with malignant oesophageal stenosis. Material and methods. Data were gathered retrospectively from the medical records of 92 consecutive patients in the period 1994–2003. The study comprised 68 men and 24 women (median age 72 years, range 46–93 years) with stenosis from cancer of the oesophagus (n=61), the gastric cardia (n=26) and the lung (n=5), located mainly above (n=4) or below (n=62) the carina, or at the gastro-oesophageal junction (n=26). One uncovered stent and six different covered stents were used. Results. Median and mean survival times after stenting (n=92) were 83 (range 4–1102) and 125 days, respectively. Thirty-day mortality was 19% (n=17), and 7% (n=6) survived more than one year. Survival was neither significantly influenced by division of the patients into diagnostic subgroups nor by comparison of the three most frequently used stents. One, two, three and four stents were received by 76, 11, 4 and 1 patient(s), respectively. There was no stent-related mortality, and complications were bleeding 1 (1%), stent migration 7 (8%), recurrent stenosis 8 (9%) from both tumour overgrowth (n=8) and tumour ingrowth (n=2) when using uncovered stents. Thirteen (14%) patients were restented because of recurrent stenosis (n=8) including fistula formation to the left main bronchus (n=2) and stent migration (n=5). Conclusions. Use of self-expandable stents in patients with inoperable malignant oesophageal stenosis carried few complications and resulted in relatively long survival in comparison with similar studies.

Long-term outcome after intestinal resection for Crohn's disease

Objective. To assess the need for intestinal repeat resection for recurrence of Crohns disease in patients observed for more than 20 years after the first resection. Material and methods. Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohns disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13–65) years, and median observation time thereafter was 26.5 (20.1–48.6) years. Disease location and behaviour were defined according to the Vienna classification. Results. The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection. Conclusions. This study indicates a diminution of Crohns disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.

Resection Rectopexy for External Rectal Prolapse Reduces Constipation and Anal Incontinence

Background and Aims: The main aim was to examine constipation and anal incontinence in patients before and after resection for external rectal prolapse. Material and Methods: Twenty patients had ligament preserving suture rectopexy and sigmoid resection (resection rectopexy) for external rectal prolapse by laparoscopic (n = 15) or open (n = 5) technique during 2001–2005. They were prospectively evaluated for constipation and anal incontinence using validated incontinence and KESS-constipation scores. Results and Conclusions: Constipation score was significantly reduced from mean 7.7 (5.4–9.9) to 4.5 (2.5–6.4) after median 4 months (1–19) and to 4.3 (2.2–6.3) after median 17 months (4–51). Six and four patients were constipated preoperatively and 17 months postoperatively, respectively. The four symptoms feeling incomplete evacuation of stool, minutes in lavatory per attempt, use of enemas/digitation and painful evacuation effort were significantly reduced, whilst stool consistency increased. Fourteen patiens (70%) had anal incontinence. Corresponding and significant reduction in their scores were from mean 12.5 (9.4–15.5) to 5.1 (2.1–8.1) and to 3.6 (1.3–5.9). Incontinence was improved in 13 and unaltered in one patient(s). Two patients with worse outcome had increased stool consistency and constipation scores. Resection rectopexy for rectal prolapse reduced anal incontinence and constipation.

Endoscopic treatment of deep infiltrating endometriosis (DIE) involving the bladder and rectosigmoid colon

Background. To study the feasibility, complications and symptom relief of laparoscopic treatment in patients with deep infiltrating endometriosis.

Surgical treatment of epiphrenic oesophageal diverticulum.

BACKGROUND Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the departments results for surgical treatment of this rare and distressing condition. MATERIAL AND METHOD In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery. RESULTS There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery. INTERPRETATION Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.

SIGMOIDOSTOMY-RELATED PARASTOMAL HERNIA

Background and Aims: The aim was to examine prevalence and treatment of parastomal hernias in patients with sigmoidostomy. Materials and Methods: In 2009, the medical records of 447 consecutive patients operated with a sigmoidostomy from January 1999 to December 2008 were retrospectiely reviewed. 119 dead patients (26.6%) were excluded because of short follow up (n = 59) and insufficient clinical data (n = 60). 328 patients (73.4%) were followed-up, of whom 210 (64%) alive patients also were scrutinized for presence of parastomal hernia by phone interview. In 2010, 92 out of 153 alive patients (60.1%) without known parastomal hernia also underwent targeted clinical examination in the ambulatory unit. Results and Conclusion: Follow up from stoma operation in 328 patients was median 20 (range 1–129) months. 319 patients had an end sigmoidostomy and nine patients had a loop sigmoidostomy. Time to parastomal hernia in 66 patients (20.1%) was median 9 (1–54) months. Fourty four patients (66.7%) reported no symptoms, eight (12.1%) had mild discomfort, six (9.1%) leakage, six (9.1%) pain, and two (3%) episodes of intestinal obstruction. Eleven (16.7%) had a hernia operation, eight with onlay mesh repair complicated with bowel perforation and ventral hernia in one patient. Three with mesh repair (37.5%) developed recurrent parastomal hernia, of whom one had tissue repair and a second recurrence 6 months later. The only patient with initial tissue repair had a recurrent hernia successfully treated with mesh repair. Two patients had their stoma uneventfully reversed. Parastomal hernia rate, mainly treated with mesh repair, was fairly low in this heterogenous patient series.

Outcome after stenting and débridement for spontaneous esophageal rupture

Abstract Objectives: Surgical repair has been the most common treatment of esophageal effort rupture (Boerhaave syndrome). Stent-induced sealing of the perforation has increasingly been used with promising results. We present our eight years´ experience with stent-based and organ-preserving treatment. Materials and methods: Medical records of 15 consecutive patients with Boerhaave syndrome from February 2007 to May 2015 were retrospectively registered in a database. Treatment was sealing of the perforation by stenting, chest tube drainage and débridement of the contaminated thorax. After median 25 months nine out of 10 patients responded to questions on fatigue and Ogilvie’s dysphagia score. Results: Fifteen patients, aged median 67.5 years (range 39–88), had a primary hospital stay of 20 days (range 1–80 days). Overall in-hospital mortality was 13%. Observation time was 44 months (range 0–87) and 10 patients were alive of August 2017. Ten patients (67%) needed surgical chest débridement. Five patients (33%) were restented for leakage, migration and for stent removal. Eleven patients (73%) had complications, which included pleural empyema (n = 4), fatal aortic bleeding, lung arterial bleeding, lung embolism, drain-induced lung laceration and respiratory failure. Dysphagia score was low (median 0.5) meaning that they were able to feed themselves. Total fatigue score (mean 14.6) was slightly increased (p = .05) compared with a reference population. Conclusions: The mortality rate after initial stenting of effort rupture seems to be comparable to standard surgical repair. Most patients required further intervention, either by restenting and/or surgical débridement. The functional result in these patients was satisfactory.

Management of gastric conduit retention following hybrid and minimally invasive esophagectomy for esophageal cancer: Two retrospective case series

Highlights • About 5% of patients experience long-term gastric conduit retention.• Two patients with hybrid and total minimally invasive Ivor-Lewis esophagectomy experienced long-term retention of the conduit.• Initial too wide hiatal opening or a combination of a redundant conduit and a too narrow hiatus led to conduit retention.• Reoperation involved open thoracoabdominal access for mobilization, reduction and diaphragmatic fixation of the herniated conduit.• One patient had an excellent result whilst the other improved despite a limited degree of reherniation of the conduit.

Gastrobronchial fistula following minimally invasive esophagectomy for esophageal cancer in a patient with myotonic dystrophy: Case report

Highlights • Myotonic dystropy patients have after major surgery increased risk for pulmonary complications because of weakness of respiratory muscles.• Such a patient tolerated a minimally invasive esophagectomy for cancer.• Minimally invasive instead of open surgery was probably the only feasible treatment due to less strain on respiratory function.• A life-threatening complication of gastrobronchial fistula healed by stenting of the gastric conduit and ventilation with low airway pressures.• Indications for stenting of gastrobronchial fistula are discussed.