Jon Arne Søreide

Incidence of acute nonperforated and perforated appendicitis: Age- specific and sex-specific analysis

Abstract. This prospective study was performed to investigate epidemiological characteristics in terms of the age- and sex-specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n = 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in-hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13–40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in-hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in-hospital observation time, probably due to patient-related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision-making for patients with suspected acute appendicitis.

Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique

METHODS From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper. RESULTS Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission < 13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P < 0.05). CONCLUSIONS The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score > or = 13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.

Islet cell carcinoma of the pancreas.

Abstract. Islet cell carcinoma (ICC) of the pancreas is a rare, indolent malignancy associated with higher resectability rate and better survival than ductal carcinoma. This retrospective study presents results of surgical treatment from a single institution. From 1985 through 1993 a total of 64 patients (36 men, 28 women) were surgically treated for ICC. Ages ranged from 22 to 80 years (median 55 years) with a median postoperative follow-up of 39 months (range 10–97 months). Of the 64 patients, 30 (47%) had functioning and 34 (53%) nonfunctioning tumors. Gastrinoma (n = 11) followed by glucagonoma (n = 6) and insulinoma (n = 4) were the most common functioning tumors. In the patients undergoing a laboratory study, 67% of the nonfunctioning tumors had elevated peptide hormone levels. Potentially curative resections were performed in 17 patients (26%), palliative procedures in 35 (55%), and exploratory laparotomy alone in 12 (19%). One patient (2%) died within 30 days after operation. Symptomatic improvement was achieved in 96% of patients with a mean duration of 22 months. Three- and five-year survivals were 66% and 49%, respectively. In patients with curative resection, the disease-free survival at 3 years was 53% (95% CI: 32–86%). The presence of diffuse hepatic metastases was a predictor of poor survival at 3 years (74% versus 58%;p = 0.05); there was no statistically significant difference in survival between functioning and nonfunctioning groups (p > 0.1). Although curative resection for ICC is rare, meaningful palliation can be achieved in most patients with rare mortality and acceptable morbidity.

Posttraumatic distress symptoms in operable breast cancer III: Status one year after surgery

One hundred and six patients with operable breast cancer were studied at intervals one day before surgery, and at six weeks and one year post-operatively by means of taped clinical interviews and self-report questionnaires (Impact of Event Scale (IES) and General Health Questionnaire (GHQ-28)). A year after surgery, 9%reported a high level of intrusive symptoms and 10% of avoidance symptoms compared to 18% and 14% after six weeks, respectively. Based on questionnaire data, a year after surgery, thirteen patients (12%) were estimated to have a posttraumatic stress disorder (PTSD) compared to fifteen patients (14%) after six weeks. Severity of posttraumatic stress symptoms (PTSS) after one year was significantly associated with impaired psychosocial functioning over the last year previous to surgery (p < 0.05), negative life events during the year before surgery (p < 0.05), health problems during the previous ten years (p < 0.01), and a personality trait characterized by high emotional reactivity (p < 0.001). Crisis support in the acute situation, type of surgery, axillary-node metastases, and postoperative adjuvant chemotherapy did not predict subsequent PTSS. Premorbid health variables, personality, and level of distress six weeks after surgery were most important risk factors for persistent PTSS in our patients with operable breast cancer stage I and II.

Bile duct cysts in adults

Bile duct cysts are rare and of uncertain origin. Most have been reported in young females of Asian descent, but an increasing number have occurred in Western adults.

Survival after surgical treatment for primary hyperparathyroidism.

BACKGROUND Reports have suggested that patients with primary hyperparathyroidism (pHPT) are at increased risk for premature death, even when they reach normocalcemia. This study addresses factors that may be of relevance for long-term outcome. METHODS Between 1980 and 1984, 1052 patients (27% men and 73% women; median age, 59 years) underwent initial cervical exploration for pHPT. Long-term follow-up was obtained with regard to overall survival and cause of death. By using univariate and multivariate (Cox) survival analysis, subgroups of patients were compared. RESULTS Median follow-up was 12 years (range, 0 to 15 years). Overall, survival was not decreased compared with the expected survival of a gender- and age-matched midwest population. Survival was better in patients with a history of kidney stones (p = 0.044), without osteoporosis (p = 0.004), and without muscle weakness (p = 0.013). CONCLUSIONS Decreased long-term survival was not evident in this study. Age at the time of initial surgical treatment and the degree of endocrine activity of the diseased glands appear to be the most important independent prognostic factors for survival. Comparison of these data to prior Scandinavian data is not justified, principally because of the less advanced stage of disease in this study.

Epidemiology of perforated peptic ulcer: Age- and gender-adjusted analysis of incidence and mortality

AIM To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population. METHODS A retrospective, population-based, single-center, consecutive cohort study of all patients diagnosed with benign perforated peptic ulcer. Included were both gastric and duodenal ulcer patients admitted to Stavanger University Hospital between January 2001 and December 2010. Ulcers with a malignant neoplasia diagnosis, verified by histology after biopsy or resection, were excluded. Patients were identified from the hospitals administrative electronic database using pertinent ICD-9 and ICD-10 codes (K25.1, K25.2, K25.5, K25.6, K26.1, K26.2, K26.5, K26.6). Additional searches using appropriate codes for relevant laparoscopic and open surgical procedures (e.g., JDA 60, JDA 61, JDH 70 and JDH 71) were performed to enable a complete identification of all patients. Patient demographics, presentation patterns and clinical data were retrieved from hospital records and surgical notes. Crude and adjusted incidence and mortality rates were estimated by using national population demographics data. RESULTS In the study period, a total of 172 patients with PPU were identified. The adjusted incidence rate for the overall 10-year period was 6.5 per 100 000 per year (95%CI: 5.6-7.6) and the adjusted mortality rate for the overall 10-year period was 1.1 per 100 000 per year (95%CI: 0.7-1.6). A non-significant decline in adjusted incidence rate from 9.7 to 5.6 occurred during the decade. The standardized mortality ratio for the whole study period was 5.7 (95%CI: 3.9-8.2), while the total 30-d mortality was 16.3%. No difference in incidence or mortality was found between genders. However, for patients ≥ 60 years, the incidence increased over 10-fold, and mortality more than 50-fold, compared to younger ages. The admission rates outside office hours were high with almost two out of three (63%) admissions seen at evening/night time shifts and/or during weekends. The observed seasonal variations in admissions were not statistically significant. CONCLUSION The adjusted incidence rate, seasonal distribution and mortality rate was stable. PPU frequently presents outside regular work-hours. Increase in incidence and mortality occurs with older age.

Validation of data in the Norwegian Arthroplasty Register and the Norwegian Patient Register : 5,134 primary total hip arthroplasties and revisions operated at a single hospital between 1987 and 2003

Background The usefulness of a national medical register relies on the completeness and quality of the data reported. The data recorded must therefore be validated to prevent systematic errors, which can cause bias in reports and study conclusions. Patients and methods We compared the number of hip replacements reported to the Norwegian Arthroplasty Register (NAR), 1987–2003, and to the Norwegian Patient Register (NPR), 1999–2002, with data recorded at a local hospital. The date of operation and the index hip were further validated to find inaccurately recorded data in the NAR. Kaplan-Meier estimated survival curves were compared to evaluate the possible influence of missing data. Results Of 5,134 operations performed at a local hospital, 19 (0.4%) had not been reported to the NAR. Completeness of registration was poorer for revisions (1.2%) than for primary operations (0.2%). Among 86 Girdlestone revisions (removal of the prosthesis only), 9 (11%) had not been reported to the NAR. Missing data on revisions, however, had only a minor influence on survival analyses. The date of the operation had been recorded incorrectly in 56 cases (1.1%), and the index hip in 12 cases (0.2%). The surgeon was responsible for 85% of these errors. Comparisons with data reported to the NPR, 1999–2002, showed that 3.4% of operations at the local hospital had not been reported to the NPR. Interpretation Only 0.4% of the data from a local hospital was missing in the NAR, as opposed to the NPR where 3.4% was missing. The information recorded in the NAR appears to have been valid and reliable throughout the entire period, and provides an excellent basis for clinically relevant information regarding total hip arthroplasty.   ▪

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours.

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Evolving molecular classification by genomic and proteomic biomarkers in colorectal cancer: Potential implications for the surgical oncologist

Colorectal cancer (CRC) is one of the most frequent cancers in the Western world and represents a major health burden. CRC development is a multi-step process that spans 10-15years, thereby providing an opportunity for early detection and even prevention. As almost half of all patients undergoing surgery develop recurrent disease, surveillance is advocated, albeit with various means and intervals. Current screening and surveillance efforts have so far only had limited impact due to suboptimal compliance. Currently, CEA is the only biomarker in clinical use for CRC, but has suboptimal sensitivity and specificity. New and better biomarkers are therefore strongly needed. Non-invasive biomarkers may develop through the understanding of colorectal carcinogenesis. Three main pathways occur in CRC, including chromosomal instability (CIN), microsatellite instability (MSI) and epigenetic silencing through the CpG Island Methylator Phenotype (CIMP). These pathways have distinct clinical, pathological, and genetic characteristics, which can be used for molecular classification and comprehensive tumour profiling for improved diagnostics, prognosis and treatment in CRC. Molecular-biological research has advanced with the sequencing of the human genome and the availability of genomic and proteomic high-throughput technologies using different chip platforms, such as tissue microarrays, DNA microarrays, and mass spectrometry. This review aims to give an overview of the evolving biomarker concepts in CRC, with concerns on methods, and potential for clinical implications for the surgical oncologist.