Omid Sadr-Azodi

Cigarette smoking, smoking cessation and acute pancreatitis: a prospective population-based study

Background Several studies have shown that smoking increases the risk of chronic pancreatitis. However, the impact of smoking on the development of acute pancreatitis has not been fully studied. Objective To clarify the association between cigarette smoking, smoking cessation and the risk of acute pancreatitis. Design A follow-up study was conducted of 84 667 Swedish women and men, aged 46–84, during 12 years to study the association between smoking status, smoking intensity and duration, duration of smoking cessation and the risk of acute pancreatitis. Only those with the first event of the disease and no previous history of acute pancreatitis were included. Cox proportional hazards models were used to estimate rate ratios (RRs) with 95% CI for different smoking-related variables, adjusted for age, gender, body mass index, diabetes, educational level and alcohol consumption. Results In total, 307 cases with non-gallstone-related and 234 cases with gallstone-related acute pancreatitis were identified. The risk of non-gallstone-related acute pancreatitis was more than double (RR=2.29; 95% CI 1.63 to 3.22, p<0.01) among current smokers with ≥20 pack-years of smoking as compared with never-smokers. The corresponding risk among individuals with ≥400 g monthly consumption of alcohol was increased more than fourfold (RR=4.12; 95% CI 1.98 to 8.60, p<0.01). The duration of smoking rather than smoking intensity increased the risk of non-gallstone-related acute pancreatitis. After two decades of smoking cessation the risk of non-gallstone-related acute pancreatitis was reduced to a level comparable to that of non-smokers. There was no association between smoking and gallstone-related acute pancreatitis. Conclusion Smoking is an important risk factor for non-gallstone-related acute pancreatitis. Early smoking cessation should be recommended as a part of the clinical management of patients with acute pancreatitis.

Influence of Major Postoperative Complications on Health-Related Quality of Life Among Long-Term Survivors of Esophageal Cancer Surgery

PURPOSE To evaluate the effect of major postoperative complications on health-related quality of life (HRQL) in 5-year survivors of esophageal cancer surgery. PATIENTS AND METHODS This study was based on the Swedish Esophageal and Cardia Cancer register with almost complete nationwide coverage and data on esophageal cancer surgery collected prospectively between 2001 and 2005. Patients who were alive 5 years after surgery were eligible. HRQL was assessed longitudinally until 5 years after surgery by using the validated European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and OES18. Linear mixed models were used to assess the mean score difference (MD) with 95% CIs of each aspect of HRQL in patients with or without major postoperative complications. Adjustment was made for several potential confounders. RESULTS Of 153 patients who survived 5 years, 141 patients (92%) answered the 5-year HRQL questionnaires. Of these individuals, 46 patients (33%) sustained a major postoperative complication. Dyspnea (MD, 15; 95% CI, 6 to 23), fatigue (MD, 13; 95% CI, 5 to 20), and eating restrictions (MD, 10; 95% CI, 2 to 17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications. Although problems with choking declined to levels comparable with patients without major postoperative complications, sleep difficulties and gastroesophageal reflux progressively worsened during follow-up. CONCLUSION The occurrence of postoperative complications exerts a long-lasting negative effect on HRQL in patients who survive 5 years after esophagectomy for cancer.

Hospital and Surgeon Volume in Relation to Survival After Esophageal Cancer Surgery in a Population-Based Study

PURPOSE The influence of hospital and surgeon volume on survival after esophageal cancer surgery deserves clarification, particularly the prognosis after the early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account. METHODS A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer who underwent esophageal resection in 1987 to 2005, with follow-up for survival until February 2011, was conducted. The associations between annual hospital volume, annual surgeon volume, and cumulative surgeon volume and risk of mortality were calculated with multivariable parametric survival analysis, providing hazard ratios (HRs) with 95% CIs. HRs were mutually adjusted for the surgery volume variables and further adjusted for the prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and neoadjuvant therapy. RESULTS There was no independent association between annual hospital volume and overall survival, and hospital volume was not associated with short-term mortality after adjustment for hospital clustering effects. A combination of higher annual and cumulative surgeon volume reduced the mortality occurring at least 3 months after surgery (P trend < .01); the HR was 0.78 (95% CI, 0.65 to 0.92) comparing surgeons with both annual and cumulative volume above the median with those below the median. These results remained when hospital and surgeon clustering were taken into account. CONCLUSION Because surgeon volume rather than hospital volume independently influences the prognosis after esophageal cancer surgery, centralization of this surgery to fewer surgeons seems warranted.

Abdominal and Total Adiposity and The Risk of Acute Pancreatitis: A Population-Based Prospective Cohort Study

OBJECTIVES:Previous research has indicated that obesity may be linked to the severity of acute pancreatitis. However, the association between abdominal and total adiposity as risk factors in the development of acute pancreatitis in a general population has not been studied.METHODS:A follow-up study was conducted, using the Swedish Mammography Cohort and the Cohort of Swedish Men, to examine the association between waist circumference and body mass index (BMI) and the risk of first-time acute pancreatitis. Severe acute pancreatitis was defined as hospital stay of >14 days, in-hospital death, or mortality within 30 days of discharge. Cox proportional hazards models were used to estimate rate ratios (RRs) with 95% confidence intervals (CIs), adjusted for confounders.RESULTS:In total, 68,158 individuals, aged 46–84 years, were studied for a median of 12 years. During this time, 424 persons developed first-time acute pancreatitis. The risk of acute pancreatitis among those with a waist circumference of >105 cm was twofold increased (RR=2.37; 95% CI: 1.50–3.74) compared with individuals with a waist circumference of 75.1–85.0 cm, when adjusted for confounders. This association was seen in patients with non-gallstone-related and gallstone-related acute pancreatitis. The results remained unchanged when stratifying the analyses with regards to sex or the severity of acute pancreatitis. There was no association between BMI and the risk of acute pancreatitis.CONCLUSIONS:Abdominal adiposity, but not total adiposity, is an independent risk factor for the development of acute pancreatitis.

Obesity and abdominal aortic aneurysm

The relationship between obesity and abdominal aortic aneurysm (AAA) is unclear. An observational cohort study was undertaken to examine the associations between waist circumference as a measure of abdominal adiposity, and between body mass index (BMI) as a measure of total adiposity, and risk of AAA.

Association of Oral Glucocorticoid Use With an Increased Risk of Acute Pancreatitis: A Population-Based Nested Case-Control Study

IMPORTANCE Oral glucocorticoid use has been suggested to cause acute pancreatitis in several case reports. However, no epidemiological study has investigated this association. OBJECTIVE To conduct a nationwide population-based case-control study to investigate the potential association between oral glucocorticoid use and acute pancreatitis. DESIGN In this population-based case-control study, all individuals aged 40 to 84 years who developed a first episode of acute pancreatitis between 2006 and 2008 in Sweden were identified. SETTING Population-based, nationwide, register-based study. PARTICIPANTS A total of 6161 cases with a first episode of acute pancreatitis and 61,637 controls were included in the final analyses. Cases were all patients diagnosed as having a first episode of acute pancreatitis during the study period, defined by the diagnosis code K85 in the International Statistical Classification of Diseases, 10th Revision (ICD-10). Controls were randomly selected from the source population at risk of developing acute pancreatitis. For each case, 10 controls, matched for age, sex, and calendar period, were randomly selected from the general population. Oral glucocorticoid use was assessed from the Swedish Prescribed Drug Register. Current, recent, and former users were defined as patients who collected their glucocorticoid prescription within 30, 31 to 180, and after 180 days before the index date, respectively. MAIN OUTCOME MEASURES Unconditional logistic regression was performed to calculate the odds ratios (ORs) with 95% confidence intervals for the association between oral glucocorticoid use and acute pancreatitis. Multivariable adjustment was made for potential confounders including, among others, alcohol abuse, diabetes, and concomitant drug use. RESULTS The study included 6161 cases of acute pancreatitis and 61,637 controls. The risk of acute pancreatitis was increased among current users of oral glucocorticoids compared with nonusers (OR, 1.53; 95% CI, 1.27-1.84). This risk was highest 4 to 14 days after drug dispensation (OR, 1.73; 95% CI, 1.31-2.28) and attenuated thereafter. There was no association between oral glucocorticoid use and acute pancreatitis immediately after drug dispensation. There was no increased risk of acute pancreatitis among recent or former users of glucocorticoids compared with nonusers. CONCLUSIONS AND RELEVANCE Current oral glucocorticoid use is associated with an increased risk of acute pancreatitis.

Patients With Celiac Disease Have an Increased Risk for Pancreatitis

BACKGROUND & AIMS Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non-gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease. METHODS We analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis. RESULTS We identified 406 patients with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53-3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06-2.40), for non-gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52-2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33-4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99-9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36-3.22). CONCLUSIONS Based on an analysis of medical records from Sweden, patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.

Mortality after a cholecystectomy: a population-based study

BACKGROUND The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality. METHODS Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio (SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index (CCI) was estimated by International Classification of Diseases (ICD) codes retrieved from the National Patient Register. RESULTS Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [SMR = 2.58; 95% confidence interval (CI): 2.02-3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio (OR) 7.04, CI: 2.23-22.26], CCI > 2 (OR 1.93, CI: 1.06-3.51), American Society of Anesthesiologists (ASA) > 2 (OR 13.28, CI: 4.64-38.02), acute surgery (OR 10.05, CI:2.41-41.95), open surgical approach (OR 2.20, CI: 1.55-4.69) and peri-operative complications (OR 3.27, CI: 1.74-6.15). DISCUSSION Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery.

Systematic underreporting of the population-based incidence of pancreatic and biliary tract cancers

Abstract Background. Incidence rates of cancers of the pancreas and biliary tract, typically derived from cancer registers, have been reported to be decreasing. This study tested whether pancreatic and biliary tract cancers are underreported in the Swedish Cancer Register (CR). Methods. The concordance of pancreatic and biliary tract cancer diagnoses in 1990–2009 between CR and the Swedish Patient Register (PR) were evaluated through record linkage. To further assess the completeness of these cancer diagnoses in both CR and PR, record linkage was also made to the Swedish Causes of Death Register (DR). Results. A total of 31 067 cases of pancreatic cancer and 14 273 cases of biliary tract cancer were identified in CR or PR. Altogether, 44% of the pancreatic cancers and 44% of the biliary tract cancers were registered in PR only, and not in CR. The concordance between CR and PR declined from 63% in the years 1990–1994 to 44% in 2005–2009 for pancreatic cancer. The corresponding figures for biliary tract cancer were 60% and 37%. This decline in concordance was also observed with increasing age, e.g. the concordance between CR and PR for pancreatic cancer declined from 62% in patients < 60 years to 36% among patients ≥ 80 years. The corresponding figures for biliary tract cancer were 52% and 38%. Conclusion. There is an overwhelming underreporting of pancreatic and biliary tract cancers within the Swedish Cancer Register, which has increased during recent years. The reported decreasing incidence rates for pancreatic and biliary tract cancers might therefore be incorrect.

Vegetables, fruit and risk of non-gallstone-related acute pancreatitis: a population-based prospective cohort study

Objective To examine the association of vegetable and fruit consumption with the risk of non-gallstone-related acute pancreatitis. Design A population-based prospective cohort of 80 019 women and men, aged 46–84 years, completed a food-frequency questionnaire at baseline and was followed up for incidence of non-gallstone-related acute pancreatitis from 1 January 1998 to 31 December 2009. Participants were categorised into quintiles according to consumption of vegetables and consumption of fruit. Cox proportional hazards models were used to estimate RRs and 95% CIs. Results In total, 320 incident cases (216 men and 104 women) with non-gallstone-related acute pancreatitis were identified during 12 years of follow-up (891 136 person-years). After adjustment for potential confounders, the authors observed a significant inverse linear dose–response association between vegetable consumption and risk of non-gallstone-related acute pancreatitis; every two additional servings per day were associated with 17% risk reduction (RR=0.83; 95% CI 0.70 to 0.98; p=0.03). Among participants consuming >1 drink of alcohol per day and among those with body mass index ≥25 kg/m2, the RR for the highest compared with the lowest quintile of vegetable consumption was 0.29 (95% CI 0.13 to 0.67) and 0.49 (95% CI 0.29 to 0.85), respectively. Fruit consumption was not significantly associated with the risk of non-gallstone-related acute pancreatitis; the RR comparing extreme quintiles of consumption was 1.20 (95% CI 0.81 to 1.78). Conclusions Vegetable consumption, but not fruit consumption, may play a role in the prevention of non-gallstone-related acute pancreatitis.