Tom Glomsaker

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.

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.

Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography

With an increased use of magnetic resonance imaging, the indications for endoscopic retrograde cholangiopancreatography (ERCP) have changed. Consequently, the patterns and factors predictive of complications after ERCP performed during current routine clinical practice are not well known.

Withdrawal time as a quality indicator for colonoscopy - a nationwide analysis.

BACKGROUND AND STUDY AIMS A withdrawal time of at least 6 min has been recommended as a quality indicator for colonoscopy. One drawback of many of the studies that have investigated withdrawal time and produced conflicting results has been their single-center design involving few endoscopists. Therefore, the validity of withdrawal time as a quality measure remains unclear. This study explores the value of individual withdrawal time in a nationwide analysis. PATIENTS AND METHODS This prospective cohort study comprised data from outpatient colonoscopies performed at 19 Norwegian centers from January to September 2009 and registered in the Norwegian Gastronet Quality Assurance (QA) program. The participating endoscopists were characterized by their median withdrawal time for visual colonoscopies (diagnostic colonoscopies without biopsy or therapy) and categorized into two visual withdrawal time (VWT) groups (< 6 min or ≥ 6 min) to analyze the predictive value of VWT for detection of one or more polyps ≥ 5 mm in diameter using multiple logistic regression models. RESULTS The study included 4429 consecutive colonoscopies performed by 67 endoscopists. The adjusted odds ratio for the detection of polyps ≥ 5 mm was 1.21 (95 %CI 0.94 - 1.56, P = 0.14) for endoscopists with a median VWT ≥ 6 min compared with endoscopists with a median VWT < 6 min. CONCLUSION Withdrawal time using 6 min as the threshold is not a strong predictor of the likelihood of finding a polyp during colonoscopy and should not be used as a quality indicator.

Surgery in Norway: beyond the scalpel in the 21st century.

Norwegian surgeons provide for a wide range of modern surgical services with excellent results. With a thriving economy and a high standard of living and education, the major disease spectrum relates to cancer and cardiovascular diseases. Almost all types of surgery are performed in Norway. Improvements have been achieved through national programs and population-based registries have served as instrumental tools (eg, for cancer surgery). About 1 in every 5 general surgeons holds a PhD degree, with an even greater number for some subspecialties (30%-40% have PhD degrees). Trauma and acute care surgery is not a formal specialty, but a formal trauma system is likely to be established in the near future. Ring-fencing of elective surgical tasks from emergency surgery is increasingly being performed in surgical departments. Governmental coverage (85% of health care costs) and equal access to care have created waiting lists and given rise to private surgical outpatient clinics. The increase of women in medical school (>60%) has yet to be paralleled in most surgical specialists (eg, about 10% of general surgeons are women). Subspecialization, the 40-hour workweek, technical improvements (interventional and minimally invasive procedures), and quality demands have changed the surgical work scenario for both junior and senior staff members. Formal requirements in training duration and educational content are likely to change. Recruitment to surgery and ensuring continuity of patient care take surgery in Norway beyond the scalpel into the 21st century.

Surgical training and working time restriction

The global prospect for surgicaleducation is influenced by techni-cal, societal and legislative change.In recent times, clinical innova-tion, improved perioperative care andemerging technologies in other dis-ciplines (such as interventional radi-ology) have changed the indicationsfor surgery. Today, 50–70 per centof medical students in most West-ern countries are women, which willinevitablyinfluencethesurgicalwork-force as the reproductive years ofchildbearing overlap those of clini-cal training. In addition, both menand women now appear to care morethan their predecessors aboutlifestyleissues when choosing a career inmedicine

Contemporary use of endoscopic retrograde cholangiopancreatography (ERCP): A Norwegian prospective, multicenter study

Abstract Objective. Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway. Material and methods. Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database. Results. A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%. Conclusions. In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.

Long-term outcome of palliative treatment with self-expanding metal stents for malignant obstructions of the GI tract

Abstract Background. Self-expanding metal stents (SEMS) are commonly used in the palliative treatment of malignant gastrointestinal (GI) obstructions with favorable short-term outcome. Data on long-term outcome are scarce, however. Aim. To evaluate long-term outcome after palliative stent treatment of malignant GI obstruction. Method. Between October 2006 and April 2008, nine Norwegian hospitals included patients treated with SEMS for malignant esophageal, gastroduodenal, biliary, and colonic obstructions. Patients were followed for at least 6 months with respect to stent patency, reinterventions, and readmissions. Results. Stent placement was technically successful in 229 of 231 (99%) and clinically successful after 1 week in 220 of 229 (96%) patients. Long-term follow-up was available for 219 patients. Of those, 72 (33%) needed reinterventions. Stent occlusions or migrations (92%) were the most common reasons. Esophageal stents required reinterventions most frequently (41%), and had a significantly (p = 0.02) shorter patency (median 152 days) compared to other locations (gastroduodenal, 256 days; colon, 276 days; biliary, 460 days). Eighty percent of reinterventions were repeated endoscopic procedures that successfully restored patency. Readmissions were required for 156 (72%) patients. Progression of the underlying cancer was the most common reason, whereas 24% were readmitted due to stent complications. Conclusions. Long-term outcome after palliative treatment with SEMS for malignant GI and biliary obstruction shows that 70% had a patent stent until death, and that most reobstructions could be solved endoscopically. Hospital readmissions were mainly related to progression of the underlying cancer disease.

Adherence to national guidelines for surveillance after curative resection of nonmetastatic colon and rectum cancer: a survey among Norwegian gastrointestinal surgeons

Aim  National guidelines recommend enrollment of patients in surveillance programmes following curative resection of colorectal carcinoma (CRC) in order to detect recurrence or distant metastasis at an asymptomatic/early stage when secondary curative treatment can be offered. Little is known about surgeons’ adherence to such guidelines. In this national survey we analyse adherence and attitudes to postoperative follow up among Norwegian gastrointestinal surgeons involved in the care of patients with CRC.

A national audit of temporal trends in endoscopic retrograde cholangiopancreatography in Norway

Abstract Objective. The introduction of non-invasive imaging for biliary–pancreatic diseases has changed the indications and volumes of endoscopic retrograde cholangiopancreatography (ERCP) over time. This study aimed to provide national figures on ERCP in Norway over the last decade. Material and methods. Data from four national surveys on ERCP activity collected from 1998 to 2009 at the surgical and medical departments of all Norwegian hospitals were analyzed for variations in volumes among centers, regions, and specialties over time. Results. A total of 42,260 procedures were reported (average 3842 procedures per year, range 3492–4632). The number of hospitals with ERCP decreased from 41 to 35 and the annual number of procedures decreased by 13% (from 4632 to 4036), but the number of ERCP endoscopists remained stable at ∼100. The proportion of procedures performed by surgeons decreased from 40% to 32% (p < 0.001) during the first half of the study period; the number of gastrointestinal surgeons performing ERCP remained stable in the latter half (46% and 48% for 2004 and 2008, respectively). In 2004, 15 endoscopists signed up for a formal ERCP training program, including 8 (53%) surgeons. This number increased to 21 (48%) in 2008. A non-significant decrease in referrals (49% in 2002 vs. 35% in 2005) between various ERCP centers was reported. Regional variation in ERCP volumes leveled off during the study period. Conclusions. Though the number of both procedures and hospitals performing ERCP in Norway decreased, the proportion of low-volume and high-volume centers remained steady. The proportion of procedures by gastroenterological surgeons decreased significantly, yet roughly half of the endoscopists in ERCP training programs are surgeons. Regional variation in the ERCP numbers appears to have diminished.