Scandinavian Journal of Surgery

We analyzed the feasibility of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei.

A prospective database comprised 90 consecutive patients with demonstrable pseudomyxoma peritonei collected during 48 months. These patients, referred to our unit for consideration for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, received both cytoreductive surgery and hyperthermic intraperitoneal chemotherapy if possible. We evaluated the factors associated with a successful procedure.

Hyperthermic intraperitoneal chemotherapy was successfully delivered to 56 of 90 patients (62%) with demonstrable pseudomyxoma peritonei. Tumor morphology of low grade (p = 0.013), age under 65 years (p = 0.004), and serum carcinoembryonic antigen level under 5.0 µg/L (p = 0.003) were associated with successful administration of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Mean peritoneal cancer index was lower (18.9 vs 32.6, p < 0.001) and age was younger (54.3 vs 61.6, p = 0.003) in patients who underwent hyperthermic intraperitoneal chemotherapy than in patients who did not. Four patients had complete cytoreductive surgery alone, and 20 patients underwent palliative debulking, but 10 were ineligible for this operation.

Although the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is currently suggested the standard practice for pseudomyxoma peritonei, not all patients are eligible for this protocol. In this study, hyperthermic intraperitoneal chemotherapy was suitable for 62% of patients with pseudomyxoma peritonei of appendiceal origin.

To study factors that influenced healing and survival after attempted closure of enterocutaneous fistula.

Retrospective analysis of prospective data concerning 101 patients operated on 132 instances for 110 enterocutaneous fistulae at two hospitals.

In all, 96 (87%) of the 110 fistulae healed and 92 (91%) patients survived. A total of 9 patients with unhealed fistula died. Multivariate analysis revealed jaundice as an independent factor for both death and failed closure and operation without anastomosis as an independent positive factor for healing. Failure rate was lower after an operation with stoma without anastomosis (6 of 43, 14%) than after an operation with anastomosis (30 of 89, 34%) p = 0.0213. Of the 36 instances with unhealed fistula, 13 (36%) could be ascribed to inadvertent bowel lesions at the reconstructive operation. In addition, univariate analysis revealed that patients with previous multiple laparotomies or with multiple operations for enterocutaneous fistula healed less likely and had higher mortality. A low serum albumin, high white blood cell count, high C-reactive protein concentration, high fistula output, total parenteral nutrition, and operation for recurrent fistula were associated with death together with long operation time and operative bleeding, both indicators of surgical complexity. Over time, staged surgery avoiding anastomosis increased from 27% to 57%. Mortality decreased from 12% to 6%, and healing increased from 73% to 94%.

Chronic inflammation, malnutrition, and liver failure causing an impaired healing capacity are important reasons for failure. Staged operation without primary anastomosis may allow the patient to reverse this condition and improve outcome. The high surgical complexity is a negative factor that requires careful planning of the operation.

Aging with comorbidities, obesity, and rapid recovery from operation may increase the need for laparoscopic cholecystectomy, but long-term use of statins may be associated with a decreased risk of gallstones. This population-based cohort study presents the changing rate and causative factors of laparoscopic cholecystectomy in Finland during the era of statin use.

Age structure of the population, changes in body mass index and diabetes, and the number of all cholecystectomies in 1995–2009 were retrieved from the registers of National Institute for Health and Welfare. Additionally, these results were supplemented by a population-based retrospective cohort (1581 laparoscopic cholecystectomy) in one community-based hospital area. The risk factors for laparoscopic cholecystectomy, use of statins, and surgical outcome were analyzed.

During the 15 years, 123,794 cholecystectomies were performed in Finland, of which 94,740 (76.5%) were performed using laparoscopic technique. The median rate of laparoscopic cholecystectomy varied between 110 and 140 operations per 100,000 inhabitants. In 1995–2009, the annual number of cholecystectomies decreased from 8600 to 7500, the number of laparoscopic cholecystectomies increased by 10%, and the number of open cholecystectomies declined by 60%. In a cohort of 1581 laparoscopic cholecystectomies, the proportion of elderly (>65 years of age), obese (body mass index > 30 kg/m²), and diabetic patients increased from 17% to 28%, 9% to 34%, and 4% to 8%, respectively. Use of statins increased more than fourfold during the 15 years.

The rates of all cholecystectomies decreased despite marked increase in laparoscopic cholecystectomies performed. The increase in risk factors for gallstones in Finland implied more marked increase in laparoscopic cholecystectomies. The possible role of statins on gallstone disease is discussed.

Octreotide is suggested to harden the pancreas, thus facilitating the construction of a pancreatic anastomosis and lowering the risk of postoperative fistula. We tested the hypothesis that intra-arterial application of octreotide in the gastroduodenal artery during pancreatectomy may increase pancreatic hardness.

A single-center, prospective, double-blinded, randomized controlled trial with parallel assignment was conducted. Patients planned for a pancreatoduodenectomy or a total pancreatectomy, who had a palpatory and durometer proven (<40 Shore units) soft pancreas, were assigned to receive intraoperatively either 5 mL 500µg octreotide or 5 mL 0.9% saline solution as a bolus injection in the gastroduodenal artery. Pancreatic hardness was measured before, early, and late after intervention. The investigator performing the durometer measurements and pathologist were masked to group assignment. The primary outcome was increased pancreatic hardness. Analysis was by intention to treat. This trial is registered at http://www.clinicaltrials.gov (ID NCT01400100).

A total of 12 patients received octreotide and 13 received saline solution. Pancreatic hardness marginally increased in the octreotide group: 0.67 ± 2.3 Shore units, whereas it decreased in the control group: −2.15 ± 2.7 Shore units. The difference was statistically significant, p = 0.029 (95% confidence interval = −4.87 to −0.77). Histology did not find any correlate for this clinically irrelevant hardening effect.

A single bolus application of octreotide did not deliver a clinically relevant increase in pancreatic hardness. Future studies on the hardening effect of octreotide should employ repeated or continuous preoperative administration of this drug.

Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis.

A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed.

Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated.

Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Atrial fibrillation is a common arrhythmia after cardiac surgery. It increases morbidity, length of hospital stay, and costs of operative treatment. Beta-blockers, sotalol, amiodarone, corticosteroids, and biatrial pacing have been shown to be efficient in the prevention of postoperative atrial fibrillation. The aim of this study was to find out how widely different prophylactic strategies for postoperative atrial fibrillation are used in Scandinavian countries.

An online link for a questionnaire was emailed to (214) cardiac surgeons in Finland, Sweden, Norway, Denmark, and Estonia to assess the use of prophylactic methods for postoperative atrial fibrillation.

A total of 97 surgeons responded to the survey. Oral beta-blockers were routinely used for atrial fibrillation prophylaxis by 62% of responders. The main reasons for nonuse of beta-blockers were that responders were unconvinced of the evidence of benefit or they preferred some alternative prophylaxis. Intravenous beta-blockers were used frequently by 6% of responders. Amiodarone was used for prophylaxis by 18% of responders. Nonusers were unconvinced of its efficacy, were afraid of its complications, or found its use too cumbersome. Other prophylactic atrial fibrillation strategies that were used are as follows: sotalol by 2%, magnesium by 17%, corticosteroids by 1%, and atrial pacing by 11% of respondents.

There is still widely varying implementation of strategies for atrial fibrillation prophylaxis among Scandinavian cardiac surgeons. Lack of confidence in the efficacy of these approaches is the main rationale for nonimplementation.

To assess the early and short-term outcome of fenestrated and chimney grafting for juxtarenal aortic aneurysms.

A prospective vascular registry of 28 patients who had undergone elective primary endovascular repair for abdominal aortic aneurysm between December 2007 and August 2011 with infrarenal neck anatomy unacceptable for conventional endovascular repair. Fenestrated endografts were designed based on reconstructed computed tomography (CT) data by the authors. Off-the-shelf grafts and stents were used for chimney cases. Patients were followed up until 31 May 2012.

A total of 21 (75%) patients were treated with fenestrated endografts, while 7 (25%) received chimney grafts. The mean aneurysm diameter was 65 mm (standard deviation = 7 mm) and the median neck length 2.5 mm (range: 0–10 mm). Altogether, 63 (mean = 2.3/patient) visceral arteries were incorporated (42 renal, 21 superior mesenteric arteries). The overall primary technical success rate was 93% (one type I and one type III endoleak). The mean follow-up was 22 months (standard deviation: 14 months). The primary type III endoleak resolved spontaneously with thrombosis of the target vessel, while the patient with primary type I endoleak died of acute myocardial infarction 3 weeks after the procedure. Two late endoleaks developed: one type II endoleak without aneurysm sac growth remains under surveillance, while in another patient, multiple attempts to treat type I endoleak proved unsuccessful and the patient later died of gastrointestinal bleeding. A total of 4 (14%) patients so far required additional procedures. Two patients died within 30 days of the device implantation and another six during the follow-up. No rupture occurred. The cumulative survival for patients with fenestrated endografts was 85% at 1 year and for those treated with chimney technique 57%.

The treatment of juxtarenal aortic aneurysms seems to be feasible by exploiting various endovascular techniques. Even with a low volume of cases, good immediate and short-term results can be achieved, especially with fenestrated endografts.

Skeletal dysplasias have been associated with upper cervical instability. Many patients are initially asymptomatic, but the instability may progress to subluxation and dislocation and complications thereof, including death. Surgery is hampered by petite osseous structures and low bone formation rate.

To review the outcomes of surgical fusion of upper cervical instability in children with rare skeletal dysplasias.

A retrospective study of eight children with five different rare skeletal dysplasias needing upper cervical instrumented stabilization. Cases were evaluated for clinical, radiologic, and quality-of-life outcomes, with median follow-up time of 5 years.

Six patients underwent posterior, segmental cervical spine instrumentation and fusion (three C1/C2 fusions, three occipitocervical fusions), one anterior cervical instrumented spinal fusion, and one anteroposterior fusion. Autogenous bone grafting was used in all patients, and seven were immobilized using a halo body jacket. Nonunion in occipitocervical fusions was common in these patients (3/8 patients). Rib autograft from occiput to cervical spine with recombinant human BMP-2 was used to salvage nonunions.

Surgical fixation in the pediatric cervical spine is hampered by fragile posterior structures. A postoperative immobilization by halo vest for 4 months is customary. Selective anterior corpectomy and plate fixation is not recommended in pediatric patients with skeletal dysplasias.

Level 4, Case Series

Recent advancements in manufacturing technology have enabled more precise tolerances and surface finishes using metal-on-metal bearing surfaces in total hip arthroplasty. The aim of this study was to compare the level of metal ions in urine after implantation of a 28-mm metal-on-metal bearing manufactured from high-carbon wrought alloy and a 28-mm metal-on-polyethylene bearing.

A total of 92 total hip arthroplasty patients were prospectively randomized into two groups: those receiving metal-on-metal bearings and those receiving metal-on-polyethylene bearings. Chromium, cobalt, and molybdenum ion levels in urine were measured preoperatively and at 1 year and 2 years postoperatively.

In the metal-on-polyethylene group, there was a slight increase in mean chromium and cobalt concentrations at 2-year follow-up compared to the preoperative level (p = 0.02 for both chromium and cobalt). In the metal-on-metal group, there was a 15-fold increase in chromium and a 26-fold increase in cobalt at 2-year follow-up compared to the preoperative level (p < 0.001 for both chromium and cobalt). However, the quantity of chromium and cobalt in urine from the metal-on-metal group was not higher at 2-year follow-up than at 1-year follow-up (p = 0.5 and p = 0.6, respectively).

The 28-mm metal-on-metal bearings yield chromium and cobalt concentrations in urine that can be higher than those recommended for occupational exposure. However, our results also indicate that a steady state in wear and ion production using metal-on-metal total hip arthroplasty can occur.

Surgery cancelations cause inappropriate use of hospital resources and additional financial and psychological stress to patients. Cancelation rates have been described to be even more than 10% of scheduled cases. Preoperative anesthesia evaluation clinics have been initialized to decrease cancelation rates. At Hyvinkää hospital, 95% of elective surgical patients are admitted on the morning of operation, and only 25% of these patients visit preoperative anesthesia evaluation clinic prior to surgery. Cancelation rate in Finnish hospitals has not been described.

We studied retrospectively 12,205 scheduled elective same-day admission surgical cases at Helsinki and Uusimaa Hospital District, Hyvinkää hospital for a period of 2 years. Obstetric cases, emergency cases, and a few inpatient cases were excluded. A case was considered as canceled if surgery was canceled after the finalization of operation room schedule for the next day. Cancelation rates among different specialties and reasons for cancelation were analyzed.

A total of 12,205 surgeries were scheduled during the study period, and 551 (4.5%) of these were canceled. The highest cancelation rate was in hand surgery, with 8.2% of scheduled cases, followed by orthopedic surgery with 5.4%, and pediatric surgery with 5.1% cancelation rate. Endocrinology had no cancelations, and breast, urology, and vein surgery also had less than 2% of canceled cases. Patient-related issues caused 72.4% of cancelations, and operation no longer being necessary caused 26% of all cancelations.

Day of surgery cancelation rate was low in same-day admission, although it varied between specialties. Specialties having explicit surgery indications had fewer cancelations than specialties having surgery indications based on more subjective diagnostic. Process improvements need to be considered continuously to further decrease cancelation rate.

Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site.

A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy.

Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20–75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up.

We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery.