Course in basic surgical skills.

BACKGROUND: The Basic Surgical Skills (BSS) course provides an introduction to basic surgical techniques. The course was held in Norway for the first time in 2009. This study was carried out to evaluate the learning outcomes of the course. MATERIAL AND METHOD: The participants from four consecutive courses were invited to take part in the study and were tested in three practical exercises immediately before and after the course. Their performance was measured using an Objective Structured Assessment of Technical Skills (OSATS) for two of the exercises and by time needed to complete the third exercise. The participants also undertook two self-evaluations of competence on each exercise, one prior to and one after completing the course. RESULTS: A total of 57 out of the 65 course participants were included in the study. The participants' scores were significantly higher for all three practical exercises after course completion, compared with the pre-course score (p < 0.001). The self-evaluations indicated that the participants felt more competent after the course. INTERPRETATION: The study indicates that the BSS course provides better basic surgical skills. In view of the lack of equivalent courses at core surgical training, consideration should be given to introducing this as a compulsory part of the surgical training in Norway.

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 department's 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.

Laparoscopic repair of incisional hernia in solid organ-transplanted patients: the method of choice?

Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ-transplanted (Tx) population with larger defects, a high rate of recurrence, and a tendency toward more seromas and infectious problems. Thirty-one Tx/IS patients with a control group of 70 non-IS patients with incisional hernia (6/7 recurrences) were included in a prospective interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR). Follow-up time and rate was 37 months and 95%. One hundred LVHR's were completed as there was one conversion in the Tx/IS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (P = 0.37) and the overall complication rates were 19% vs. 27% (P = 0.80). The Tx/IS group had a higher mesh-protrusion rate (29% vs. 13%, P = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% of kidney-Tx). Incisional hernias in Tx/IS patients may be treated by LVHR with the same low complication rate and recurrence rate as non-IS patients. By LVHR, the highly problematic seroma/infection problems encountered in Tx/IS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the Tx/Is population and should be the method of choice. (ClinicalTrials.gov number: NCT00455299, date: 5 May 2006).

A national survey on temporary and delayed abdominal closure in Norwegian hospitals.

INTRODUCTION: Temporary abdominal closure (TAC) is included in most published damage control (DC) and abdominal compartment (ACS) protocols. TAC is associated with a range of complications and the optimal method remains to be defined. The aim of the present study was to describe the experience regarding TAC after trauma and ACS in all acute care hospitals in a sparsely populated country with long transportation distances. MATERIAL AND METHODS: A questionnaire was sent to all 50 Norwegian hospitals with acute care general surgical services. RESULTS: The response rate was 88%. A very limited number of hospitals had treated more than one trauma patient with TAC (5%) or one patient with ACS (14%) on average per year. Most hospitals preferred vacuum assisted techniques, but few reported having formal protocols for TAC or ACS. Although most hospitals would refer patients with TAC to a trauma centre, more than 50% reported that they would perform a secondary reconstruction procedure themselves. CONCLUSION: This study shows that most Norwegian hospitals have limited experience with TAC and ACS. However, the long distances between hospitals mandate all acute care hospitals to implement formal treatment protocols including monitoring of IAP, diagnosing and decompression of ACS, and the use of TAC. Assuming experience leads to better care, the subsequent treatment of these patients might benefit from centralization to one or a few regional centers.

Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature.

We report four patients with pancreatic fistulas that failed to respond to conservative treatment. The fistulas were closed by endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) diluted with an oily contrast agent (Lipiodol). A literature review revealed 32 similar cases in which endoscopic treatment with fibrin sealants (n = 11) or cyanoacrylate (n = 21) was used to close the fistulas. Based on our own experience and the literature review, we conclude that endoscopic sealing of pancreatic fistulas can be performed safely and effectively by experienced endoscopists in a tertiary centre. The procedure seems useful in the management of complicated pancreatic fistulas which do not respond to conservative treatment and may obviate the need for surgery.

[A 68-year-old woman with iron deficiency anemia]. / En 68 år gammel kvinne med blødningsanemi.

A 68-year-old woman with iron deficiency anemia (due to gastrointestinal bleeding) was evaluated. Over a period of two years she received iron supplementation perorally and intravenously, as well as multiple blood transfusions, but the hemoglobin level did not exceed 10 g/dL. The investigations included upper endoscopy, duodenoscopy with side optical view, ileocolonoscopy, capsule endoscopy, antegrad single-balloon enteroscopy and conventional angiography of the abdominal vessels. Upper and lower endoscopies were performed repeatedly. The only consistent finding was linear erosions of the gastric mucosa in a large hiatal hernia at the level of the diaphragm. The association between large hiatal hernias and iron deficiency anemia was first described in the 1930s. The bleeding source is thought to be erosions or ulcerations in the hiatal hernia, as described by Cameron & Higgins in 1986. These lesions are analogous to the finding in our patient. The recognized treatment options are iron supplementation, proton pump inhibition and fundoplication. In our case we decided to start treatment with pantoprazole. Her hemoglobin level had normalized within an observational period of three months.

[A patient with acute abdominal pain and known cardiovascular disease]. / En pasient med akutte magesmerter og kjent kardiovaskulaer sykdom.

BACKGROUND: Emphysematous cholecystitis (EC) is a serious variant of acute cholecystitis (AC), with gas-forming bacteria in the biliary system and the surrounding tissues. The pathogenesis of EC is assumed to be ischemia. EC is associated with diabetes mellitus and arteriosclerosis; has a higher mortality rate and a more rapid progression than AC, but has initial clinical findings, similar to those in AC-patients. METHOD: We present a case report describing a patient with cardiovascular disease and sepsis, who has acalcular emphysematous cholecystitis. The patient was treated with antibiotics and percutaneus drainage. We performed a PubMed search for "Cholecystitis, Emphysematous, Acalcular". The literature study describes case reports and retrospective analyses. INTERPRETATION: EC arises in 1-3% of AC, with a mortality rate of 15%, compared to 4% in AC. EC has a 30-fold risk of necrosis and a 5-fold risk of perforation of the gall bladder wall compared to AC. Ultrasound imaging may be difficult to interpret and CT scanning is the preferred method of diagnosis. Recommended treatment is immediate cholecystectomy in association with antibiotics directed against the most common infectors, Cl. perfringens and enteropathogenic bacteria. Open and laparoscopic procedures seem equal in outcome. Some reports, as the present, describe successful treatment with percutaneous drainage when necrosis-mediated perforation is absent.

[Anti-reflux surgery in Norway]. / Antirefluksoperasjoner i Norge.

BACKGROUND: The aim of this study was to investigate the incidence of gastro-oesophageal antireflux surgery in Norway from 1999 to 2003, in comparison with the 1990 to 1998 period. MATERIAL AND METHODS: Operation codes for laparoscopic and open antireflux surgery were compiled from the Norwegian Patient Registry for analysis of incidence rates, geographic variations, postoperative hospital stay and rates of readmission. RESULTS: The incidence rates of antireflux operation in 1999-2003 were 18.6 per 100,000 men and 10.2 per 100,000 women, a ten-fold increase compared to 1990. There were significant differences in operation rates between the five Norwegian health regions, highest in northern region. In 1999, 85% of the patients had a laparoscopic operation, compared with 89% in 2003. Postoperative hospital stay was significantly shorter after laparoscopic operations. The proportion of laparoscopic procedures varied between the regions (78%-93%). The total rate of readmission within 60 days was 7%. There was no significant difference between readmission rates for patients treated by laparoscopy (6%) compared to patients treated by laparotomy (9%). In one health region, a high proportion of the patients were day surgery cases. CONCLUSION: The incidence of antireflux operation increased strongly during the 1990s and varies significantly between the Norwegian health regions. Laparoscopy is the leading mode of surgery. Patients treated by open surgery have a significant longer postoperative hospital stay than patients treated by laparoscopy.

[Laparoscopic treatment of splenic cysts]. / Laparoskopisk behandling av miltcyster.

Splenic cysts are uncommon. The symptoms are usually vague, but complications such as haemorrhage, rupture and infection may occur. The majority of splenic cysts are seen in children and young adults. Surgical treatment is recommended and splenic preservation is advantageous. We present two patients with splenic cysts successfully treated with laparoscopic resection of the cyst wall.

[Secretin stimulated magnetic resonance cholangiopancreatography in diseases of the biliary and pancreatic ducts]. / Sekretinstimulert magnetisk resonanskolangiopankreatografi ved lidelser i galle--og pancreasganger.

BACKGROUND: MRCP has replaced ERCP as the diagnostic tool in diseases in the biliary and pancreatic ducts. Secretin increases the secretion to ducts, and this has been reported to improve MRCP image quality. MATERIAL AND METHODS: We report our experience with S-MRCP in our first 20 patients. Secretin was given intravenously and images were obtained every minute for 10 minutes. These images were compared with MRCP images taken before and after secretin stimulation. RESULTS: New information was yielded in 18 cases, i.e. information not observed in previous radiological examinations. INTERPRETATION: In diagnostics of dysfunction of the sphincter of Oddi, the method may be useful, given the functional aspect of the procedure where increased pressure in the ducts may lead to pain. It may further improve the diagnostics of pancreatic cancer versus pancreatitis, in pancreas divisum and sclerosing cholangitis. The method is also valuable for clarifying whether there is injury to the pancreatic duct after blunt abdominal trauma. Surgical common bile duct injuries may be better assessed than with any other method. In difficult pancreatic and biliary investigations, S-MRCP seems to be a useful and complication-free supplement to existing diagnostic methods.

[Laparoscopic cholecystectomy]. / Laparoskopiske galleoperasjoner.

Gallbladder stones are common, but most persons with stones are asymptomatic. The symptoms of gallbladder stones are usually characteristic. They are often associated with other types of abdominal symptoms, which are not affected by cholecystectomy. Day surgery laparoscopic cholecystectomy is increasingly popular. The operation may be associated with serious complications, but the risk is low. 85-90% of patients operated with cholecystectomy are asymptomatic after the operation.

[Laparoscopic fundoplication for gastroesophageal reflux disease]. / Laparoskopisk fundoplikasjon for gastroøsofageal reflukssykdom.

BACKGROUND: In 1995 we introduced laparoscopic technique as routine for fundoplication for gastro-esophageal reflux disease. MATERIAL AND METHODS: 222 patients were scheduled for laparoscopic fundoplication; the operation was completed laparoscopically in 219 patients. They all had an observation period of one year as a minimum; 205 patients returned a follow-up questionnaire. RESULTS: 12 patients had major complications, six of them have been reoperated. At follow-up, 95% reported excellent or good results, 3% had persisting reflux symptoms, 4% had moderate to severe dysphagia and 17% had moderate to severe gas bloat syndrome and flatulence problems which adversely affected an otherwise good outcome. Thus, 63% reported excellent, 23% good and 7% fair outcome, and 6% were moderately or very dissatisfied. Bloating and increased flatulence were the major reasons for dissatisfaction. INTERPRETATION: The risk of troublesome postoperative bloating and flatulence should be addressed thoroughly during the preoperative information, and especially in patients who have similar symptoms preoperatively.

[Outpatient laparoscopic fundoplication for gastroesophageal reflux disease]. / Dagkirurgisk laparoskopisk fundoplikasjon for gastroøsofageal reflukssykdom.

BACKGROUND: Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997. MATERIAL AND METHODS: Inclusion criteria were ASA grade 1-2, living within 30 minutes by car from the hospital, or staying over in the patient hotel the first night, with company. Initially, only selected patients were offered day-case treatment; later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil and were given prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rossetti fundoplication or semifundoplication. RESULTS: 83 patients were included. Ten patients were admitted, 73 (88%) were discharged as planned 3-8 hours after the operation. Eight patients (10%) were readmitted; one of them underwent reoperation for necrosis of the gastric fundus. Eight patients visited the outpatient department without need for readmission. At seven-day follow-up, 55 discharged patients (75%) were satisfied with the day-case treatment, nine (12%) were indifferent, and nine (12%) were dissatisfied, mostly because of pain. If offered a similar operation in the future, 50 patients (68%) would have preferred and 11 (15%) would have accepted day-case treatment; 12 (16%) would not. INTERPRETATION: Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.