Randomised controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma--PCS Nordic study.

BACKGROUND: Photodynamic therapy (PDT) in combination with stent have shown promising results in the treatment of biliary tract cancer (BTC) in patients not suitable for surgery. Chemotherapy has been shown to improve survival in patients with local advanced and metastatic BTC. MATERIAL AND METHODS: In the current randomized trial the combination of chemotherapy and stent with and without temoporfin (Foscan) photodynamic therapy (PDT), with a primary endpoint on feasibility and safety, has been performed. Ten patients in each group. RESULTS: No serious, acute procedure-related complication related to PDT or the treatment combination was seen. The number of patients with cholangitis was equal in both groups. In the PDT group--arm A--two patients had cutaneous erythema after sun exposition, one of them with a localized blister. No neutropenic infection was seen. Quality of Life (QoL) was similar in both treatment groups. Progression free survival was numerically longer in the PDT group. CONCLUSION: The treatment combination was feasible. There was no serious complication related to PDT or the treatment combination. Number of cholangitis was equal in both groups, two abscesses were observed in the PDT group. Progression free survival was numerically longer in the PDT group.

Differential expression of miRNAs in pancreatobiliary type of periampullary adenocarcinoma and its associated stroma.

Periampullary adenocarcinomas can be of two histological subtypes, intestinal or pancreatobiliary. The latter is more frequent and aggressive, and characterized by a prominent desmoplastic stroma, which is tightly related to the biology of the cancer, including its poor response to chemotherapy. Whereas miRNAs are known to regulate various cellular processes and interactions between cells, their exact role in periampullary carcinoma remains to be characterized, especially with respect to the prominent stromal component of pancreatobiliary type cancers. The present study aimed at elucidating this role by miRNA expression profiling of the carcinomatous and stromal component in twenty periampullary adenocarcinomas of pancreatobiliary type. miRNA expression profiles were compared between carcinoma cells, stromal cells and normal tissue samples. A total of 43 miRNAs were found to be differentially expressed between carcinoma and stroma of which 11 belong to three miRNA families (miR-17, miR-15 and miR-515). The levels of expression of miRNAs miR-17, miR-20a, miR-20b, miR-223, miR-10b, miR-2964a and miR-342 were observed to be higher and miR-519e to be lower in the stromal component compared to the carcinomatous and normal components. They follow a trend where expression in stroma is highest followed by carcinoma and then normal tissue. Pathway analysis revealed that pathways regulating tumor-stroma interactions such as ECM interaction remodeling, epithelial-mesenchymal transition, focal adhesion pathway, TGF-beta, MAPK signaling, axon guidance and endocytosis were differently regulated. The miRNA-mRNA mediated interactions between carcinoma and stromal cells add new knowledge regarding tumor-stroma interactions.

Molecular signatures of mRNAs and miRNAs as prognostic biomarkers in pancreatobiliary and intestinal types of periampullary adenocarcinomas.

Periampullary adenocarcinomas include four anatomical sites of origin (the pancreatic duct, bile duct, ampulla and duodenum) and most of them fall into two histological subgroups (pancreatobiliary and intestinal). Determining the exact origin of the tumor is sometimes difficult, due to overlapping histopathological characteristics. The prognosis depends on the histological subtype, as well as on the anatomical site of origin, the former being the more important. The molecular basis for these differences in prognosis is poorly understood. Whole-genome analyses were used to investigate the association between molecular tumor profiles, pathogenesis and prognosis. A total of 85 periampullary adenocarcinomas were characterized by mRNA and miRNA expressions profiling. Molecular profiles of the tumors from the different anatomical sites of origin as well as of the different histological subtypes were compared. Differentially expressed mRNAs and miRNAs between the two histopathological subtypes were linked to specific molecular pathways. Six miRNA families were downregulated and four were upregulated in the pancreatobiliary type as compared to the intestinal type (P < 0.05). miRNAs and mRNAs associated with improved overall and recurrence free survival for the two histopathological subtypes were identified. For the pancreatobiliary type the genes ATM, PTEN, RB1 and the miRNAs miR-592 and miR-497, and for the intestinal type the genes PDPK1, PIK3R2, G6PC and the miRNAs miR-127-3p, miR-377* were linked to enriched pathways and identified as prognostic markers. The molecular signatures identified may in the future guide the clinicians in the therapeutic decision making to an individualized treatment, if confirmed in other larger datasets.

Follow-up after curative surgery for pancreatic ductal adenocarcinoma: asymptomatic recurrence is associated with improved survival.

AIM: There is no consensus on the optimal follow-up schedule of patients after surgery for pancreatic cancer. In this retrospective study, recurrence and survival were investigated for patients presenting with either symptomatic or asymptomatic recurrence. Patient, tumor and treatment characteristics that predicted the length of postrecurrence survival were identified. METHODS: Clinical records of 164 patients who underwent a pancreatic resection (R0/R1) for pancreatic ductal adenocarcinoma from January 2000 to December 2010 were retrieved. Patients underwent a systematic follow-up program. Patient, tumor and treatment characteristics were compared between patients with asymptomatic and symptomatic recurrence. RESULTS: Of 164 consecutive patients, 144 patients (88%) had recurrence (29 asymptomatic, 115 symptomatic). The most frequent reported symptoms were abdominal pain, fatigue/weakness, back pain, weight loss, nausea/loss of appetite and jaundice. Median time to recurrence was 12.0 months for asymptomatic and 7.0 months for symptomatic patients (P = 0.036). Median postrecurrence survival was 10.0 months for asymptomatic and 4.0 months for symptomatic patients (P < 0.0001). Median overall survival was 24.5 months for asymptomatic and 11.0 months for symptomatic patients (P < 0.0001). Symptomatic recurrence, disease free survival <12 months, and no adjuvant chemotherapy were the only independent predictors of poor postrecurrence survival. 72% of asymptomatic and 37% of symptomatic patients received oncological treatment. CONCLUSIONS: Patients with asymptomatic pancreatic cancer recurrence have improved recurrence-free, postrecurrence and overall survival. Symptoms when recurrence is diagnosed are a good surrogate marker of biological aggressiveness. Detection of asymptomatic recurrence may facilitate patient eligibility for investigational studies or other forms of treatment.

Altered expression of genes in adipose tissues associated with reduced fat mass in patients with pancreatic cancer.

Loss of adipose tissue in patients with pancreatic cancer may involve altered gene expression. Peri-operative mRNA levels of 44 genes were analysed by RT-PCR in intra-abdominal (IAAT) and subcutaneous adipose tissue (SCAT) sampled from pancreatic ductal adenocarcinoma (PDAC) patients undergoing tumour resection (n = 20), and control patients without cancer (n = 11). Peri- and post-operative IAAT and SCAT masses were measured by computerized tomography. PDAC patients displayed 2.6- and 1.7-fold higher Zn-α2-glycoprotein (AZGP1) mRNA levels than controls in IAAT and SCAT, respectively (P < 0.01), but expression was not correlated with post-operative changes in fat masses. IAAT mass changes correlated with genes in lipid metabolism, inflammation and apoptosis: e.g. stearoyl-Coenzyme A desaturase 1 (SCD), tumour necrosis factor (TNF) and chemokine (C-C motif) ligand 2 (CCL2; MCP-1). Patients with PDAC displayed increased AZGP1 mRNA levels in both IAAT and SCAT, but expression of other genes may predict IAAT loss.

Single-centre experience of laparoscopic pancreatic surgery.

BACKGROUND: Laparoscopic resection is regarded as safe and feasible in selected patients with benign pancreatic tumours. Few data exist on laparoscopic surgery for malignant lesions and larger neoplasms in unselected patients. METHODS: The study included all patients admitted to Oslo University Hospital, Rikshospitalet, from March 1997 to March 2009 for surgery of lesions in the body and tail of the pancreas, and selected patients with lesions in the pancreatic head, who underwent surgery by a laparoscopic approach with curative intent. RESULTS: A total of 166 patients had 170 operations, including 138 pancreatic resections, 18 explorations, nine resections of peripancreatic tissue and five other therapeutic procedures. Four patients had repeat procedures. There were 53 endocrine tumours (31.0 per cent), 28 pancreatic carcinomas (16.4 per cent), five cases of metastases (2.9 per cent), 48 cystic tumours (28.1 per cent) and 37 other lesions (21.6 per cent). The total morbidity rate was 16.5 per cent. Fistula was the most common complication (10.0 per cent). Three patients needed reoperation for complications. There were three hospital deaths (1.8 per cent). Median hospital stay following surgery was 4 days. CONCLUSION: Laparoscopic resection of lesions in the body and tail of the pancreas in an unselected patient series was safe and feasible, and should be the method of choice for this patient group in specialized centres.

Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract.

PURPOSE: To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT) MATERIAL AND METHODS: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated. RESULTS: In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT. CONCLUSION: S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.

Telomerase peptide vaccination of patients with non-resectable pancreatic cancer: A dose escalating phase I/II study.

Patients with inoperable pancreatic cancer have a dismal prognosis with a mean life expectancy of 3-6 months. New treatment modalities are thus urgently needed. Telomerase is expressed in 85-90% of pancreas cancer, and immunogenic telomerase peptides have been characterised. A phase I/II study was conducted to investigate the safety, tolerability, and immunogenecity of telomerase peptide vaccination. Survival of the patients was also recorded. Forty-eight patients with non-resectable pancreatic cancer received intradermal injections of the telomerase peptide GV1001 at three dose levels, in combination with granulocyte-macrophage colony-stimulating factor. The treatment period was 10 weeks. Monthly booster vaccinations were offered as follow-up treatment. Immune responses were measured as delayed-type hypersensitivity skin reaction and in vitro T-cell proliferation. GV1001 was well tolerated. Immune responses were observed in 24 of 38 evaluable patients, with the highest ratio (75%) in the intermediate dose group. Twenty-seven evaluable patients completed the study. Median survival for the intermediate dose-group was 8.6 months, significantly longer for the low- (P = 0.006) and high-dose groups (P = 0.05). One-year survival for the evaluable patients in the intermediate dose group was 25%. The results demonstrate that GV1001 is immunogenic and safe to use. The survival data indicate that induction of an immune response is correlated with prolonged survival, and the vaccine may offer a new treatment option for pancreatic cancer patients, encouraging further clinical studies.

Outpatient laparoscopic surgery: feasibility and consequences for education and health care costs.

BACKGROUND: The purpose of this paper is to describe the outcome of ambulatory laparoscopic cholecystectomy (LC), antireflux surgery, adrenalectomy and splenectomy and possible implications for surgical education and health care costs. METHODS: Prospective, observational study 1994-2003. RESULTS: The success rate of ambulatory treatment was 83.5% in 1060 LC patients, 80% in 113 antireflux procedures, 100% in 22 laparoscopic adrenalectomies, and 75% in 12 laparoscopic splenectomies. In a total number of 1207 patients, health care costs were reduced by almost 700,000 dollars, compared to 1-day hospital stay. The educational potential of same-day surgery is large, due to high numbers of patients, and 80% of our educational potential has been exploited. CONCLUSION: Ambulatory laparoscopic surgery is cost effective, patient friendly, and appropriate for surgical resident training. Strict organization of security rules is mandatory.

Increased spillover of norepinephrine to the portal vein during CO-pneumoperitoneum in pigs.

BACKGROUND: Elevated intra abdominal pressure (IAP) during CO2-insufflation has been associated with increased catecholamine concentrations in plasma. We have previously indicated that this may be due to a regional increased spillover from the abdominal region. In this experimental study we investigated catecholamine spillover from the drainage area of the portal vein during CO2-pneumoperitoneum. METHODS: Eight pigs under general anesthesia were investigated before and after CO2-pneumoperitoneum with an IAP of 15 mmHg. Regional spillover of catecholamines was determined by measuring plasma catecholamine concentrations and flow simultaneously. Plasma concentrations of catecholamines were measured from the portal and femoral veins, the pulmonary and carotid arteries. Flow data were collected with laser-Doppler transit time flow probes around the portal and femoral veins. Cardiac output was measured by the thermo-dilution technique. Estimated spillover was calculated by the veno-arterial difference multiplied by flow. RESULTS: We found a significant increase in estimated spillover of norepinephrine from the drainage area of the portal vein from 10 (-1.2, 78) ng x min(-1) to 27 (1.8, 475) ng x min(-1)[median (range)] (P = 0.05), but no change in estimated spillover of norepinephrine from the drainage area of the femoral vein. Plasma concentrations of norepinephrine increased in central venous and arterial blood. There was no significant change in epinephrine concentrations in arterial blood. CONCLUSION: Estimated norepinephrine spillover from the drainage area of the portal vein increased during CO2-pneumoperitoneum in pigs. This may indicate that the increased norepinephrine concentrations found in arterial plasma reflects a local activation of sympathetic nerves in the region of the portal drainage area.

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome.

BACKGROUND: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. METHODS: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors ( n=13), unspecified tumors ( n=11), cysts ( n=2), idiopathic thrombocytopenic purpura with ectopic spleen ( n=2), annular pancreas ( n=1), trauma ( n=1), aneurysm of the splenic artery ( n=1), and adenocarcinoma ( n=1). RESULTS: Enucleations ( n=7) and distal pancreatectomy with ( n=12) and without splenectomy ( n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2-22). Postoperatively, opioid medication was given for a median of 2 days (range, 0-13). CONCLUSION: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Outpatient laparoscopic splenectomy: patient safety and satisfaction.

BACKGROUND: We assessed the feasibility of outpatient laparoscopic splenectomy, as performed by an experienced laparoscopic term and combined with optimal anesthesia. METHODS: Inclusion criteria in the study was limited to patients not hospitalized before the procedure who had hematological or neoplastic indications for splenectomy and were classified as American Society of Anesthesiologists (ASA) I-III. They received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic splenectomy was performed via three trocars. The specimen was removed via an incision in the left iliac fossa. RESULTS: Ten of the 12 patients were discharged 3-6 h postoperatively; the other two were admitted primarily to hospital. One was readmitted due to a fever, which was finally explained by measles. The median operative times was 58 min (range, 45-135). Patient satisfaction was excellent in nine and intermediate in two cases; it was poor in one case, due to postoperative pain. CONCLUSION: Laparoscopic splenectomy can be completed in a relatively short time; therefore, it is feasible, safe, and satisfactory for most patients as an outpatient procedure.

Catecholamine release during laparoscopic fundoplication with high and low doses of remifentanil.

BACKGROUND: Reports on stress responses to laparoscopic surgery have been conflicting. Depth of anesthesia may influence the neuro-hormonal release, including catecholamines. Opioids depress general sympathetic activation in a dose-dependent manner. We investigated the hypothesis that remifentanil would depress the catecholamine response to pneumoperitoneum and laparoscopic surgery differently with a high dose (HD) compared with a low dose (LD). METHODS: In a randomized, prospective study we investigated 18 ASA I-II patients undergoing laparoscopic fundoplication with an intra-abdominal pressure of 12 mmHg. The patients were randomized to receive either a LD (0.13 microg kg-1x min-1) or HD (0.39 microg kg-1 x min-1) of remifentanil with a target-controlled infusion (TCI) technique. Bispectral index of EEG (BIS) was maintained at 40-55 by propofol delivered by a TCI system. Arterial catecholamines were analyzed at different times during the procedure. RESULTS: Norepinephrine increased equally in both groups during pneumoperitoneum and surgical intervention. Epinephrine stayed low in the HD-group, while increasing during surgery in the LD-group. CONCLUSION: High dose of remifentanil depressed the epinephrine response to pneumoperitoneum and surgery, indicating no general activation of the sympathetic nervous system. Neither a LD nor HD of remifentanil depressed the norepinephrine response during pneumoperitoneum. This suggests a centrally independent release of norepinephrine.

Outpatient laparoscopic adrenalectomy in patients with Conn's syndrome.

BACKGROUND: [corrected] We set out to record the operative times of an experienced laparoscopic team and assess the feasibility of outpatient laparoscopic adrenalectomy when optimal anesthesia was also offered to all patients. METHODS: The study included 13 patients with aldosterone/cortisone hypersecretion and/or adrenal gland tumors, excluding those with pheochromocytoma. They had to live within 30 min travel from the hospital, and adult company had to be present at home. All patients received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic adrenalectomy was performed by the transabdominal lateral flank approach. Postoperatively, all patients were contacted by phone in the evening and the next morning. RESULTS: All 13 patients were discharged 3-6 h postoperatively. None were readmitted; thus, the day care success was 100%. The mean operative time was 38 min (range, 35-112). Patient satisfaction was excellent in all but one case, due to pain on the 1st postoperative day. CONCLUSION: Laparoscopic adrenalectomy can be a fast operation. It is feasible and safe and yields satisfactory results for patients as an outpatient procedure when the necessary surgical experience and optimal anesthesia are both available.

Pancreatic carcinoma: MR, MR angiography and dynamic helical CT in the evaluation of vascular invasion.

OBJECTIVE: To assess the value of MR angiography in combination with contrast-enhanced MR imaging, and to compare MR imaging including MR angiography with dynamic contrast-enhanced dual phase helical CT in the preoperative assessment of vascular invasion in patients with suspected pancreatic carcinoma. METHODS AND MATERIAL: MR imaging only, MR imaging including MR angiography and dynamic contrast-enhanced dual phase helical CT images of 48 patients who were operated due to suspicion of pancreas cancer were correlated with the surgery results in terms of vascular invasion. Pathologic diagnosis were pancreatic adenocarcinoma in 31 patients of which nine had surgically confirmed vascular invasion. Sensitivity, specificity, predictive values (including 95% confidence intervals) and accuracy of MR imaging only, MR imaging including MR angiography and helical CT were calculated. RESULTS: Sensitivity, specificity, positive and negative predictive values and accuracy were 56, 100, 100, 85, 87%; 67, 100, 100, 88, 90% and 67, 100, 100, 88, 90%, respectively, for MR imaging only, MR imaging including MR angiography and helical CT in the adenocarcinoma group. The corresponding figures in the overall study group were 56, 97, 83, 90, 90%; 67, 97, 86, 93, 92% and 67, 97, 86, 93, 92%. Confidence intervals (95%) showed that the differences in the diagnostic efficacy of the techniques were not statistically significant in the overall study group, but the confidence intervals were undefined in the adenocarcinoma group due to the small sample size. CONCLUSION: Diagnostic efficacy of MR imaging when combined with MR angiography is equal to that of dynamic contrast-enhanced dual phase helical CT in the assessment of vascular invasion of pancreatic tumors.

Intradermal ras peptide vaccination with granulocyte-macrophage colony-stimulating factor as adjuvant: Clinical and immunological responses in patients with pancreatic adenocarcinoma.

K-RAS mutations are frequently found in adenocarcinomas of the pancreas, and induction of immunity against mutant ras can therefore be of possible clinical benefit in patients with pancreatic cancer. We present data from a clinical phase I/II trial involving patients with adenocarcinoma of the pancreas vaccinated by i.d. injection of synthetic mutant ras peptides in combination with granulocyte-macrophage colony-stimulating factor. Forty-eight patients (10 surgically resected and 38 with advanced disease) were treated on an outpatient basis. Peptide-specific immunity was induced in 25 of 43 (58%) evaluable patients, indicating that the protocol used is very potent and capable of eliciting immune responses even in patients with end-stage disease. Patients followed-up for longer periods showed evidence of induction of long-lived immunological memory against the ras mutations. CD4(+) T cells reactive with an Arg12 mutation also present in the tumor could be isolated from a tumor biopsy, demonstrating that activated, ras-specific T cells were able to selectively accumulate in the tumor. Vaccination was well tolerated in all patients. Patients with advanced cancer demonstrating an immune response to the peptide vaccine showed prolonged survival from the start of treatment compared to non-responders (median survival 148 days vs. 61 days, respectively; p = 0.0002). Although a limited number of patients were included in our study, the association between prolonged survival and an immune response against the vaccine suggests that a clinical benefit of ras peptide vaccination may be obtained for this group of patients.

Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease.

BACKGROUND: Based on a series of successful outpatient laparoscopic cholecystectomies, day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997. The initial results are reported. METHODS: Inclusion criteria were American Society of Anesthesiologists grade I-II, living within 30 min travel from the hospital, and adult company at home. Initially only selected patients were offered day-case treatment, but later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil, and were given ketorolac, propacetamol, droperidol and ondansetron as prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rosetti fundoplication or semifundoplication depending on oesophageal manometric results. RESULTS: Forty-five patients were included. Four patients were admitted; 41 were discharged as planned 3-8 h after operation, and five of these patients were readmitted. One underwent reoperation for necrosis of the gastric fundus. A further five patients visited the outpatient department without need for admission. At follow-up 31 patients were satisfied with the day-case treatment, five were indifferent, and five were dissatisfied because of pain. If offered a similar operation in the future, 26 patients would have preferred and seven would have accepted day-case treatment, and eight would not. CONCLUSION: Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.

[Telemedicine collaboration between the Rikshospitalet and the Ulleval hospital]. / Telemedisinsk samarbeid mellom Rikshospitalet og Ullevål sykehus.

BACKGROUND: During the last two years the Intervention Centre at the Nation Hospital of Norway and Ullevål Hospital have pursued a research programme in telemedicine aimed at exploring the potential of inter-hospital collaboration. MATERIAL AND METHODS: Both hospitals established a communication network between operating rooms and lecture halls. Sound and video from minimally invasive surgical and radiology procedures were transmitted on a wide bandwidth ATM network (34 Mbits/s) to gain experience with the use of telemedicine for educational purposes and the treatment of patients. RESULTS: Evaluations of technical off-line and clinical line transmissions have given us helpful information about the potential of telemedicine and what it will take to utilise this potential. With the MPEG2 standard, a wide bandwidth network yields sufficient sound and image quality for educational and clinical collaboration. However, multimedia communication requires changes in the organisation to secure quality of service in relation to technical management and telemedical production. INTERPRETATION: Inter-hospital collaboration on telemedicine may be a resource in clinical practice, facilitating professional enhancements, particularly in surgery, radiology and internal medicine. Changes in the organisation are needed, but they are feasible.

Standard preoperative assessment can improve outcome after cholecystectomy.

OBJECTIVE: To assess the outcome of cholecystectomy after standard preoperative handling and selection of patients, focusing on the potential of the operation to eliminate biliary colic. DESIGN: Prospective study. SETTING: University Hospital, Norway. PATIENTS: 806 patients (median age 56, range 18-91 years, male:female ratio 1:2.7), were referred to our clinic for cholecystectomy between 1992 and 1996. INTERVENTIONS: Unless there was a clear indication for cholecystectomy (frequent attacks of biliary colic/or recent complications of gallstones or both), patients were investigated in a standard way to find out what else was causing the abdominal pain. MAIN OUTCOME MEASURES: Residual pain was assessed at a clinical examination three months postoperatively, and clinical condition a median of three years later was assessed by a questionnaire. RESULTS: 465 (58%) patients were operated on primarily, and an additional 29 patients were operated on after further evaluation. Three months after cholecystectomy, 35 (7%) had persistent pain, mostly caused by other specific diseases and relieved after specific treatment. A median 3 years postoperatively, only 21 (4%) reported that they still had abdominal pain. CONCLUSION: Standard selection of patient improved the outcome of cholecystectomy. Compared with a historical control group, residual pain after three months was reduced from 20% to 7%. After three years, 96% of the patients no longer had their main clinical problem.