Impact of COVID-19 on the incidence of CT-diagnosed appendicitis and its complications in the UK and Sweden.

AIM: To compare the number of appendicitis cases and its complications, during the first months of the COVID-19 pandemic in Sweden and the UK and the corresponding time period in 2019. METHOD: Reports of emergency abdominopelvic CT performed at 56 Swedish hospitals and 38 British hospitals between April and July 2020 and a corresponding control cohort from 2019 were reviewed. Two radiologists and two surgeons blinded to the date of cohorts analyzed all reports for diagnosis of appendicitis, perforation, and abscess. A random selection of cases was chosen for the measurement of inter-rater agreement. RESULT: Both in Sweden (6111) and the UK (5591) fewer, abdominopelvic CT scans were done in 2020 compared to 2019 (6433 and 7223, respectively); p < 0.001. In the UK, the number of appendicitis was 36% lower in April-June 2020 compared to 2019 but not in Sweden. Among the appendicitis cases, there was a higher number of perforations and abscesses in 2020, in Sweden. In the UK, the number of perforations and abscesses were initially lower (April-June 2020) but increased in July 2020. There was a substantial inter-rater agreement for the diagnosis of perforations and abscess formations (K = 0.64 and 0.77). CONCLUSION: In Sweden, the number of appendicitis was not different between 2019 and 2020; however, there was an increase of complications. In the UK, there was a significant decrease of cases in 2020. The prevalence of complications was lower initially but increased in July. These findings suggest variability in delay in diagnosis of appendicitis depending on the country and time frame studied.

Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction.

INTRODUCTION: This study aimed to determine whether day-case closure of loop ileostomy with discharge within 23 h was both feasible and accepted by patients. MATERIALS AND METHODS: We conducted a prospective pilot study where selected rectal cancer patients with diverting loop ileostomy underwent stoma closure in a 23-h stay setting. Patients were followed up on the third, seventh, and 30th postoperative day and phoned daily during the first week. A comparable group of 30 patients who underwent standard in-hospital stoma closure prior to the start of the study were selected retrospectively as historical controls. RESULTS: In total, 30 patients (median age, 67 years; range, 41-79 years) were included. All patients met discharge criteria and were discharged within 23 h of surgery, except one. In total, seven patients (23%) were admitted. Two of these patients underwent laparotomy because of anastomotic leakage and small bowel obstruction, respectively. The mean total length of stay was 1.7 days. Most patients (87%) were satisfied with the treatment without feeling neglected or anxious and preferred the 23-h stay setting. In the control group, the mean length of stay was 5 days. Seven patients (23%) were readmitted. Two of these patients underwent laparotomy because of small bowel obstruction and abscess, respectively. CONCLUSION: Ileostomy closure in a 23-h stay setting in selected patients with meticulous follow up is feasible and safe with high patient satisfaction. CLINICALTRIALS.GOV NUMBER: (NCT02774447).

Risk factors for developing anorectal dysfunction after anterior resection.

BACKGROUND: Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR. METHODS: This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996-2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I-III rectal cancer patients had AR whereof 412 were included in this study. RESULTS: Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63-0.90; p < 0.001) and clustering (OR 0.78; CI 0.67-0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08-3.31; p = 0.03), incontinence (OR 2.48; 1.29-4.77; p < 0.01), and urgency (OR 4.61; CI 2.02-10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis. CONCLUSION: The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.

Risk factors for small bowel obstruction after open rectal cancer resection.

BACKGROUND: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery. METHODS: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed. RESULTS: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO. CONCLUSIONS: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings.

PURPOSE: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. METHODS: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model. RESULTS: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469). CONCLUSIONS: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann's procedure: a report from a national registry.

PURPOSE: To describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann's procedure (HP). METHODS: Data were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007-2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed. RESULTS: Of 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3-4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14-2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08-3.67), T4 tumours (OR, 1.68; 95% CI 1.04-2.69) and female gender (OR, 1.73; 95% CI, 1.15-2.61) as risk factors for intra-abdominal infection. ASA score 3-4 (OR, 1.62; 95% CI, 1.12-2.34), elevated BMI (OR, 1.05; 95% CI, 1.02-1.09) and female gender (OR, 2.06; CI, 1.41-3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP. CONCLUSIONS: Despite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann's procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Low risk of complications in patients with first-time acute uncomplicated diverticulitis.

PURPOSE: First-time acute uncomplicated diverticulitis (AUD) has been considered to have an increased risk of complication, but the level of evidence is low. The aim of the present study was to evaluate the risk of complications in patients with first-time AUD and in patients with a history of diverticulitis. METHODS: This paper is a population-based retrospective study at Västmanland's Hospital, Västerås, Sweden, where all patients were identified with a diagnosis of colonic diverticular disease ICD-10 K57.0-9 from January 2010 to December 2014. The records of all patients were surveyed and patients with a computed tomography (CT)-verified AUD were included. Complications defined as CT-verified abscess, perforation, colonic obstruction, fistula, or sepsis within 1 month from the diagnosis of AUD were registered. RESULTS: Of 809 patients with AUD, 642 (79%) had first-time AUD and 167 (21%) had a previous history of AUD with no differences in demographic or clinical characteristics. In total, 16 (2%) patients developed a complication within 1 month irrespective of whether they had a previous history of diverticulitis (P = 0.345). In the binary logistic regression analysis, first-time diverticulitis was not associated with increased risk of complications (OR 1.58; CI 0.52-4.81). The rate of antibiotic therapy was about 7-10% during the time period and outpatient management increased from 7% in 2010 to 61% in 2014. CONCLUSIONS: The risk for development of complications is low in AUD with no difference between patients with first-time or recurrent diverticulitis. This result strengthens existing evidence on the benign disease course of AUD.

Socioeconomic characteristics and comorbidities of diverticular disease in Sweden 1997-2012.

PURPOSE: This study aimed to evaluate the association of socioeconomic status and comorbidities with uncomplicated and complicated diverticular disease (DD) in Sweden. METHODS: We identified all individuals aged ≥30 years in Sweden diagnosed with DD between 1997 and 2012 using the Swedish National Population and Housing Census and the Hospital Discharge Register. Data were analyzed by multivariable logistic regression, with individual-level characteristics as covariates. RESULTS: A total of 79,481 patients (median age 66 [range 30-86] years) were hospitalized for DD, 15,878 (20%) of whom for complicated DD. Admissions for both uncomplicated and complicated DD were more common in women (p < 0.001). A low education level was identified as a risk factor for uncomplicated (unadjusted hazard ratio [HR] 1.79, 95% confidence interval [CI] 1.75-1.82; adjusted HR 1.22, 95% CI 1.19-1.24) and complicated DD (unadjusted HR 1.84, 95% CI 1.77-1.92; adjusted HR 1.26, 95% CI 1.21-1.32). Patients with the lowest income had a lower risk of hospitalization for uncomplicated (adjusted HR 0.94, 95% CI 0.91-0.96) and complicated DD (adjusted HR 0.87, 95% CI 0.83-0.92) than those with the highest income. The correlation coefficient between income and education was 0.25. Diabetes and cardiovascular disease were identified as protective factors against uncomplicated DD (adjusted HR 0.68, 95% CI 0.66-0.69 and HR 0.79, 95% CI 0.74-0.84, respectively). CONCLUSIONS: Patients with the lowest education level had an increased risk of hospitalization for DD. Further studies are needed to explore the association of diabetes and cardiovascular disease with uncomplicated DD.

Lymphovascular and perineural invasion in stage II rectal cancer: a report from the Swedish colorectal cancer registry.

BACKGROUND: Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level. MATERIALS AND METHODS: Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012. RESULTS: Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09-1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34-2.43, p < .001) had significantly increased risks of recurrence. CONCLUSIONS: Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.

Hartmann's procedure vs abdominoperineal resection with intersphincteric dissection in patients with rectal cancer: a randomized multicentre trial (HAPIrect).

BACKGROUND: The use of Hartmann's procedure in the old and frail and/or in patients with fecal incontinence is increasing, even though some data have reported high postoperative rates of pelvic abscesses. Abdominoperineal excision with intersphincteric dissection has been proposed as a better alternative and is performed increasingly both nationally and internationally. However, no studies have been performed to support this. The aim of this study is to randomize patients between Hartmann's procedure and abdominoperineal excision with intersphincteric dissection and compare post-operative surgical morbidity and quality of life. The hypothesis is that intersphincteric abdominoperineal excision provides less pelvic and perineal morbidity. METHODS/DESIGN: In this multicentre randomized controlled study, Hartmann's procedure will be compared with intersphincteric abdominoperineal excision in patients with rectal cancer unsuitable for an anterior resection. The patients are operated in different ways around the ano-rectum, otherwise the same procedure is performed with total mesorectal excision and all will receive a colostomy. The one-month postoperative control will focus on post-operative surgical complications, especially the perineal-pelvic, reoperations and other interventions. After one year, late complications such as pain in the perineal or pelvic area or disorders such as secretion or bleeding from the anorectal stump will be recorded and a follow-up of quality of life performed. Histological and oncological data will also be recorded, the latter up to 5 years post-operatively. DISCUSSION: The HAPIrect trial is the first randomized controlled trial comparing standard low Hartmann's procedure with intersphincteric abdominoperineal excision in patients with rectal cancer with the aim of categorizing the post-operative surgical morbidity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01995396 . Date of registration November 25, 2013.

Circumferential resection margin as a prognostic marker in the modern multidisciplinary management of rectal cancer.

BACKGROUND: A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer. OBJECTIVE: The purpose of this study was to analyze the involvement of circumferential resection margin in local recurrence and survival in a multidisciplinary population-based setting by using tailored oncological therapy and surgery with total mesorectal excision. DESIGN: Data were collected in a prospective database and retrospectively analyzed. Between 1996 and 2009, 448 patients with rectal cancer underwent a curative bowel resection. SETTINGS: Population-based data were collected at a single institution in the county of Västmanland, Sweden. RESULTS: Preoperative radiotherapy was delivered to 334 patients (74%); it was delivered to 35 patients (8%) concomitantly with preoperative chemotherapy. In 70 patients (16%), en bloc resections of the prostate and vagina were performed. Intraoperative perforations were seen in 7 patients (1.6%). The mesorectal fascia was assessed as complete in 117/118 cases. In 32 cases (7%), the circumferential resection margin was 1 mm or less. After a median follow-up of 68 months, 5 (1.1%) patients developed a local recurrence; one of them had circumferential resection margin involvement. The 5-year overall survival was 77%. In the multivariate analysis, the circumferential resection margin was not an independent factor for disease-free survival. LIMITATIONS: Mesorectal fascia was not assessed before 2007. The findings might be explained by a type II error but, from a clinical perspective, enough patients were included to motivate the conclusion of the study. CONCLUSIONS: Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.

Hartmann's procedure in rectal cancer: a population-based study of postoperative complications.

PURPOSE: Hartmann's procedure for rectal cancer patients is increasingly performed but few studies have reported the postoperative outcome. The purpose was to report postoperative complications and analyse risk factors in rectal cancer patients operated with Hartmann's procedure. To describe the selection and postoperative complication patterns, all bowel-resected rectal cancer patients were included. METHODS: Population-based data were from the county of Västmanland, Sweden. All rectal cancer patients operated with an elective bowel resection between 1996 and 2012 were included. Demographics and postoperative complications were prospectively registered and data retrospectively analysed. RESULTS: Of the 624 patients included, 396 (64%) were operated with an anterior resection, 159 (25%) with an abdominoperineal excision and 69 (11%) a Hartmann's procedure of which 90% were low Hartmann's. Patients operated with a Hartmann's procedure were significantly older, had higher ASA-score, poorer WHO performance score and lower serum albumin levels. Operative time for Hartmann's procedure was a median of 49 and 99 min shorter than after anterior resection and abdominoperineal excision, respectively, and entailed less bleeding. Complications related to the pelvic and perineal dissections were more common after abdominoperineal excision compared with anterior resection and Hartmann's procedure (32 vs. 9 and 13%, p < 0.001). CONCLUSIONS: Few rectal cancer patients, operated with Hartmann's procedure, developed pelvic complications despite a higher age, more co-morbidities, metastases in different localities and functional inferiority when compared with the patients operated with anterior resection or abdominoperineal excision. Hartmann's procedure is a valid alternative procedure in the old and frail rectal cancer patient.

Prophylactic stoma mesh did not prevent parastomal hernias.

PURPOSE: Parastomal herniation is reported in up to 50 % of patients with a colostomy. A prophylactic stoma mesh has been reported to reduce parastomal hernia rates. The aim of the study was to evaluate the rate of parastomal hernias in a population-based cohort of patients, operated with and without a prophylactic mesh at two different time periods. METHODS: All rectal cancer patients operated with an abdominoperineal excision or Hartmann's procedure between 1996 and 2012 were included. From 2007, a prophylactic stoma mesh was placed in the retro-muscular plane. Patients were followed prospectively with clinical and computed tomography examinations. RESULTS: There were no differences with regard to age, gender, pre-operative albumin levels, ASA score, body mass index (BMI), smoking or type of surgical resection between patients with (n = 71) and without a stoma mesh (n = 135). After a minimum follow-up of 1 year, 187 (91%) of the patients were alive and available for analysis. At clinical and computed tomography examinations, exactly the same parastomal hernia rates were found in the two groups, viz, 25 and 53%, respectively (p = 0.95 and p = 0.18). The hernia sac contained omentum or intestinal loops in 26 (81%) versus 26 (60%) patients with and without a mesh, respectively (p = 0.155). In the multivariate analyses, high BMI was associated with parastomal hernia formation. CONCLUSIONS: A prophylactic stoma mesh did not reduce the rate of clinically or computed tomography-verified parastomal hernias. High BMI was associated with an increased risk of parastomal hernia formation regardless of prophylactic stoma mesh.

No antibiotics in acute uncomplicated diverticulitis: does it work?

BACKGROUND: The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence. METHODS: This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Västmanland Hospital Västerås, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence. RESULTS: In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year. CONCLUSION: The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.

Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR).

Objective: The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III). Background: There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable. Methods: Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed. Results: Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45). Conclusions: HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.

Time trends of the association of body mass index with mortality in 3.5 million young Swedish adults.

PURPOSE: We investigated time trends of the obesity-mortality association, accounting for age, sex, and cause-specific deaths. METHODS: We analysed pooled nationwide data in Sweden for 3,472,310 individuals aged 17-39 years at baseline in 1963-2016. Cox regression and flexible parametric survival models investigated BMI-mortality associations in sub-groups of sex and baseline calendar years (men: <1975, 1975-1985, ≥1985 and women: <1985, 1985-1994, ≥1995). RESULTS: Comparing men with obesity vs. normal weight, all-cause and "other-cause" mortality associations decreased over periods; HR (95% CI) 1.92 (1.83-2.01) and 1.70 (1.58-1.82) for all-cause and 1.72 (1.58-1.87) and 1.40 (1.28-1.53) for "other-cause" mortality in <1975 and ≥1985, but increased for CVD mortality; HR 2.71 (2.51-2.94) and 3.91 (3.37-4.53). Higher age at death before 1975 coincided with more obesity-related deaths at higher ages. Furthermore, the all-cause mortality association for different ages in men showed no clear differences between periods (p-interaction=0.09), suggesting no calendar effect after accounting for attained age. Similar, but less pronounced, results were observed in women. Associations with cancer mortality showed no clear trends in men or in women. CONCLUSIONS: Accounting for differences in age and death causes between calendar periods when investigating BMI-mortality time trends may avoid misinterpreting the risks associated with obesity over time.

Cohort profile: The Obesity and Disease Development Sweden (ODDS) study, a pooled cohort.

PURPOSE: The Obesity and Disease Development Sweden (ODDS) study was designed to create a large cohort to study body mass index (BMI), waist circumference (WC) and changes in weight and WC, in relation to morbidity and mortality. PARTICIPANTS: ODDS includes 4 295 859 individuals, 2 165 048 men and 2 130 811 women, in Swedish cohorts and national registers with information on weight assessed once (2 555 098 individuals) or more (1 740 761 individuals), in total constituting 7 733 901 weight assessments at the age of 17-103 years in 1963-2020 (recalled weight as of 1911). Information on WC is available in 152 089 men and 212 658 women, out of whom 108 795 have repeated information on WC (in total 512 273 assessments). Information on morbidity and mortality was retrieved from national registers, with follow-up until the end of 2019-2021, varying between the registers. FINDINGS TO DATE: Among all weight assessments (of which 85% are objectively measured), the median year, age and BMI (IQR) is 1985 (1977-1994) in men and 2001 (1991-2010) in women, age 19 (18-40) years in men and 30 (26-36) years in women and BMI 22.9 (20.9-25.4) kg/m2 in men and 23.2 (21.2-26.1) kg/m2 in women. Normal weight (BMI 18.5-24.9 kg/m2) is present in 67% of assessments in men and 64% in women and obesity (BMI≥30 kg/m2) in 5% of assessments in men and 10% in women. The median (IQR) follow-up time from the first objectively measured or self-reported current weight assessment until emigration, death or end of follow-up is 31.4 (21.8-40.8) years in men and 19.6 (9.3-29.0) years in women. During follow-up, 283 244 men and 123 457 women died. FUTURE PLANS: The large sample size and long follow-up of the ODDS Study will provide robust results on anthropometric measures in relation to risk of common diseases and causes of deaths, and novel findings in subgroups and rarer outcomes.

CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy.

OBJECTIVE: The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard. METHODS: A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner. RESULTS: Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27-84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 min for both methods. The mean time for CTC evaluation was 20 min. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (κ = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (κ = 0.17). No cancer was found. CONCLUSION: CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Lower need for allogeneic blood transfusion after robotic low anterior resection compared with open low anterior resection: a propensity score-matched analysis.

Robotic low anterior resection (R-LAR) for rectal cancer may decrease estimated blood loss compared with open low anterior resection (O-LAR). The aim of this study was to compare estimated blood loss and blood transfusion within 30 days after O-LAR and R-LAR. This was a retrospective matched cohort study based on prospectively registered data from Västmanland Hospital, Sweden. The first 52 patients operated on using R-LAR for rectal cancer at Västmanland Hospital were propensity score-matched 1:2 with patients who underwent O-LAR for age, sex, ASA (American Society of Anesthesiology physical classification system), and tumor distance from the anal verge. In total, 52 patients in the R-LAR group and 104 patients in the O-LAR group were included. Estimated blood loss was significantly higher in the O-LAR group compared with R-LAR: 582.7 ml (SD ± 489.2) vs. 86.1 ml (SD ± 67.7); p < 0.001. Within 30 days after surgery, 43.3% of patients who received O-LAR and 11.5% who received R-LAR were treated with blood transfusion (p < 0.001). As a secondary post hoc finding, multivariable analysis identified O-LAR and lower pre-operative hemoglobin level as risk factors for the need of blood transfusion within 30 days after surgery. Patients who underwent R-LAR had significantly lower estimated blood loss and a need for peri- and post-operative blood transfusion compared with O-LAR. Open surgery was shown to be associated with an increased need for blood transfusion within 30 days after low anterior resection for rectal cancer.

Changes in the aerobic faecal flora of patients treated with antibiotics for acute intra-abdominal infection.

BACKGROUND: An open observational study was performed to investigate changes in the rectal flora and antibiotic susceptibility among faecal bacteria in patients treated with antibiotics for acute intra-abdominal infection. METHODS: One hundred and forty patients with acute intra-abdominal infection requiring antibiotic treatment and hospitalization were included. Eight surgical units from the southern part of Sweden participated, between January 2006 and November 2007. Antibiotic treatments were according to local guidelines. Rectal swabs were obtained on admission (sample 1) and 2-14 days after the end of antibiotic treatment (sample 2). Aerobic bacteria and yeasts were analysed. The material was divided into 2 groups: 1 group with Enterobacteriaceae and 1 group with non-fermentative Gram-negative bacteria. The susceptibility to antibiotics in each group was compared between samples 1 and 2. RESULTS: The main finding of this study on patients with severe intra-abdominal infections was a shift in the aerobic faecal flora following antibiotic treatment, from Escherichia coli to other more resistant Enterobacteriaceae, Enterococcus faecium, and yeasts. The susceptibility to cephalosporins and piperacillin-tazobactam decreased in Enterobacteriaceae. CONCLUSIONS: Following antibiotic treatment, a shift in the aerobic rectal flora to species with intrinsic antibiotic resistance was observed. This indicates that the emergence of resistance is not due to new mutations, but rather to selection of more resistant species. This should be taken into account when designing treatments for secondary intra-abdominal infections.