RESUMO
Background and study aims Knowledge on self-reported quality of life (QoL) in achalasia and QoL improvements after peroral endoscopic myotomy (POEM) is limited. Furthermore, the clinical role of QoL in achalasia follow-up has not been evaluated. The present study aimed to examine QoL in achalasia patients before and after POEM and assess associations between QoL, Eckardt score (ES) and objective results. Patients and methods This was a single-center prospective study of treatment-naïve achalasia patients with 12-month follow-up after POEM including manometry, upper endoscopy, 24-hour pH registration, and timed barium esophagogram. QoL data were registered using European Organisation for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal module (QLQ-OES18). Comparison with a reference population was performed to assess impact of achalasia on QoL and effect of therapy. Mixed models for repeated measures were applied. Results Fifty patients (26 females) with a median age of 47 years (18-76) were included. Before treatment, all QoL domains were significantly impaired compared with an age- and gender-adjusted reference population ( P â<â0.05). No significant QoL-differences were found after POEM, except for fatigue and nausea/vomiting. Clinically relevant QoL improvement was observed inâ≥â50â% of the patients in all QoL domains, except for physical and role functioning. QoL was significantly associated with ES ( P â<â0.05) but not with objective results. Conclusions Achalasia is associated with severe QoL impairment. Following POEM, a significant and clinically relevant QoL improvement is observed. QoL is associated with ES, but not with objective results after POEM.
RESUMO
BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but outcome evaluation has often been limited to Eckardt score (ES). The present study was aimed to improve knowledge about outcome evaluation and predictive outcome factors by performing a comprehensive objective evaluation of achalasia patients treated by POEM. METHODS: This single centre prospective study reports outcome data 12 months after POEM in treatment-naive achalasia patients. A predefined follow-up protocol included ES, high resolution manometry, 24-h pH measurement, upper endoscopy and timed barium esophagogram (TBE). Univariate and multivariate regression analyses were performed to analyze association between post-POEM variables and identify predictive factors for objective outcome. RESULTS: Fifty patients were included with a drop-out rate of <5%. ES, lower oesophageal sphincter pressures, TBE heights and maximal oesophageal diameter were all reduced after POEM (p < .001), and 28% (13/47) of the patients had a positive 24-h pH registration. An oesophageal diameter >3 cm after POEM was associated with treatment failure assessed by ES (p = .04) and TBE (p = .03). Advanced achalasia stage (p = .02) and long symptom duration (p = .04) were identified as independent predictive factors for poor outcome assessed by TBE. CONCLUSIONS: The present study confirms that POEM is an efficient therapy for achalasia. The comprehensive objective evaluation after POEM demonstrates that long symptom duration and major changes in oesophageal anatomy at diagnosis imply poor treatment outcome, and a post-POEM dilated oesophagus is associated with treatment failure.Key messagesPeroral endoscopic myotomy (POEM) is established as a safe and effective therapy for achalasia.Timed barium esophagogram offers objective variables that are valuable in treatment response evaluation. Advanced achalasia stage and long symptom duration are predictive factors for poor objective treatment response after POEM.
Assuntos
Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Esofagoscopia/métodos , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Adulto , Idoso , Bário , Acalasia Esofágica/diagnóstico por imagem , Esfíncter Esofágico Inferior/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14. MATERIAL AND METHOD: We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively. RESULTS: Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period. INTERPRETATION: Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Idoso , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Although non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality? METHODS: We performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008. RESULTS: 583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%-24%; p<0.01), as did the AE rate (11%-5%; p<0.01). The 30-day crude mortality decreased from 14% to 7% (p<0.05). A logistic regression model predicted an OR of 0.45 (95% CI 0.21 to 0.98) for dying when admitted in P2. In OIS grades 4 and 5 injuries (n=149, median ISS 34), similar reduction in AE rate was seen (30%-12%; p<0.05). The NOM rate for OIS grades 4 and 5 injuries was 70%, with 98% success rate. For the 30% requiring surgery, the mortality remained high (P1 52%; P2 40%), despite more balanced transfusion strategy. DISCUSSION: Changes in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome. LEVEL OF EVIDENCE: IV.
RESUMO
BACKGROUND: Non-operative management of splenic injuries has become the treatment of choice in hemodynamically stable patients over the last decades. The aim of the study is to describe the incidence, initial treatment and early outcome of patients with splenic injuries on a national level. METHODS: All hospitals in Norway admitting trauma patients were invited to participate in the study. The study period was January through December 2013. The hospitals delivered anonymous data on primarily admitted patients with splenic injury. RESULTS: Three of the four regional trauma centers and 26 of the remaining 33 acute care hospitals delivered data on a total of 151 patients with splenic injury indicating an incidence of 4 splenic injuries per 100,000 inhabitants/year, and a median of 4 splenic injuries per hospital per year. A total of 128 (85%) patients were successfully treated non-operatively including 20 patients who underwent an angiographic procedure. The remaining 23 (15%) patients underwent open splenectomy or spleen-preserving surgery. CONCLUSION: Most patients with splenic injuries are managed non-operatively. Despite the low number of splenic injuries per hospital, the results indicate satisfactory outcome on a national level.
Assuntos
Traumatismos Abdominais/terapia , Baço/lesões , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/epidemiologia , Adolescente , Adulto , Angiografia , Embolização Terapêutica , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Admissão do Paciente , Estudos Retrospectivos , Esplenectomia , Centros de Traumatologia , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Although nonoperative management (NOM) has become standard care, optimal treatment of liver injuries in children is still challenging since many of these patients have multiple injuries. Moreover, the role of angiography remains poorly defined, and a high index of suspicion of complications is warranted. This study reviews treatment and outcomes in children with liver injuries at a major Scandinavian trauma centre over a 12-year period. METHODS: Patients <17 years old with liver injury admitted to Oslo University Hospital Ullevaal during the period 2002-2013 were retrospectively reviewed. Data were compiled from the institutional trauma registry and medical records. RESULTS: A total of 66 children were included. The majority was severely injured as reflected by a median injury severity score of 20.5 (mean 22.2). NOM was attempted in 60 (90.9%) patients and was successful in 57, resulting in a NOM success rate of 95.0% [95% CI 89.3 to 100]. Only one of the three NOM failures was liver related, occurred in the early part of the study period, and consisted in operative placement of drains for bile leak. Two (3.0%) patients underwent angiographic embolization (AE). Complications occurred in 18 (27.3% [95 % CI 16.2 to 38.3]) patients. Only 2 (3.0%) patients had liver related complications, in both cases bile leak. Six (9.1%) patients underwent therapeutic laparotomy for non-liver related injuries. Two (3.0%) patients died secondary to traumatic brain injury. DISCUSSION: This single institution paediatric liver injury cohort confirms high attempted NOM and NOM success rates even in patients with high grade injuries and multiple accompanying injuries. AE can be a useful NOM adjunct in the treatment of paediatric liver injuries, but is seldom indicated. Moreover, bile leak is the most common liver-related complication and the need for liver-related surgery is very infrequent. CONCLUSION: NOM is the treatment of choice in almost all liver injuries in children, with operative management and interventional radiology very infrequently indicated.
Assuntos
Traumatismos Abdominais/cirurgia , Previsões , Laparotomia/métodos , Fígado/lesões , Traumatismo Múltiplo , Centros de Traumatologia , Ferimentos não Penetrantes/cirurgia , Adolescente , Criança , Embolização Terapêutica/métodos , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Fígado/cirurgia , Masculino , Estudos Retrospectivos , Fatores de RiscoRESUMO
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.
Assuntos
Competência Clínica , Avaliação Educacional , Procedimentos Cirúrgicos Operatórios/educação , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Humanos , Programas de AutoavaliaçãoRESUMO
BACKGROUND: The justification and safety of splenic angiographic embolization (SAE) as an adjunct to nonoperative management (NOM) in high-grade splenic injuries are matters of controversy. At Oslo University Hospital-Ulleval, mandatory SAE was introduced in hemodynamically stable Organ Injury Scale (OIS) Grades 3 to 5 injuries in 2002. From October 2008, mandatory SAE was restricted to OIS Grade 4 injuries or higher. The aim of the present study was to evaluate clinical outcome in patients with high-grade splenic injuries and further define the role of SAE. METHODS: All patients 17 years or older with splenic injury admitted from August 1, 2002, to July 31, 2010, were included. Patient charts, computed tomographic scans, and trauma registry data were reviewed. The OIS Grade 3 protocol was amended on October 1, 2008. RESULTS: A total of 296 patients with splenic injuries (mean splenic OIS grade, 3.0) resulted in a 70% attempted NOM rate, with 96% success rate. NOM was attempted in 64 (70%) of 91 patients with Grades 4 and 5 injuries, with a 95% success rate.Comparing OIS Grade 3 injuries admitted before (n = 81) and after (n = 35) October 2008, we found similar admission physiology and Injury Severity Score (ISS). Despite the reduction in SAE rate (from 49% to 26%), the NOM rate remained unchanged, as did NOM failure rate (3% vs. 4%), rate of rebleeding, complications, and mortality. CONCLUSION: A protocol with mandatory SAE in OIS Grades 4 and 5 injuries resulted in an overall 95% success rate among the 70% eligible for NOM. In OIS Grade 3 splenic injuries, mandatory SAE does not seem justified. LEVEL OF EVIDENCE: Therapeutic study, level IV.
Assuntos
Embolização Terapêutica , Radiografia Intervencionista , Baço/irrigação sanguínea , Baço/diagnóstico por imagem , Baço/lesões , Adulto , Angiografia , Embolização Terapêutica/efeitos adversos , Humanos , Escala de Gravidade do FerimentoRESUMO
BACKGROUND: The terrorist attacks in Norway on July 22, 2011, consisted of a bomb explosion in central Oslo, followed by a shooting spree in a youth camp. We describe the trauma center response, identifying possible success factors and suggesting improvements for institutional major incident plans. METHODS: The in-hospital response is analyzed. Data on triage, patient flow, injuries, treatment, resources, and outcome were collected. RESULTS: The explosion caused a total of 98 casualties and 8 died at scene. Ten patients were triaged to the trauma center, with the first patient arriving 18 minutes after the explosion and 7 patients within the next 19 minutes. The shooting caused 68 deaths at the scene and 61 injured. The trauma center received a total of 21 patients from the shooting incident.Surgical leadership was divided between emergency department triage with control of personnel and communication as well as control and supervision of treatment with retriage and optimal use of trauma surgical resources (dual command). Surge capacity was never exceeded in the emergency department, operating rooms, or intensive care units.Of the 31 patients treated at the trauma center, 20 had an Injury Severity Score of more than 15 and 25 required repeated operation, for a total of 125 operations during the first 4 weeks. One patient died, for a critical mortality of 5%. CONCLUSION: A trauma center can handle many patients with severe injury, with low critical mortality when protected from a large number of walking wounded. Limited specific trauma surgical competence was managed by the adoption of a dual surgical command model. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.