[Liver surgeries in Iceland 2013-2017 - Comparison with Sweden in terms of quality registration].

INTRODUCTION: Cancers in the liver, bile duct system, gallbladder as well as metastases of the liver, have poor prognosis. Their treatment is comparable, with surgery being the most widespread, available curative treatment. Surgical treatment is anatomical or non-anatomical resection of the liver where the tumor and the adjacent liver tissue are removed. MATERIALS/METHODS: A list of patients diagnosed with cancer in the liver, bile duct system, gallbladder or metastases of the liver, during the time period 2013-2017, was obtained from the Icelandic Cancer Registry. Additional information was retrieved from medical records and entered into the electronic quality registration forms of Landspítalinn. A comparison was made between Sweden and Iceland. RESULTS: In total 108 patients were diagnosed with primary cancer of the liver, of which 24 (22%) underwent liver surgery. Of 264 diagnosed with liver metastases 38 (14%) underwent surgical treatment. A total of 63% of all reported cases were discussed at a multidisciplinary team meeting in Iceland but 93% in Sweden (p<0.0001). A sum of 29 patients (43%) developed complications within 30 days of surgery. Number of partial liver resections per 100.000 inhabitants were 2-8 in Iceland versus 4-13 in Sweden. The difference was even more apparent in patients with liver metastases. CONCLUSION: Liver surgeries performed in Iceland seem to be comparable to Sweden in terms of complications and post operative mortality. In Iceland, considerably fewer operations are performed per capita, especially on liver metastases which could be explained by the fact that fewer patients are discussed at multidisciplinary team meetings.

[Gallstones - review].

The prevalence of gallstones is 20 % making it one of the most common causes for admissions to surgical wards. It seems that admissions and operations for gallstone disease are increasing. Gallstones are formed in the gallbladder but can also form in the biliary tree and most are made of cholesterol which is absorbed from the diet. Risk factors for gallstones and gallstone related disease are for example female gender, obesity and rapid weight loss. Most patients with gallstones never experience any symptoms but the risk of presenting with complications related to gallstones is two percent per year. Patients with gallstones can present with pain or other more serious complications that demand surgical treatment and follow-up. This article will cover pathophysiology, complications, diagnosis and treatment of gallstone disease.

[Inflammatory fibroid polyp in the jejunum - a case report].

Inflammatory fibroid polyps (IFP) are rare type of benign tumours found in the gastrointestinal tract. IFP´s are in most cases small in size and without symptoms but can cause intussuception and haemorrhage. We present a case of a 25 year old female who presented with abdominal pain and symptoms and signs of anemia, hemoglobin was 36 g/L upon arrival. Further workup revealed a large tumor in the small intestine. The patient underwent a partial resection of the proximal jejunum. Pathology of the specimen showed inflammatory fibroid polyp.

[Percutaneous cholecystostomy as treatment for acute cholecystitis at Landspitali University Hospital 2010 - 2016].

INTRODUCTION: Acute cholecystitis is one of the most common reasons for acute admission in abdominal surgery. The recom-mended therapy is cholecystectomy but occasionally that is not possible and a conservative treatment with intravenous antibiotics is used. Should the patient not respond to conservative treatment a percutaneous catheter can be placed in the gallbladder (cholecystostomy). The aim of the study was to look at the frequency of which cholecystostomies were used and the complication rates at Landspitali, The National University Hospital of Iceland. MATERIALS AND METHODS: A retrospective study where patient charts of those with ICD - diagnosis numbers K80 - 85 at Landspitali University Hospital looked at and patients who received cholecystostomies were identified in the period from 2010 - 2016. Clinical information was registered in Excel. Descriptive statistics were used. RESULTS: A total of 4423 patients were diagnosed with biliary disease during the study period. 1255 (28%) of them had acute cholecystitis with mean age of 58 years (range: 18 - 99). A cholecystostomy was put in 88 patients (14%), mean age 71 years (range: 28 - 92). A transhepatic route was used for 62 (70%) and the drain was in place for an average of 12 days (range: 0 - 87). A secondary cholangiography was performed in 71 cases. Seventeen patients were discharged home with the cholecystostomy in place. Half of the patients underwent a laparoscopic cholecystectomy 101 days from drain insertion (range: 30 - 258). A total of 28 complications were noted in 27 patients (31%) and the most common complication was dislodgement of the catheter (n=20). Five patients (6%) died within thirty days of the intervention, three from septic shock and two from reasons unrelated to the treatment. CONCLUSIONS: Cholecystostomy is not a common choice of treatment for acute cholecystitis at Landspitali, The National University Hospital of Iceland. Few serious complications arise from the treatment and no patients died in relation to the intervention.

The risk of developing a mismatch repair deficient colorectal cancer after undergoing cholecystectomy.

OBJECTIVES: Mismatch repair deficient (dMMR) colorectal cancer (CRC) is caused by inactivation of the MMR DNA repair system, most commonly via epigenetic inactivation of the MLH1 gene, and these tumors occur most frequently in the right colon. The objective was to determine whether cholecystectomy (CCY) increases the risk of a dMMR CRC by comparing CCY incidence in patients with dMMR CRC and proficient MMR (pMMR) CRC to unaffected controls. MATERIALS AND METHODS: All patients diagnosed with CRC in Iceland from 2000 to 2009 (n = 1171) were included. They had previously been screened for dMMR by immunohistochemistry (n = 129 were dMMR). Unaffected age- and sex-matched controls (n = 17,460) were obtained from large Icelandic cohort studies. Subjects were cross-referenced with all pathology databases in Iceland to establish who had undergone CCY. Odds ratios were calculated using unconditional logistic regression. RESULTS: Eighteen (13.7%) dMMR CRC cases and 90 (8.7%) pMMR CRC cases had undergone CCY compared to 1532 (8.8%) controls. CCY-related odds ratios (OR) were 1.06 (95% CI 0.90-1.26, p = .577) for all CRC, 1.16 (95% CI 0.66-2.05 p = .602) for dMMR CRCand 1.04 (95% CI 0.83-1.29, p = .744) for pMMR CRC. Furthermore, OR for dMMR CRC was 0.51 (95% CI 0.16-1.67, p = .266), 2.04 (95% CI 0.92-4.50, p = .080) and 1.08 (95% CI 0.40-2.89, p = .875) <10 years, 10-20 years and >20 years after a CCY, respectively. CONCLUSIONS: There was no evidence of increased risk of developing dMMR CRC after CCY although a borderline significantly increased 2-fold risk was observed 10-20 years after CCY. Larger studies are warranted to examine this further.

[Finger necrosis following arterial cannulation - a case report].

Arterial cannulation is a common procedure in critically ill patients, as it facilitates continuous monitoring of blood pressure, titration of inotropes, vasopressors and fluids and is also used for blood sampling. Serious complications from arterial lines are very rare, permanent ischemic damage occurs in less than 0,1% of patients. We report the case of a 60-year-old woman in septic shock caused by a perforated duodenal ulcer which was treated with emergent laparoscopic repair. She required high doses of vasopressors and received several arterial lines, including lines in both the ulnar and the radial arteries of the left arm. After two weeks in the intensive care unit she developed ischemia in all fingers of her left hand. She received anticoagulative therapy which was complicated by serious gastrointestinal bleeding and the therapy had to be discontinued. Eight weeks later she had demarcated necrosis in all fingers of her left hand and underwent partial amputation of fingers II-V, the thumb recovered without surgery. The cause of the necrosis was believed to be arterial embolism or ischemia secondary to arte- rial cannulations in combination with her underlying critical septic condition.

[Gallbladder carcinoma in Iceland 2004-2013].

INTRODUCTION: Gallbladder carcinoma is about 0.5% of all cancer. The outcome of patients with gallbladder carcinoma is overall bad and the only potentially curative treatment is surgery. The aim of this study was to determine the disease's prevalence in Iceland and outcome of the patients diagnosed in the study period. PATIENTS AND METHODS: This was a retrospective study of all diagnosed patients with gallbladder carcinoma during the years 2004-2013. A list of patients was obtained from the Icelandic Cancer Registry. Information was gathered from the patient's charts in Landspitali University Hospital and the Hospital in Akureyri. Descriptive statistics was used to analyze the results. Median follow-up time was 6 years. RESULTS: Twenty-four patients were diagnosed with gallbladder carci-noma in Iceland during the study period, 16 women and 8 men. Eighteen patients were diagnosed in Landspitali and six in the Hospital in Akureyri. The average age at diagnosis was 73 years. Eighteen patients have died, on average 5 months after the time of diagnosis. Adenocarcinoma was the most common cancer type (n=19). Three patients (3/24, 12.5%) underwent extended operation following the diagnosis of the gallbladder carcinoma. Nine patients (9/24, 37.5%) had advanced disease at the time of diagnosis and died within two months after being diagnosed with gallbladder carcinoma. CONCLUSION: Gallbladder carcinoma is a rare cancer type in Iceland and has a bad prognosis. One third of the patients had no connection with Landspitali University Hospital following the diagnosis. Extended surgery following the diagnosis was seldom performed. Key words: gallbladder carcinoma, gastrointestinal cancer, adenocarcinoma, extended cholecystectomy. Correspondence: Kristin Huld Haraldsdottir, kristinh@landspitali.is.

[Surgical treatment of hepatocellular carcinoma at Landspitali The National University Hospital of Iceland 1993 - 2012].

INTRODUCTION: Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. The incidence in Iceland is very low probably due to a low prevalence of cirrhosis. The only curative treatment is surgery, either transplant or resections, but only about 30% of patients are operable at the time of diagnosis. The aim of this study was to determine the number of patients who undergo liver resection due to HCC and to investigate outcomes after surgery at Landspitali University Hospital in Iceland. MATERIAL AND METHODS: A retrospective study of all HCC patients, 18 years of age or older, who underwent surgical resection at Landspitali University Hospital from January 1st 1993 to December 31st 2012. Data was collected from clinical records. Descriptive statistical analysis was used. RESULTS: During the time period 22 patients were operated with a liver resection and of those patients 12 (55%) had a major hepatectomy. 105 individuals in total were diagnosed with HCC in the time period, six patients had transplantation which results in 28 operations (27%). The average size of the tumors was 8.5 cm (3-22). Four individuals had cirrhosis. The frequency of intra-operative complications was 23% and post-operative complications 32% (Clavien-Dindo grade III and IV). A total of three individuals needed reoperation. The 30 day mortality rate was 0%. Twelve (55%) individuals were diagnosed with recurrence during the research period and eleven died. The one year mortality rate was 23%. CONCLUSION: The proportion of operable individuals with HCC in Iceland is low, few of whom have cirrhosis or other chronic liver disease. The mortality rate is comparable to other researches but the frequency of serious complications is higher probably due to tumor size.

Long-term Follow-up After Interstitial Laser Thermotherapy of Breast Cancer.

AIM: To review the effect of immunological changes induced by interstitial laser thermotherapy (ILT) on long-term outcome of patients with breast cancer. PATIENTS AND METHODS: Twenty-four patients with invasive breast cancer were treated with ILT followed by standard surgical excision. Immunohistological reactions on immunocompetent cells were performed on specimens obtained before and after ILT. Follow-up time was 116 (range=91-136) months. RESULTS: Significant prognostic factors were histologically-positive axillary lymph nodes and Ki67 positivity. ILT increased cytotoxic T (CD8(+)) lymphocytes within the tumor and mature dendritic cells (CD83(+)) and reduced the number of T-regulatory cells (Treg) CD25(+)/Forkhead box p3(+) (FOXP3(+)) lymphocytes in regional lymph nodes. These changes did not correlate with prognosis. The number of CD8(+) cells within the tumor, both before and after treatment, was significantly higher in patients with recurrence than in those without recurrence (p<0.01 and p<0.05, respectively). Patients with recurrent disease had a lower number of CD57(+) cells in tumor-free lymph nodes than did patients without recurrence (p<0.05). CONCLUSION: ILT did not have any long-term adverse effects. The clinical impact of the supposedly favourable immune changes after ILT should be examined in a larger patient population.

[Choledochal cyst--case report]. / Blödrur á gallvegum - sjúkratilfelli.

The clinical manifestation of a choledochal cyst is diverse and can mimic common diseases like gallstones, cholecystitis or pancreatitis. Initial diagnosis is often suspected after ultrasound of the biliary tract and confirmed with more specific studies as magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography. The risk of malignant transformation is well documented and the mainstay of therapy is excision of the choledochal cysts along with the gallbladder. Choledochal cysts are a rare phenomenon and only three cases were diagnosed in Iceland in the years 2000-2010. The following is a description of one of these cases along with an overview of the literature.