Does tumor size influence the outcome of laparoscopic distal pancreatectomy?

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned. METHODS: Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III). RESULTS: 218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II - 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar - 38.5, 32 and 34% in the group I, II and III. CONCLUSION: LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.

Hospitalisations during the final three years of life. / Sykehusinnleggelser de tre siste leveårene.

BAKGRUNN: Kunnskap om sykehusbruk i livets sluttfase er nyttig for å forstå behovet for sykehustjenester. MATERIALE OG METODE: Registeropplysninger fra Statistisk sentralbyrå og Norsk pasientregister er brukt for å analysere tallet på innleggelser ved somatiske sykehus de siste tre leveårene blant individer som døde i alderen 56-95 år. RESULTATER: Analyseutvalget besto av 35 954 individer som hadde 136 484 innleggelser i observasjonsperioden. De som døde da de var 56-65 år hadde 5,2 innleggelser i gjennomsnitt de siste tre leveårene, mot 2,8 for dødsalder 86-95 år. 14,1 % hadde ingen innleggelser, mens 13,3 % hadde åtte eller flere. De som døde på grunn av ondartede svulster hadde 5,6 innleggelser i gjennomsnitt, mot 4,2 hvis dødsfallet skyldtes åndedrettslidelser, og 3,1 om årsaken var sirkulasjonssykdom. FORTOLKNING: Krevende behandlinger er antatt å ha mindre sjanse for å lykkes blant eldre pasienter. Dette kan være en grunn til færre sykehusinnleggelser i livets sluttfase blant 80- og 90-åringer enn blant de som døde i 60- og 70-årsalderen. Gjennomsnittsalder ved død vil øke etter hvert som levealderen stiger, og derfor vil aldersvariasjonen i sykehusinnleggelser de siste leveårene ha betydning for behovet for sykehusinnleggelser.

Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson's disease in the Nordic region.

OBJECTIVE: Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson's disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. MATERIAL AND METHODS: A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson's disease patients with the primary goal of providing guidance on best practice for the Nordic countries. RESULTS: Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. CONCLUSIONS: LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson's disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.

[Continuous treatment with levodopa of Parkinson disease]. / Kontinuerlig behandling med levodopa ved Parkinsons sykdom.

BACKGROUND: The advanced stage of Parkinson's disease is characterised by motor fluctuations which are often difficult to control on traditional, peroral levodopa medication. We present our experience and a literature search regarding a method for continuous intraduodenal administration of a levodopa/carbidopa gel (Duodopa). METHODS: In a pilot study based on the compassionate use of continuous intraduodenal levodopa, patients were tested via nasoduodenal administration of the gel and on-off registration. For patients in whom a significant improvement in time in near-normal function per day was seen, permanent administration was started through a permanent duodenal port via percutaneous endoscopic gastrostomy with an inner catheter to the duodenal-jejunal transition. RESULTS AND CONCLUSION: In the nine patients tested, a significant functional improvement over time was seen. Five patients now have a permanent system with lasting good effect. Qualitative evaluation shows maintained good effect over a follow up time of up to 2.5 years (mean 19 months). We conclude that continuous enteral levodopa administration is a good and safe alternative especially for patients not offered deep brain stimulation. Its place among other treatment methods needs further assessment.

Real life cost and quality of life associated with continuous intraduodenal levodopa infusion compared with oral treatment in Parkinson patients.

Advanced-stage Parkinson's disease (PD) strongly affects quality of life (QoL). Continuous intraduodenal administration of levodopa (IDL) is efficacious, but entails high costs. This study aims to estimate these costs in routine care. 10 patients with advanced-PD who switched from oral medication to IDL were assessed at baseline, and subsequently at 3, 6, 9 and 12 months follow-up. We used the Unified PD Rating Scale (UPDRS) for function and 15D for Quality of Life (QoL). Costs were assessed using quarterly structured patient questionnaires and hospital registries. Costs per quality adjusted life year (QALY) were estimated for conventional treatment prior to switch and for 1-year treatment with IDL. Probabilistic sensitivity analysis was based on bootstrapping. IDL significantly improved functional scores and was safe to use. One-year conventional oral treatment entailed 0.63 QALY while IDL entailed 0.68 (p > 0.05). The estimated total 1-year treatment cost was NOK419,160 on conventional treatment and NOK890,920 on IDL, representing a cost of NOK9.2 million (€1.18 mill) per additional QALY. The incremental cost per unit UPDRS improvement was NOK25,000 (€3,250). Medication was the dominant cost during IDL (45% of total costs), it represented only 6.4% of the total for conventional treatment. IDL improves function but is not cost effective using recommended thresholds for cost/QALY in Norway.

Total mesorectal excision for rectal cancer: difference in outcome for low and high rectal cancer.

PURPOSE: This prospective study was designed to assess the outcome through the first five years after the introduction of total mesorectal excision in 1993 in a Norwegian central hospital, with special regard to the difference between low (< or =6 cm from anal verge) and high (>6 cm) rectal cancers. METHODS: A total of 140 patients (81 males; median age, 64 (range, 29-87) years) underwent surgery for rectal cancer under curative intention. RESULTS: Local recurrence rates were 8 of 44 (18 percent) for the low cancers and 5 of 96 (5 percent) for the high, a statistically significant difference (P = 0.0014). Corresponding numbers when the R1 resections are excluded were 5 of 36 (13 percent) for the low and 4 of 92 (4 percent) for the high cancers (P = 0.002). The five-year survival after R0 resections of cancers <6 cm was significantly reduced compared with those >6 cm. The five-year overall survival for the whole material was 72 percent. CONCLUSIONS: Surgery alone for rectal cancer can achieve overall good results, with five-year overall survival of 72 percent. The prognosis of the cancers of the lower rectum seems to be inherently different from the tumors of the higher level, both concerning local recurrence and five-year survival, suggesting different biologic behavior of the two cancers.