Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography: a population-based registry study.

BACKGROUND: Each year 13 000 patients undergo cholecystectomy in Sweden, and routine intraoperative cholangiography (IOC) is recommended to minimize bile duct injuries. The risk of requiring endoscopic retrograde cholangiopancreatography (ERCP) following cholecystectomy for common bile duct (CBD) stones where IOC is omitted and in patients with CBD stones left in situ is not well known. METHODS: Data were retrieved from the population-based Swedish Registry of Gallstone Surgery and ERCP between 1 January 2009 and 10 December 2019. Primary outcome was risk for postoperative ERCP for retained CBD stones. RESULTS: A total of 134 419 patients that underwent cholecystectomy were included and 2691 (2.0 per cent) subsequently underwent ERCP for retained CBD stones. When adjusting for emergency or planned cholecystectomy, preoperative symptoms suggestive of CBD stones, sex and age, there was an increased risk for ERCP when IOC was not performed (hazard ratio (HR) 1.4, 95 per cent c.i. 1.3 to 1.6). The adjusted risk for ERCP was also increased if CBD stones identified by IOC were managed with surveillance (HR 5.5, 95 per cent c.i. 4.8 to 6.4). Even for asymptomatic small stones (less than 4 mm), the adjusted risk for ERCP was increased in the surveillance group compared with the intervention group (HR 3.5, 95 per cent c.i. 2.4 to 5.1). CONCLUSION: IOC plus an intervention to remove CBD stones identified during cholecystectomy was associated with reduced risk for retained stones and unplanned ERCP, even for the smallest asymptomatic CBD stones.

This population-based registry study shows that when common bile duct (CBD) stones are identified by intraoperative cholangiography (IOC) and not removed, there is a risk for retained stones requiring endoscopic retrograde cholangiopancreatography. For asymptomatic stones less than 4 mm diameter, 10.7 per cent in the surveillance group had a retained stone following surgery. These findings imply that even the smallest CBD stones identified by IOC should be removed.

Is out-of-hours cholecystectomy for acute cholecystitis associated with complications?

BACKGROUND: Existing data on the safety of out-of-hours cholecystectomy are conflicting. The aim of this study was to investigate whether out-of-hours cholecystectomy for acute cholecystitis is associated with a higher risk for complications compared with surgery during office hours. METHODS: This was a population-based cohort study. The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) was used to investigate the association between out-of-hours cholecystectomy for acute cholecystitis and complications developing within 30 days. Data from patients who underwent cholecystectomy between 2006 and 2017 were collected. Out-of-hours surgery was defined as surgery commencing between 19.00 and 07.00 hours on weekdays, or any time at weekends (Friday 19.00 hours to Monday 07.00 hours). Multivariable logistic regression analysis was used to assess the risk of complications, with time of procedure as independent variable. The proportion of open procedures and proportion of procedures exceeding 120 min were also analysed. Adjustments were made for sex, age, ASA grade, time between admission and surgery, and hospital-specific features. RESULTS: Of 11 153 procedures included, complications occurred within 30 days in 1573 patients (14·1 per cent). The adjusted odds ratio (OR) for complications for out-of-hours versus office-hours surgery was 1·12 (95 per cent c.i. 0·99 to 1·28). The adjusted OR for procedures completed as open surgery was 1·39 (1·25 to 1·54), and that for operating time exceeding 120 min was 0·63 (0·58 to 0·69). CONCLUSION: Out-of-hours complications may relate to patient factors and the higher proportion of open procedures.

ANTECEDENTES: Los datos existentes sobre la seguridad de la colecistectomía fuera del horario laboral son discordantes. El objetivo de este estudio fue investigar si la colecistectomía para el tratamiento de la colecistitis aguda realizada fuera del horario laboral se asocia con un mayor riesgo de complicaciones en comparación con la cirugía efectuada durante el horario laboral. MÉTODOS: Se trata de un estudio de cohortes de base poblacional. Se utilizó el registro Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) para examinar la asociación entre la colecistectomía por colecistitis aguda realizada fuera del horario laboral y las complicaciones a los 30 días. Se recogieron los datos de los pacientes en los que se realizó una colecistectomía entre 2006 y 2017. Se definió como cirugía fuera del horario laboral aquella realizada entre las 19:00 y las 07:00 de lunes a viernes y en cualquier momento durante los fines de semana (de viernes 19:00 a lunes 07:00) Se realizó un análisis de regresión logística multivariable para evaluar el riesgo de complicaciones, considerando la hora de la cirugía como variable independiente. También se analizó el porcentaje de intervenciones por vía abierta y el de aquellas cuya duración excedió de los 120 minutos. Se realizaron ajustes por sexo, edad, puntuación ASA, días desde el ingreso hasta la cirugía y características específicas del hospital. RESULTADOS: Se produjeron 1.573 (14,1%) complicaciones en las 11.153 intervenciones incluidas. La razón de oportunidades, odds ratio (OR) ajustada para las complicaciones comparando la cirugía fuera del horario laboral con la cirugía dentro del horario laboral, fue de 1,12 (i.c. del 95% 0,99-1,28). La OR ajustada para los procedimientos realizado por vía abierta fue de 1,39 (1,25-1,54). La OR ajustada para el tiempo operatorio > 120 minutos fue de 0,63 (0,58-0,69). CONCLUSIÓN: Las complicaciones que suceden en la cirugía efectuada fuera del horario laboral es más probable que se deban a factores relacionados con el paciente que con la hora del día en que se practica la cirugía. Debe tenerse en cuenta que las intervenciones realizadas por vía abierta fuera del horario laboral tienen una mayor morbilidad.

The Short-Form Inguinal Pain Questionnaire (sf-IPQ): An Instrument for Rating Groin Pain After Inguinal Hernia Surgery in Daily Clinical Practice.

BACKGROUND: The Inguinal Pain Questionnaire (IPQ) is a standardised and validated instrument for assessing persisting pain after groin hernia surgery. The IPQ is often perceived as being too extensive for routine use. The aim of this study was to develop and evaluate a condensed version of the IPQ in order to facilitate its use in daily clinical practice. METHODS: The condensed form, i.e. Short-Form Inguinal Pain Questionnaire (sf-IPQ), comprises two main items taken from the IPQ. Four hundred patients were recruited from the Swedish Hernia Register and were sent the IPQ, sf-IPQ and the Short-Form McGill Pain Questionnaire (SF-MPQ) three years after hernia repair. Ratings from the IPQ and the sf-IPQ were converted to a 12-point scale. The reported scores for the two shared items in the IPQ and sf-IPQ were compared using the Intraclass Correlation Coefficient (ICC), Cohen's kappa and McNemar's test. RESULTS: After two reminders, the response rate was 69.8% (n = 279/400). The ICC for the IPQ and sf-IPQ scores was 0.78 (95% confidence interval 0.73-0.82, p < 0.001). Cohen's kappa was 0.66 (95% confidence interval 0.55-0.77, p < 0.001). The sf-IPQ systematically indicated a higher pain score than the IPQ (p = 0.013). CONCLUSIONS: Despite the systematic difference in level of pain scored, correlation, consistency and agreement were seen between the IPQ and sf-IPQ. The forms appear to be interchangeable, though the sf-IPQ may be a more sensitive instrument. The condensed structure of the sf-IPQ is more user-friendly and shows promise as a useful tool in daily clinical practice.

Morbidity of cholecystectomy and gastric bypass in a national database.

BACKGROUND: There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated. METHODS: Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored. RESULTS: There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P < 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P < 0·001) to the duration of surgery. CONCLUSION: Cholecystectomy should be performed before, not during or after, RYGB.

Perirenal fat surface area as a risk factor for perioperative difficulties and 30-day postoperative complications in elective colon cancer surgery.

AIM: Visceral obesity is associated with perioperative and postoperative complications in colorectal surgery. We aimed to investigate the association between the perirenal fat surface area (PRF) and postoperative complications. METHOD: Data on 610 patients undergoing curative, elective colon cancer resection between 2006 and 2016 at Stockholm South General Hospital were retrieved from a local quality register. We assessed perioperative and postoperative outcomes using a multinomial regression model adjusted for age, sex, American Society of Anesthesiologists classification and surgical approach (open/laparoscopy) in relation to PRF. RESULTS: PRF could be measured in 605 patients; the median area was 24 cm2 . Patients with PRF ≥ 40 cm2 had longer operation time (median 223 vs 184 min), more intra-operative bleeding (250 vs 125 ml), reoperations (11% vs 6%), surgical complications (27% vs 13%) and nonsurgical infectious complications (16% vs 9%) than patients with PRF < 40 cm2 , but there were no differences in the need for intensive care or duration of hospital stay. The multivariate analyses revealed an increased risk of any complication [OR 1.68 (95% CI 1.1-2.6)], which was even more pronounced for moderate complications [Clavien-Dindo II, OR 2.14 (CI 1.2-2.4]; Clavien-Dindo III, OR 2.35 (CI 1.0-5.5)] in patients with PRF ≥ 40 vs < 40 cm2 . The absolute risk of complications was similar in men and women with PRF ≥ 40 cm2 . CONCLUSION: PRF, an easily measured indirect marker of visceral obesity, was associated with overall and moderate complications in men and women and could serve as a useful tool in the assessment of preoperative risk.

Impact of Comorbidity and Prescription Drugs on Haemorrhage in Cholecystectomy.

BACKGROUND: The purpose of the present study was to analyse the impact of patient-related risk factors and medication drugs on haemorrhagic complications following cholecystectomy. METHODS: All cholecystectomies registered in the Swedish population-based Register for Gallstone Surgery and ERCP (GallRiks) were identified. Risk factors for bleeding were assessed by linking data in the GallRiks to the National Patient Register and the Prescribed Drug Register, respectively. The risk of haemorrhage leading to intervention was determined by variable regression, and Kaplan-Meier analysis assessed survival rate following perioperative haemorrhage. RESULTS: A total of 94,557 patients were included between 2005 and 2015, of which 799 (0.8%) and 1192 (1.3%) patients were registered as having perioperative and post-operative haemorrhage, respectively. In multivariable analysis, an increased risk of haemorrhagic complications was seen in patients with cerebrovascular disease (p = 0.001), previous myocardial infarction (p = 0.001), kidney disease (p = 0.001), heart failure (p = 0.001), diabetes (p = 0.001), peripheral vascular disease (p = 0.004), and obesity (p = 0.005). Prescription of tricyclic antidepressant (p = 0.018) or dipyridamole (p = 0.047) was associated with a significantly increased risk of perioperative haemorrhage. However, this increase in risk did not remain significant following Bonferroni correction for mass significance. Perioperative haemorrhage increased the risk of death occurring within the first post-operative year [Hazard Ratio, (HR) 4.9, CI 3.52-6.93] as well as bile duct injury (OR 2.45, CI 1.79-3.37). CONCLUSION: The increased risk of haemorrhage associated with comorbidity must be taken into account when assessing patients prior to cholecystectomy. Perioperative bleeding increases post-operative mortality and is associated with an increased risk of bile duct injury.

[ASSESSMENT OF THE QUALITY OF LIFE OF PATIENTS AFTER CHOLECYSTECTOMY].

Assessment of the quality of life (QOL) in modern medicine takes an important role, and can also provide a comprehensive evaluation of the patient's health status. The article presents the data of our own research evaluating the QOL of patients after cholecystectomy for a period of 0.7 to 4.1 years. The patients were interviewed using the international questionnaire - GastrointestinalQualityofLifeIndex (GIQLI). QOLs were evaluated depending on factors such as postoperative time, type of hospitalization, sex, age, marital status, changes in the gallbladder structure, activity, duration of hospitalization, and the type of surgical access. As a result of the research, it was determined that the increase in the QOL index correlates with the period elapsed since the surgery. Positive effects on QOL were influenced by such factors as patients' staying with the family, the planned of cholecystectomy (vs. urgent surgery), laparatomic surgical access, age and sex. QOL also proved to be higher in patients with chronic changes in the gallbladder.

[DYNAMICS OF ENTEROPERITONEAL TRANSLOCATION OF MICROORGANISMS ON THE EXPERIMANTAL MODEL OF ACUTE INTESTINAL OBSTRUCTION].

The article presents an analysis of the dynamics of enteroperitoneal translocation of bacteria on the model of acute intestinal obstruction (AIO) in rats by performing an experimental study on laboratory animals. Using the proposed model of AIO we have tried to determine the level of enteroperitoneal translocation as a function of the time of the impassable obstruction. The results which presented in the article clearly demonstrate that when AIO is developing in experimental animals the greatest level of translocation was revealed on the 3rd and 5th days. Statistically significant growth of the microflora in the lumen of the intestine above the level of obturation was observed on the 1st day and the whole period of observation was maintained, and it was also revealed that the level of CFU depends on the duration of the AIO and in the abdominal cavity it increases dramatically by 7 days, compared to 1 and 3 days. However, there is no significant correlation between enteroperitoneal translocation and the level of CFU in the lumen of the intestine and abdominal cavity.

Does the Frequency of Cholecystectomy Affect the Ensuing Incidence of Gallbladder Cancer in Sweden? A Population-Based Study with a 16-Year Coverage.

BACKGROUND: Gallbladder cancer (GBC) is rare among the different gastrointestinal cancers with a significant global variation in incidence. High cholecystectomy rates on benign indications have been assumed to prevent the development of gallbladder cancer. The aim of the present study was to explore the relationship between the rate of cholecystectomy at different time periods and regions of the country and the annual incidence of GBC. METHODS: Standardized cholecystectomy and GBC incidences for Swedish counties have been obtained from the Swedish national inpatient and National Cancer registries for the years 1998­2013. The incidences have been calculated for ages over 15 years and per 100,000 population. The relationships between cholecystectomy and GBC incidences have been analyzed using regression models. Correlation analyses were performed for the total cumulative incidence rates as well as the incidence rates calculated for the first and last 8 years of the entire study period. RESULTS: Cholecystectomy rates ranged from 99 to 205 per 100,000 and year, and the GBC incidence from 2.3 to 5.1. Overall, we observed a slow but steady decline in cholecystectomy rates­as well as GBC incidences during the 16-year period. No significant correlation between the cholecystectomy rates and GBC incidences was seen. CONCLUSIONS: This nationwide population-based study demonstrates substantial geographic differences in annual cholecystectomy rates without any significant inverse co-variation between cholecystectomy rates and the ensuing GBC incidence which would have supported the idea that frequent cholecystectomy affects the incidence of GBC.

The impact of type of mesh repair on 2nd recurrence after recurrent groin hernia surgery.

BACKGROUND: According to the Swedish Hernia Register (SHR), the reoperation rate is more than doubled after recurrent groin hernia repair compared with primary repair. The aim was to study the impact of type of mesh repair used in recurrent groin hernia surgery on a 2nd recurrence in a population-based cohort derived from the SHR. MATERIAL AND METHOD: All 1st recurrent hernia repairs in the south-west region of Sweden, registered in SHR between 1998 up to 2007 were included. A questionnaire was sent in 2009. Patients stating a new lump or persisting problems were examined. A 2nd recurrence was identified as a 2nd reoperation or at physical examination. The incidence was analysed comparing anterior mesh repair (AMR) and posterior mesh repairs (PMR) (endoscopic and open). RESULTS: Eight hundred and fifteen recurrent operations in 767 patents were analysed, 401 AMRs and 414 PMRs. PMR had a lower 2nd recurrence rate compared with AMR (5.6 vs. 11.0 %) (p = 0.025). An increased risk [3.21 (CI 1.33-7.44) (p = 0.009)] of a subsequent 2nd recurrence was seen after anterior index repair followed by AMR and a decreased risk [0.08 (CI 0.01-0.94) (p = 0.045)] after posterior index repair followed by AMR. CONCLUSION: PMR in recurrent groin hernia surgery was associated with a lower 2nd recurrence rate compared to anterior. A posterior approach for 1st recurrent operation is recommended after an anterior index repair and an anterior approach after a posterior index operation.

Effects of Intra-abdominally Instilled Isotonic Saline on Pain, Recovery, and Health-Related Quality-of-Life Following Laparoscopic Cholecystectomy: A Randomized Prospective Double-Blind Controlled Study.

INTRODUCTION: The postoperative installation of isotonic saline in the abdomen has been suggested as a method to reduce the effect of local toxins, thereby reducing postoperative pain in patients undergoing laparoscopic surgery. The aim of this randomized prospective double-blind trial was to assess whether installation of isotonic saline can reduce postoperative pain and nausea following laparoscopic cholecystectomy (LC). METHODS: Altogether 71 LC patients were randomized to either intra-abdominal instillation of isotonic saline group (S) (n = 36) or no saline (NS) group (n = 35) at the end of surgery. Data were collected by means of questionnaires. The postoperative recovery profile questionnaire was answered prior to surgery and 1 week postoperatively, SF-36 prior to surgery and at 1 month postoperatively, and a pain diary recording a Visual Analogue Scale score each day during the first week. RESULTS: The overall response rate was 94%. No significant differences were seen between the groups regarding abdominal and shoulder pain. However, the NS group reported more pain (NS = 53 %, S = 29 %) and fatigue (NS = 50%, S = 35%) than the S group postoperative day 7. Moreover, the most frequently reported problem in both groups 7 days after surgery was getting back to normal life (60%). Females reported a slower recovery profile than males and also more postoperative symptoms day 7. HRQoL results were similar between the groups. CONCLUSION: Instillation of isotonic saline does not improve recovery after laparoscopic cholecystectomy. Postoperative pain was more often reported in the NS group than in the S group, though the difference was not significant.

Incidence and risk factors for symptomatic venous thromboembolism following cholecystectomy.

BACKGROUND: The benefit of thromboembolism prophylaxis in cholecystectomy is controversial. This population-based study report on the incidence of and risk factors for symptomatic venous thromboembolism (VTE) after cholecystectomy. METHOD: All cholecystectomies registered in the Swedish Register of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2006 and 2011 were reviewed. By linking patient data to the Swedish National Patient Register (NPR), the 30-day postoperative incidence of VTE (deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) was identified. Age- and gender-standardized incidence ratio (SIR) for deep venous thrombosis (DVT) and pulmonary embolism (PE) were calculated. Multivariable analysis determined risk factors for VTE by calculating odds ratio (OR). RESULTS: Altogether 62,488 procedures were registered and postoperative VTE was seen in 154 (0.25%) patients. DVT was seen in 36 (0.06%) patients and PE in 25 (0.04%) patients within 30 days after surgery. The SIR for DVT was 22.2 (95% confidence interval (CI) 13.1-31.3) and for PE 5.6 (95% CI 2.3-8.9). Risk factors for VTE within 30 days after cholecystectomy were age >70 years (odds ratio [OR] = 2.69; 95% confidence interval [CI] 1.68-4.30), open cholecystectomy (OR = 1.95; CI 1.31-2.92), operation time >120 min (OR = 1.66; CI 1.18-2.35), acute cholecystitis (OR = 1.69; CI 1.18-2.42), and previous history of VTE (OR = 50.5; CI 27.3-92.8). Thromboembolism prophylaxis (TP) increased the risk for postoperative bleeding (OR = 1.72; 1.44-2.05). CONCLUSION: The incidence of VTE after cholecystectomy is low and thromboembolism prophylaxis (TP) increases the risk for postoperative bleeding. Patients with previous VTE events should be given TP when undergoing cholecystectomy.

Outcomes of antibiotic prophylaxis in acute cholecystectomy in a population-based gallstone surgery registry.

BACKGROUND: The aim of this study was to assess the effect of antibiotic prophylaxis (AP) on postoperative infections in acute cholecystectomy. METHODS: The study was based on acute cholecystectomies registered in the nationwide Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2006 and 2010. The association between AP and the risk of postoperative infectious complications was tested in a multivariable regression analysis, with stepwise addition of age, sex, duration of operation, indication for surgery, surgical approach (laparoscopic versus open) and American Society of Anesthesiologists (ASA) fitness grade as co-variables. Postoperative infections requiring antibiotic treatment and postoperative abscesses were defined as outcome measures. RESULTS: AP was given to 9549 (68.6 per cent) of 13 911 patients. Postoperative infections requiring antibiotic treatment occurred following 1070 procedures (7.7 per cent), including 805 patients (8.4 per cent) who received AP (P < 0.001 versus patients without AP). Postoperative abscesses developed after 273 procedures (2.0 per cent), including 208 patients (2.2 per cent) who received AP (P = 0.007). In univariable analysis, the odds ratio for development of infectious complications necessitating treatment with antibiotics was 1.42 (95 per cent confidence interval 1.23 to 1.64) for those who received AP versus those who did not, and for postoperative abscesses it was 1.47 (1.11 to 1.95). In multivariable analysis, adjusting for confounders, the odds ratios were 0.93 (0.79 to 1.10) and 0.88 (0.64 to 1.21) respectively. CONCLUSION: The present study suggests that AP provides no benefit in acute cholecystectomy.

Incidence of groin hernia repairs in women and parity: a population-based cohort study among women born in Sweden between 1956 and 1983.

INTRODUCTION: The aim of this study was to evaluate the association between parity and the incidence rate of groin hernia repair in women. METHOD: This study was based on two Swedish national registers, the Medical Birth Register (MBR), and the Swedish Hernia Register (SHR). The cohort constituted of women born between 1956 and 1983. Data on vaginal and cesarean deliveries were retrieved from the MBR. The birth and hernia registers were cross matched to identify hernia repairs carried out after deliveries. RESULTS: A total of 1,535,379 women were born between 1956 and 1983. Among these, 1,417,237 (92.3%) were registered for at least one birth. The incidence rate for Inguinal Hernia Repair (IHR) and Femoral Hernia Repair (FHR) was 10.7 per 100,000 person-year and 2.6 per 100,000 person-year, respectively. Compared with women registered for one delivery, the incidence rate ratio for IHR was 1.31 (95% Confidence Interval: 1.23-1.40) among women registered for two deliveries, 1.70 (1.58-1.82) among women registered for ≥ 3 deliveries. Additionally, the incidence rate ratios were higher 1.30 (1.14-1.49) and 1.70 (1.49-1.95) for FHR among women with two and ≥ 3 registered deliveries, respectively. CONCLUSION: In the present cohort, higher parity was associated with a higher incidence of inguinal as well as FHRs.

Reference Data on the Normal Abdominal Wall Anatomy and Baseline Characteristics in Seventy-One Nulliparous Women.

Aims: The aim of this study was to describe the prepartum anatomy of the abdominal wall in a cohort of nulliparous women, for use as a reference for management of patients with postpartum abdominal wall insufficiency with or without rectus diastasis. Materials and Methods: Seventy-one women were examined with ultrasonography of the abdominal wall. The inter-recti distance (IRD), anatomical variations of the linea semilunaris, and the oblique muscles were assessed. The waistline was measured during activation and relaxation of the abdominal core. Participant characteristics were registered. Questionnaires regarding habitual physical activity (Baecke), low back pain (Oswestry), physical functioning (DRI), urinary incontinence (UDI-6 and IIQ-7), and quality-of-life (SF-36) were answered. Results: Mean age was 30.5 years (range 19-50 years) and mean BMI 23.5 kg/m2 (range 18-37). Ultrasonography showed a mean IRD of 10 mm (range 3-24) at the superior border of the umbilicus, 9 mm (4-20) 3 cm above the umbilicus, and 2 mm (-5-10) 2 cm below the umbilicus. The mean thickness of the linea alba was 3 mm (1.5-5) and mean distances between the lateral edge of the rectus muscle and the external, internal, and transverse oblique muscles were 12 mm (-10-28), 1 mm (-14-13) and 15 mm (-14-32) at umbilicus level. Responses to the DRI, UDI-6, IIQ-7 and Oswestry questionnaires showed generally lower scores than the normal population whereas Baecke and SF-36 scores were similar. Conclusion: This study provides baseline data on normal abdominal wall anatomy in a healthy nulliparous female cohort, as well as levels of activity, physical function, disability, and quality-of-life.

The TOR concept (training, operation, and rehabilitation) applied to a cohort of postpartum women with training-resistant symptomatic rectus diastasis: evaluation 1 year after surgery.

BACKGROUND: Rectus diastasis is a common sequela of pregnancy and is associated with functional disabilities such as back pain, abdominal core instability, abdominal muscle weakness, urinary incontinence, and psychological issues such as a negative body image. The aim of this study was to evaluate the effect of the TOR concept (training, operation, and rehabilitation), a novel concept for treating abdominal wall insufficiency combined with rectus diastasis, after pregnancy. TOR consists of preoperative evaluation of symptoms and custom-designed abdominal core training, tailored rectus diastasis repair, and individual progressive postoperative rehabilitation. METHODS: A consecutive series of women diagnosed with rectus diastasis and core dysfunction resistant to training, underwent plication of the linea alba between 2018 and 2020. After surgery, all patients participated in an individually designed rehabilitation programme over a 4-month interval. Physical function was recorded before surgery and 1 year after surgery using the disability rating index questionnaire. Symptoms associated with core instability were recorded before and 1 year after surgery. Quality of life was assessed using the SF-36. The abdominal wall anatomy was assessed with ultrasound before and 1 year after surgery. RESULTS: Seventy-one women were included and all attended 1-year follow-up. Response rate was 81.7 per cent (58) for the disability rating index, and 59.2 per cent (42) for SF-36. Self-reported physical function (disability rating index) improved in 54 of 58 patients (93.1 per cent), with a median score reduction of 91.3 per cent. Core instability symptoms decreased significantly. All SF-36 subscales improved significantly compared with preoperative scores, reaching levels similar to or higher than the normative Swedish female population. No recurrence of rectus diastasis was seen at the 1-year follow-up. CONCLUSIONS: Surgical reconstruction within the TOR concept resulted in significant improvements in physical function and quality of life as well as a significant decrease in symptoms of core instability.

Appendectomy during pregnancy: rates, safety, and outcomes over a five-year period. A hospital-based follow-up study.

INTRODUCTION: Appendicitis is the most common acute abdominal complication during pregnancy. If appendix perforation occurs there is an increasing risk of preterm delivery and other pregnancy complications. OBJECTIVE: To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates, and complications. METHODS: A prospective cohort study of pregnant women with, or without, appendectomy at South Stockholm General Hospital, December 2015 to February 2021 in a setting where pregnant women are prioritized for surgery and laparoscopic surgery was standard of care in first half of pregnancy. Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. A non-pregnant control group was gathered comprising women of fertile age in the same study interval. RESULTS: During the study period 50 pregnant women, of whom 44 gave birth, underwent appendectomy of 38 199 women giving birth. There were no differences between women with or without appendectomy in proportion of preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or Cesarean delivery (18.2% vs. 20.4%). The rate of appendix perforation was 19% in non-pregnant control group compared to 12% among pregnancy. There was no case of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks (4/11 vs. 2/39, p = .005). Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks. As compared to first half, the appendectomy rate was three times lower during the second half of pregnancy. Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, this resulted in a shorter time-to-surgery among pregnant women (p < .001). CONCLUSION: Routine laparoscopic surgery and time priority for pregnant surgery is associated with a low risk of perforation, preterm birth and other complications. However, a low threshold for surgery may increase the risk of a negative exploration.

Do postoperative complications correlate to chronic pain following inguinal hernia repair? A prospective cohort study from the Swedish Hernia Register.

PURPOSE: To analyse if postoperative complications constitute a predictor for the risk of developing long-term groin pain. METHODS: Population-based prospective cohort study of 30,659 patients operated for inguinal hernia 2015-2017 included in the Swedish Hernia Register. Registered post-operative complications were categorised into hematomas, surgical site infections, seromas, urinary tract complications, and acute post-operative pain. A questionnaire enquiring about groin pain was distributed to all patients 1 year after surgery. Multivariable logistic regression analysis was used to find any association between postoperative complications and reported level of pain 1 year after surgery. RESULTS: The response rate was 64.5%. In total 19,773 eligible participants responded to the questionnaire, whereof 73.4% had undergone open anterior mesh repair and 26.6% had undergone endo-laparoscopic mesh repair. Registered postoperative complications were: 750 hematomas (2.3%), 516 surgical site infections (1.6%), 395 seromas (1.2%), 1216 urinary tract complications (3.7%), and 520 hernia repairs with acute post-operative pain (1.6%). Among patients who had undergone open anterior mesh repair, an association between persistent pain and hematomas (OR 2.03, CI 1.30-3.18), surgical site infections (OR 2.18, CI 1.27-3.73) and acute post-operative pain (OR 7.46, CI 4.02-13.87) was seen. Analysis of patients with endo-laparoscopic repair showed an association between persistent pain and acute post-operative pain (OR 9.35, CI 3.18-27.48). CONCLUSION: Acute postoperative pain was a strong predictor for persistent pain following both open anterior and endo-laparoscopic hernia repair. Surgical site infection and hematoma were predictors for persistent pain following open anterior hernia repair, although the rate of reported postoperative complications was low.

Risk of bleeding associated with use of systemic thromboembolic prophylaxis during laparoscopic cholecystectomy.

BACKGROUND: The extent to which systemic perioperative thromboembolic prophylaxis affects peroperative and postoperative bleeding during cholecystectomy is not known. This article reports on risk of bleeding in a national cohort of cholecystectomies. METHODS: All cholecystectomies registered in the Swedish Register of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) between 2005 and 2010 were reviewed. Peroperative bleeding was defined as bleeding that could not be controlled by standard surgical techniques, necessitated conversion to an open procedure or required peroperative blood transfusion. Postoperative bleeding was defined as bleeding that necessitated reoperation, transfusion or a prolonged hospital stay. Risk estimates were performed using univariable and multiple logistic regression, and reported as odds ratios (ORs). RESULTS: A total of 51 621 procedures were registered in GallRiks. Some 48 010 patients were included in the analyses, of whom 21 259 (44·3 per cent) received thromboembolic prophylaxis. Peroperative bleeding complications occurred in 400 (1·9 per cent) and postoperative bleeding in 296 (1·4 per cent) given thromboembolic prophylaxis, compared with 189 (0·7 per cent) and 195 (0·7 per cent) respectively without thromboprophylaxis. After adjusting for age, sex, indication for surgery, American Society of Anesthesiologists grade, mode of admission, operative approach, duration of surgery and hospital volume, the OR for peroperative or postoperative bleeding complications in the group receiving prophylaxis was 1·35 (95 per cent confidence interval 1·17 to 1·55). However, in a subgroup analysis the risk was increased in laparoscopic surgery only. At 30-day follow-up, a total of 74 patients (0·2 per cent) had developed postoperative thromboembolism, 43 (0·2 per cent) of those who received thromboembolic prophylaxis compared with 31 (0·1 per cent) of those who did not. CONCLUSION: Thromboprophylaxis in patients undergoing laparoscopic cholecystectomy increased the risk of bleeding, but the occurrence of thromboembolic events was not significantly reduced. Identification of high- and low-risk patients is needed to guide clinical decisions regarding medical thromboprophylaxis.

Long-term reoperation rate following primary ventral hernia repair: a register-based study.

BACKGROUND: The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair. METHODS: The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010-2019. Reoperation was defined as repeat repair after primary repair. RESULTS: Altogether 29,360 umbilical hernia repairs and 6514 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.292 (95% confidence interval (CI) 0.109-0.782) after open onlay mesh repair, 0.484 (CI 0.366-0.641) after open interstitial mesh repair, 0.382 (CI 0.238-0.613) after open sublay mesh repair, 0.453 (CI 0.169-1.212) after open intraperitoneal onlay mesh repair, 1.004 (CI 0.688-1.464) after laparoscopic repair, and 0.940 (CI 0.502-1.759) after other techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged < 50 years (HR 1.669, CI 1.389-2.005), for women (HR 1.401, CI 1.186-1.655), and for patients with liver cirrhosis (HR 2.544, CI 1.049-6.170). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age < 50 years (HR 2.046, CI 1.337-3.130). CONCLUSIONS: All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method.