Increased incidence and reduced mortality after first attack of acute pancreatitis over an 18-year period.

AIMS: To determine time trends in the incidence and etiology of acute pancreatitis and identify predictors for in-hospital mortality. PATIENTS AND METHODS: Retrospective study of 1722 patients with acute pancreatitis admitted to Akershus University Hospital between January 2000 and December 2017. Data were obtained from electronic patient files and computed tomography scans. We estimated a logistic regression model to assess differences in associations between patient characteristics and in-hospital mortality in two time periods, 2000-2009 (first period) and 2010-2018 (second period). RESULTS: First attack of acute pancreatitis (FAAP) was identified in 1579 patients (91.7%). The incidence of FAAP increased from 20.1/100,000 during the first period to 27.7/100,000 in the second period (p = .011). Etiology showed no differences between the two time periods. Gallstone was the most frequent etiology (47.2%). In total, 187 patients (11.8%) had necrotizing pancreatitis; more in the second period compared to the first (14.2 vs. 7.7%; p < .001). The overall mortality rate was 3.9%. Mortality rates decreased for both inflammatory and necrotizing pancreatitis during the study period. Age and comorbidity according to Charlson Comorbidity Index (CCI) were predictors of in-hospital mortality (OR 1.07, 95% CI 0.07; 0.40 and 13.58, 95% CI 3.88; 47.52), as were alcohol and organ failure (OR 7.20, 95% CI 2.02; 25.67 and OR 34.15, 95% CI 8.94; 130.53, respectively). CONCLUSIONS: The incidence of FAAP is increasing in southeast Norway. The etiology has remained unchanged over an 18-year period, with gallstones being the most frequent cause. The outcomes for both inflammatory and necrotic pancreatitis are improving.

Enhanced recovery after colorectal surgery. Results from a prospective observational two-centre study.

BACKGROUND AND AIMS: Enhanced recovery after surgery (ERAS) has reduced the median hospital stay from 8-10 days with traditional peri-operative routines to four days. The aim of the present study was to introduce the principles of ERAS in our hospital and measure the effect on hospital stay, complications and quality of life after discharge from hospital. MATERIAL AND METHODS: 94 consecutive patients, 40 males, 54 females, median age 66 years, were included in a prospective non-randomised observational study at Haukeland University Hospital and Haugesund Hospital from October 2000 until February 2003. After a three-month preparation period, the principles of ERAS were implemented. The results were evaluated with questionnaires and by follow-ups 8-10 and 30 days after surgery. The results were compared to the results of colorectal surgery before introduction of accelerated recovery. RESULTS: 45 (48%) and 73 (78%) patients were discharged within three and five days after surgery with ERAS, compared to zero and seven (5%) patients with traditional recovery. The complication rate with ERAS was 31%, and the readmission rate was 15%. After one week, 57% had resumed their daily activities at home. After 30 days, 65% of the patients had resumed their normal and leisure activities. CONCLUSION: After a proper preparation period, ERAS principles may be implemented in surgical department, and is followed by a reduced median hospital stay and rapid return to normal daily activities for most patients after colorectal surgery.

Low local recurrence rates after rectal cancer resection with limited use of preoperative radiotherapy.

BACKGROUND: Local recurrence rates after curative rectal resection for rectal cancer have decreased after introduction of TME. In order to achieve even further reduction in local recurrence rates, several hospitals increase the use of preoperative radiotherapy. Thus, therapy-related side effects will increase. The aim of the study was to evaluate the results of the TME-technique with minimal use of radiotherapy. MATERIALS AND METHODS: a prospective observational study from 1993 to 2000 of 137 consecutive patients treated for rectal cancer at the department of surgery, Nordland Hospital HF, Bodø, Norway. RESULTS: 115 patients underwent curative resections (84%). eight patients (6.4 %) received peri-operative radiotherapy: three preoperatively (2.4%) because of clinically fixed tumours and five patients (4%) postoperatively; four with pR1-resections and one patient after perforation of the rectum. The local recurrence rate was 3.4 % with an observation time of 5 years. The total survival rate was 74% in curative group. In 22 patients the treatment was palliative. Only one of these patient survived 5 years. CONCLUSION: With TME-technique it is possible to achieve low recurrence rates and high survival rates with a high curative rate with minimal use of additional radiotherapy.

Local resection of rectal tumors by transanal endoscopic microsurgery: experience with the first 70 cases.

BACKGROUND: Transanal endoscopic microsurgery (TEM) can access the whole rectum up to 20 cm from the anal verge. Due to its excellent view and accurate dissection, TEM is useful for the removal of adenoma and selected low risk cancers of the rectum. We report our experience with the first 70 patients presenting. METHODS: A prospective descriptive study of 70 patients treated for rectal tumor with TEM from December 99 until October 2002 at Haukeland University Hospital. RESULTS: TEM was performed in 37 men and 33 women, median age 70.5 (19-90) years, for anticipated adenoma (n = 64), adenocarcinoma (n = 3), rectal ulcer (n = 1), and re-resection after snare resection of rectal polyp with adenocarcinoma (n = 1) and carcinoid tumor (n = 1). The median observation time was 12 (1-33) months. The distance from the anal verge to the lower tumor border was 5.5 (2.5-14) cm. The median resected area was 15.4 (1.5-132) cm(2). 56 of the 64 anticipated adenomas were true adenoma, resected without recurrences; 8 (12.5%) were unexpected adenocarcinoma. Three of these underwent a secondary rectal resection and 5 patients have been observed without recurrence. Of the 3 patients with known adenocarcinoma, there was one recurrence which was treated with a secondary curative rectal resection. CONCLUSIONS: TEM can access tumors in the whole rectum. Large tumors may be removed with low frequency of per- and postoperative complications and short hospital stay. TEM is highly useful for removal of rectal adenoma. A role for primary treatment of selected low-risk rectal cancers may emerge.

[Clostridium septicum infection and cancer]. / Clostridium septicum-infeksjon og kreft.

BACKGROUND: Unusual infections may occasionally be the first sign of cancer. MATERIAL, METHODS AND RESULTS: We present a patient admitted with septicaemia caused by Clostridium septicum. After successful treatment of the infection, cancer of the transverse colon was revealed by further examination. INTERPRETATION: In cases of unusual infections, underlying malignant disease should be suspected.

Upper gastrointestinal contrast study in the management of small bowel obstruction--a prospective randomised study.

OBJECTIVE: To find out whether contrast radiography helps to resolve small bowel obstruction. DESIGN: Prospective randomised trial. SETTING: University hospital, Norway. SUBJECTS: 98 consecutive patients with symptoms of small bowel obstruction and a plain abdominal radiograph that confirmed the diagnosis. INTERVENTIONS: The patients were randomly allocated to receive a mixture of barium and sodium diatrizoate (Gastrografin) (n = 48) or not (n = 50). Both groups were followed up clinically and by repeated abdominal films. MAIN OUTCOME MEASURES: Non-operative resolution of small bowel obstruction; number of patients with strangulated bowel; bowel resections; mortality; complications; hospital stay; and time from admission to operation. RESULTS: No significant differences were observed between the groups in the incidence of non-operative resolution (31/48 in contrast group, 35/50 in control group, OR: 0.89), strangulation obstruction (1/48 in contrast group, 4/50 in control group, OR: 0.24), bowel resection (3/48 in contrast group, 4/50 in control group, OR: 0.76), complications (8/48 in contrast group, 5/50 in control group, OR: 1.80), mortality (3/48 in contrast group, 1/50 in control group, OR: 3.26), and hospital stay (0-7 days: 34/48 in contrast group, 38/50 in control group, p = 0.95). The contrast group had a shorter interval between admission and operation than the control group (0-24 hours: 12/48 in contrast group, 3/50 in control group, p = 0.005). CONCLUSION: The contrast examination did not contribute to the resolution of small bowel obstruction.

Traumatic and postoperative ischemic liver necrosis: causes, risk factors and treatment.

BACKGROUND: To study the cause and outcome of ischemic liver necrosis and suggest treatment of these patients. METHODS: Retrospective study of 13 patients with ischemic liver necrosis treated at our departments from 1990 until 1997. RESULTS: Ischemic liver necrosis was caused by general hypoxia (n = 1) or acute arterial occlusion (n = 12) of the celiac and superior mesenteric artery (SMA, n = 3), proper hepatic artery (PHA, n = 1), right hepatic artery (RHA, n = 2), left hepatic artery (LHA, n = 2) and intrahepatic vessels (n = 4). Six of the cases were related to surgical procedures, 5 of these (38%) were unintended arterial injuries after biliary surgery. Ten patients (77%) had risk factors contributing to the development of liver necrosis: septicemia (n = 4), jaundice and septicemia (n = 2), shock and hypoxia (n = 3) and alcoholic cirrhosis (n = 1). Five patients (38%) needed resection of the liver necrosis due to infected necrosis. Three patients (23%) died; two of these had celiac/SMA occlusion. One died due to complete gastrointestinal ischemia and severe lactacidosis, two died of multiorgan failure after bile leakage and septicemia. CONCLUSION: Ischemic liver necrosis is mainly caused by arterial occlusion due to arteriosclerosis, arterial transection during biliary surgery or blunt liver trauma, and seldom occurs without additional risk factors. 50% of the patients develop infected necrosis and need liver resection. Patients with sterile necrosis may recover without surgical procedures of the liver. The mortality in patients with central (celiac/SMA) and peripheral (CHA, PHA, RHA, LHA, intrahepatic branches) occlusions was 67% (2/3) and 11% (1/9), respectively.

Effect of cimetidine on development of gastric cancer in rats after gastrojejunostomy.

OBJECTIVE: To find out if cimetidine has an immunomodulating effect on gastric carcinogenesis in rats. DESIGN: Experimental prospective study. SETTING: Teaching hospital, Norway. ANIMALS: 132 male PGV/Mol rats given gastrojejunostomies. INTERVENTION: Half the rats were given cimetidine in their drinking water postoperatively for a minimum of 38 weeks. They were killed after 52 weeks observation and the stomach was investigated macroscopically and microscopically. MAIN OUTCOME MEASURE: In the cimetidine fed group 19/48 animals developed cancer (49%), versus 12/43 (28%) in the control group (p = 0.24). CONCLUSION: Cimetidine had no immunomodulatory effect on the development of gastric cancer in rats.

[Abdominal metastases from signet cell carcinoma of the appendix vermiformis]. / Metastaser i bukhulen fra signetcellekarsinom i appendix vermiformis.

Signet cell carcinomas are often aggressive tumours. A patient with this tumour, originally located in the appendix, was diagnosed with peritoneal metastases. When she later got abdominal symptoms, computer axial tomography indicated large infiltrating tumour masses in the pelvis. However, when a laparotomy was performed, the only macroscopic tumour masses was localised to the ovaries (Krukenberg tumour). The surgical intervention gave the patient an improved quality of life, and most likely prolonged survival. We stress the importance of thinking of this possibility.

Endotoxin and cytokine release in strangulation obstruction and in partial occlusion of the mesenteric artery in pigs.

BACKGROUND: The study was performed to determine if endotoxin or the cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor (TNF) are liberated from strangulated or partially ischemic small bowel. METHODS: Strangulation obstruction was induced by elevating pressure in a gasket placed around a loop of ileum until venous pressure reached 50 mm Hg. Low arterial flow in a loop of ileum was produced by arterial clamping reducing blood flow by 70%. A proximal bowel loop was used for control. Arterial blood flow was measured by transit time flowmetry. Blood samples were collected before and after 30, 90 and 180 min of strangulation or clamping. Plasma levels of endotoxin and cytokines (TNF, IL-1 and IL-6) were measured by limulus amebocyte lysate test and bioassays, respectively. RESULTS: Strangulation obstruction caused more extensive mucosal damage than arterial clamping. Strangulation was followed by markedly increased venous concentration and release of IL-6 in the strangulated loop. Partial arterial occlusion did not cause increased release of IL-6. Strangulation or partial clamping did not influence the concentration of endotoxin, IL-1 or TNF in intestinal venous blood. CONCLUSIONS: Strangulation obstruction causes increased release of IL-6 to intestinal venous blood. IL-6 levels did not increase after 70% reduction of arterial blood flow. The early IL-6 increase was not detected in systemic blood. Strangulation did not cause early changes in plasma levels of endotoxin, TNF or IL-1.

Single-session alcohol sclerotherapy in benign symptomatic hepatic cysts.

PURPOSE: To evaluate the results of single-session alcohol sclerotherapy in benign symptomatic liver cysts. MATERIAL AND METHODS: Ten cysts (volume 200-4,800 ml) in 10 patients were treated by percutaneous catheterization and injection of 96% ethanol at a dose of 10% of the cyst volume but never more than 100 ml. The treatment was applied for a maximum of 20 min, after which the alcohol and catheter were removed. RESULTS: A satisfactory reduction in cyst volume was achieved in all patients. In 8 patients there was a re-accumulation of fluid during the first period after therapy, followed by a significant reduction in volume on later follow-up examinations. Except for pain, there were no complications. CONCLUSION: Sclerotherapy as a single-session procedure resulted in a significant reduction in cyst volume in all 10 patients. The postprocedural re-accumulation of fluid seen in 8 patients proved to be temporary. It was not necessary to repeat the sclerotherapy procedure in any patient.

Successful management of eleven splanchnic artery aneurysms.

OBJECTIVE: To describe our experience with the management of aneurysms of the splanchnic arteries. DESIGN: Retrospective study. SETTING: Teaching hospital, Norway. SUBJECTS: Eleven consecutive patients with aneurysms of the splanchnic arteries treated between 1986 and 1996, six of them between 1994 and 1996. Four aneurysms were hepatic (37%), two splenic (18%), one coeliac (9%), one gastroepiploic (9%), one pancreaticoduodenal (9%), one superior mesenteric (9%), and one jejunal (9%). Five were pseudoaneurysms (46%). INTERVENTIONS: Six patients (55%) were treated by operation, four (36%) by embolisation and one (9%) expectantly. RESULTS: The pathogenesis was inflammatory (acute pancreatitis, anastomotic leak) in four patients (36%), athero-sclerotic in three (27%), arterial infusion of cytotoxic drugs in one (9%), and unknown in four (36%). Seven patients (64%) presented with rupture, two (18%) with other symptoms, and two patients (18%) were diagnosed incidentally. There was no mortality. CONCLUSION: There may be an increased incidence in splanchnic artery aneurysms, particularly those created by inflammatory lesions. The diagnosis should be suspected if acute bleeding occurs during the course of severe intra-abdominal inflammation. Arteriography should be used to diagnose an aneurysm in haemodynamically stable patients. Control of bleeding is obtained either by transarterial catheter embolisation or by operation.

Release of cytokines associated with gastric mucosal injury.

This study was performed to examine if the cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) or tumor necrosis factor (TNF) are released from the gastric mucosa during acute mucosal damage, and if the generation of these cytokines is affected by indomethacin. Cat stomachs were exposed to 2 M NaCl for 10 min followed by luminal perfusion at pH 1. Gastric mucosal blood flow was determined by radioactive microspheres, portal vein blood flow by transit-time flowmetry, and H+ back diffusion/secretion by pH-stat titration. Concentrations of active cytokines and of histamine in aortic and portal vein blood were measured by bioassay and RIA, respectively. Active IL-6, but not IL-1 and TNF, is released from the gastric mucosa during acute mucosal damage by 2 M NaCl and acid back diffusion. Indomethacin increased mucosal injury and enhanced the TNF generation but reduced the release of IL-6 from the gastric mucosa. We conclude that IL-1 and TNF probably do not play an important modulating role during acute gastric mucosal damage. The generation of IL-6 may, however, contribute to mucosal protection.

[Hepatic artery aneurysm. Diagnosis and treatment]. / Aneurisme i arteria hepatica. Diagnose og behandling.

From 1990 until 1995, four patients were successfully treated for symptomatic aneurysm of the hepatic artery, with rupture in three of them. In two of the patients, the aneurysm was located in the common hepatic artery. In one patient it ruptured. Both aneurysms were resected. One patient also underwent vascular reconstruction. The other two aneurysms ruptured in the left and right hepatic artery respectively. The aneurysm in the right hepatic artery was treated by selective embolization. The aneurysm in the left hepatic artery was ligated, and the patient was subsequently reoperated on for septic necrosis of the left lobe of the liver.

[Determination of the activated proto-oncogene (Ki-ras) in feces. A new laboratory analysis for early diagnosis of colorectal cancer]. / Påvisning av aktivert protoonkogen (Ki-ras) i avføringsprøver. Ny laboratorieanalyse for tidlig diagnostikk av kolorektal cancer.

Colorectal cancer is one of the most common malignancies in Norway. Many cases of the disease are detected at a stage where surgery is unlikely to result in cure. Currently used screening tests based on faecal occult blood and other tumour markers are poor indicators of colorectal neoplasia. Multiple gene alterations are associated with colorectal carcinogenesis. Mutations in the Ki-ras oncogene occur in 50% of colorectal carcinomas and also in 50% of the precursor lesions, the adenomas. These mutations have proved to be detectable in the faeces of patients with colorectal tumours, but the techniques used so far have been impractical for screening purposes. We have developed a rapid and simple laboratory technique, based on the polymerase chain reaction, for detecting mutated Ki-ras in the faeces. In eight of 12 patients with mutated Ki-ras in adenomas or carcinomas we found the corresponding mutations in stool samples. Our results represent a significant progression towards a simple and effective DNA-based screening strategy for early detection of curable colorectal cancer.

High levels of interleukin 10 in serum are associated with fatality in meningococcal disease.

Interleukin 10 (IL-10) suppresses the production of proinflammatory cytokines in vitro and in murine models of endotoxemia and has been suggested as a candidate for treatment of bacterial septicemia. To investigate the role of IL-10 in meningococcal disease, a sandwich IL-10 enzyme-amplified sensitivity immunoassay was used to quantitate IL-10 in serum and cerebrospinal fluid samples from 41 patients with meningococcal bacteremia or meningitis with or without septic shock. High levels of IL-10 were demonstrated in sera from patients with meningococcal septic shock (mean, 21,221 pg/ml; range, 25 to 64,500 pg/ml). All cases involving fatalities had IL-10 levels in serum of > or = 1,000 pg/ml (mean, 23,058 pg/ml; range, 1,000 to 64,500 pg/ml). Patients with meningococcal meningitis without septic shock had comparably low concentrations of IL-10 in serum (mean, 119 pg/ml; range, 0 to 1,050 pg/ml) but exhibited compartmentalized release of IL-10 in cerebrospinal fluid. Concentrations of IL-10 in serum were positively correlated with the previously reported concentrations of tumor necrosis factor alpha, IL-6, and IL-8 in serum in the same patients. We conclude that IL-10 is extensively activated along with the proinflammatory cytokines during the initial phase of meningococcal septic shock and that IL-10 is associated with fatality in meningococcal disease.

[Acute abdomen among children and adolescents. A retrospective study of 470 children and adolescents with acute abdominal pain]. / Akutt abdomen blant barn og unge. En retrospektiv undersøkelse av 470 barn og unge med akutte abdominalsmerter.

The causes of acute abdominal pain among children admitted to a surgical department were few and the fraction that needed surgical treatment was low (37%). The surgical intervention rate was age-dependent, rising from 11.4% (zero to three years of age) to 48.9% (12-15 years of age). The increase in surgical intervention rate was due to increasing incidence of acute appendicitis while the incidence of intestinal obstruction was unchanged during childhood. No child below the age of four had appendicitis, and the rate of perforated appendix among children seven years and younger (41.7%) was significantly higher than among children eight years and older (20.4%). For acute appendicitis, the surgeons' diagnostic accuracy was 77.9% and there was no significant difference between complications after appendectomy for appendicitis and complications after negative laparotomy. The diagnostic value of biochemical measurements was limited. However, the combined evaluation of C-reactive protein measurements and leucocyte counts possibly supports further observation rather than immediate operation.

The synergistic effect of trauma and infection on interleukin-1 but not tumor necrosis factor liberation during posttraumatic gram-negative septicemia.

The release profiles of interleukin 1 (Il-1) and tumor necrosis factor (TNF) were studied during experimental Escherichia coli septicemia and peritonitis with and without a preceding (-48 h) moderate trauma (femur marrow nailing). The trauma alone did not induce significant Il-1 or TNF liberation to plasma. During septicemia, a rapid IL-1-rise (+30 min) and subsequent normalization (+120 min) was seen. A previous trauma delayed (30 min), but accentuated (2x) and prolonged (> 4 h) the Il-1 response. During peritonitis, a delayed (30 min) but otherwise similar Il-1-response was observed. TNF levels rose rapidly (+30 min) in all animals, and remained high throughout the experimental period (6 h). The trauma did not influence the TNF response. We conclude that a synergism exists between trauma and infection with regard to the magnitude of the Il-1 response.