[Performing major upper abdominal operations in a low-volume hospital: is it possible?]. / Større kirurgiske indgreb i øvre abdomen ved et mellemstort sygehus. Går det an?

INTRODUCTION: The outcomes of cardio-oesophageal resection, gastric resection, total gastrectomy and Whipple's operation in a low-volume hospital over a decade are presented. MATERIALS AND METHODS: Thirty-seven patients were followed for five years after a cardio-oesophageal resection, 21 after a Billroth II resection, 15 after total gastrectomy and 28 after a Whipple's operation. Mortality and morbidity rates, post-operative in-hospital period and long-term survival were measured. RESULTS: Cardio-oesophageal resection: The morbidity rate was 19%, the mortality rate was 11%, and the median post-operative stay in hospital was 11 days. The five-year survival rate based on death from cancer was 37% and from all causes 32%. Gastric resection and gastrectomy: The morbidity rate was 14%, the mortality rate was 3%, and the median post-operative period in hospital was 9 days after gastric resection and 11 days after gastrectomy. The five-year survival rate based on death from was cancer 55% and from all causes 37%. Whipple's procedure: The morbidity rate was 17%, the mortality rate was 4% and the median post-operative stay in hospital was 10 days. The survival rate based on death from cancer was 77% and from all causes was 54% after five years for cancer of the ampulla of Vater, and 27% and 31% after three years for pancreatic head carcinoma. CONCLUSION: Major gastric and pancreatic operations can be performed in a low-volume hospital with satisfactory results.

[Self-expanding metal stents as palliative treatment of a malign obstruction in the distal part of the ventricle or duodenum]. / Selvekspanderende metalstents ved palliativ behandling af malign obstruktion i distale del af ventriklen eller duodenum.

INTRODUCTION: Self-expanding metal stents (SEMS) have emerged as a simple therapeutic option for the palliation of patients with non-resectable malignant gastric outlet obstruction. We present our results from a three-year period. MATERIALS AND METHODS: Twenty-nine patients with obstruction from tumors in the pancreas (15), bile ducts (3), stomach (9) or transverse colon (2) underwent palliative stenting with a 9-cm-long, 22 mm Wallstent under general anaesthesia. Insertion of the SEMS was done under endoscopic and fluoroscopic control. Biliary stents were implanted prior to or simultaneously with the duodenal stent in eight patients. Seven were covered 6-cm-long, 10 mm Wallstents. Two patients had biliary stents implanted 12 and 262 days, respectively, after the duodenal stent by "rendezvous" technique. RESULTS: The stent deployment was successful in all patients. There were no procedure-related complications, but one patient died of cardiac arrest 12 hours after the operation. Obstruction was relieved in all patients, and an exclusively oral diet was possible for 23 of them. Seven patients with rapid progression of the disease stayed in hospital and died 0-16 days after the procedure. The median length of stay in hospital after the procedure was 2 days (1-32 days), after which the patients stayed at home for 40 days (2-270 days). The overall median survival time was 47 days (median, 0-274 days). There were no late complications (stent migration or perforation), but two patients needed an overlapping stent due to tumor overgrowth. DISCUSSION: Duodenal stents effectively resolve the obstructive symptoms of gastric outlet obstruction. There are few procedure-related complications, and the vast majority of patients can leave hospital and spend the short time left to them at home.

[Endoclip on the cystic duct after laparoscopic cholecystectomy]. / Klips i de dybe galdeveje efter laparoskopisk kolecystektomi.

We report on a case that occurred after laparoscopic cholecystectomy in a 70-year-old man, where a polymer endoclip placed on the cystic duct migrated into the common bile duct. The clip migration was detected two months after surgery during endoscopic retrograde cholangiography, when a stone and the clip were removed. Based on this and other similar cases, we suggest the use of absorbable clips in laparascopic cholecystectomy.

[Rectal cancer treated at a county hospital. A prospective study of an 11-year period]. / Cancer recti-behandling ved et provinssygehus. En prospektiv undersøgelse gennem 11 år.

INTRODUCTION: The results of rectal cancer surgery in a county hospital during an 11-year period from 1991 to 2002 are presented. Complications, local recurrence rate and survival were registered. MATERIAL AND METHODS: One hundred patients operated by one surgeon were included in the study. Twelve were Dukes' type A, 36 B, 48 C, and four were D. Low anterior resection was performed in 68 patients (six with J-pouch), abdominoperineal resection in 29 and a Hartmann's procedure in three patients. The operation was radical in 80 patients. Until December 31, 1994 a conventional operation was performed in 34 patients. Thereafter total mesorectal excision was introduced with excision of the mesorectum for tumours below 10 cm from the anal verge and resection of the mesorectum 5 cm below tumour for higher tumours (46 patients). RESULTS: Thirty days mortality was 4%. The clinical leakage rate after resection was 10% and 6% ended up with a permanent stoma. There were no deaths among patients with leakage. As a consequence of the change in surgical technique from January 1, 1995 the 5-year local recurrence rate declined from 0.32 to 0.11 (p = 0.13) and the overall survival rate exhibited a slightly rising tendency from 0.62 to 0.70 (p = 0.47). DISCUSSION: Operations for rectal cancer can be performed in a county hospital with a satisfactory outcome as to complication rates and operative mortality provided the operations are concentrated on few hands. The local recurrence rate and the overall survival showed non-significant tendencies to improvement with the introduction of a more radical operation which is in accordance with results from international trials.

[Thyroidectomy. A prospective assessment of hemithyroidectomy]. / Thyroideakirurgi. En prospektiv vurdering af hemityroidektomi og total tyroidektomi.

AIM: The results of hemithyroidectomy and total thyroidectomy were assessed in a prospective study. Total thyroidectomy was compared to hemithyroidectomy and contralateral resection. The rate of vocal cord palsy, hypocalcaemia, changes in PTH, and the frequency of sequelae were used to monitor the results. MATERIAL AND METHODS: One hundred and twenty patients underwent hemithyroidectomy for unilateral thyroid lesions and 80 hemithyroidectomy contralateral resection (35 patients) or total thyroidectomy (45 patients) for bilateral disease. Plasma calcium and PTH were measured pre- and post-operatively, and the need for calcium and vitamin D supplementation was registered. RESULTS: No permanent vocal cord palsy was encountered. Calcium substitution was not needed after hemithyroidectomy but for more than one year in 9% after hemithyroidectomy and contralateral resection, and in 7% after total thyroidectomy (NS). One needed substitution 2 years after total thyroidectomy. Pre- and postoperative plasma-PTH was found unchanged after hemithyroidectomy and after total thyroidectomy. DISCUSSION: Hemithyroidectomy and total thyroidectomy are safe procedures with few side effects, if a meticulous dissection is performed. Hypocalcaemia following bilateral operations is usually transient and the need for calcium and vitamin D supplementation is low and usually related to the underlying disease rather than to the operation. Total thyroidectomy will remove the target organ for the immune response in patients with hyperthyroidism and the risk of toxic ophthalmopathy is minimised. Lastly, the risk of recurrent disease is eliminated. Six per cent had minor and probably transient local complaints at control three months after the operation.

[Cystic parathyroid adenoma. A rare cause of primary hyperparathyroidism]. / Cystisk parathyroideaadenom. En sjaeldnere årsag til primaer hyperparatyroidisme.

Two cases of primary hyperparathyroidism associated with parathyroid cysts were identified by an elevated plasma Ca++ level. The diagnosis was established preoperatively by the presence of high quantities of PTH in the cyst fluid in one of the patients. Cysts in the neck or superior mediastinum should raise suspicion of primary hyperparathyroidism.