Aetiology, treatment and mortality after oesophageal perforation in Denmark.

INTRODUCTION: Perforation of the oesophagus into the thoracic cavity is a potentially life-threatening condition. The causes are numerous. Treatment for oesophageal perforation targets mediastinal and pleural contamination. Present knowledge about the causes of perforation and the types of treatment is poor. MATERIAL AND METHODS: A retrospective review was made between 1997 and 2005 based on extracts from the National Patient Registry. RESULTS: A total of 286 patients were diagnosed with perforation of the oesophagus (131 women and 155 men). Their average age was 60 years. A wide spectrum of causes was reported, e.g. instrumentation of the oesophagus 136 (47.6%), spontaneous rupture 89 (31.1%) or procedures otherwise related to surgical intervention 9 (3.1%). One third of the patients started conservative treatment 91 (31.9%). The majority of the patients were transferred to a thoracic surgery department for further treatment: about 25% of patients underwent surgery. The average hospitalization time was 18 days. The mortality rate was 21%. CONCLUSION: Oesophageal perforation remains a diagnostic and therapeutic challenge and the condition requires aggressive treatment. Recent consensus in early treatment with thoracotomy, debridement, irrigation and subsequent parenteral nutrition has improved survival. In this material, most perforations were iatrogenic in nature. In the 2002-2005 period, the study showed that 29% of the iatrogenic perforations were caused by the use of a rigid endoscope which is risky and whose use should therefore be restricted. It is advisable to set up national guidelines for treatment of oesophageal perforation and to centralise treatment.

[Need for a national database on lumbar fusion surgery]. / Behov for national database ved operation for lumbal spondylodese.

INTRODUCTION: The indication for surgical technique in lumbar fusion is debated. The objective of this study was to analyse the indication and operative technique in lumbar surgery clinics in Denmark. MATERIAL AND METHODS: A cohort study based on a sample from four public and four private clinics in 2006 was used. RESULTS: There was no difference in patient demographics and diagnosis between public and private clinics. In 62% of the patient files, information was lacking. Considerations on indication and surgery did not differ from public to private clinics. A standard preoperative rehabilitation program was performed in 59% of the cases. Combined anterior and posterior fusion was performed in 37 cases, posterior instrumented fusion in 77 cases and posterior uninstrumented fusion in 105 cases, interspinous spacer was used in six cases and disc arthroplasty in 13 cases. CONCLUSION: Adequate evaluation of indication and choice of surgical technique in lumbar fusion based on patient files was not possible. We found no qualitative differences between public and private clinics. A national database is needed to monitor indication and choice of operative procedure.

[Pancreaticoduodenectomy in Denmark 2005-2008]. / Pankreatikoduodenektomi i Danmark 2005-2008.

INTRODUCTION: Pancreaticoduodenectomy (PD) is associated with high mortality and morbidity. Results can be optimised through centralisation and adjustment of perioperative care. The aim of this study was to describe organisation, postoperative stay, readmission and hospital mortality in the period 2005-2008 and to evaluate postoperative care and treatment after PD in 2007-2008. MATERIAL AND METHODS: The study is based on data from the National Patient Registry for the period 2005-2008 and medical records for 2007-2008 from PD patients. RESULTS: The median duration of postoperative stay in hospital 2005-2008 was 17 days (range 2-649). The readmission rate was 11%, and hospital mortality was 6%. In 2007-2008, both wound infections and intraabdominal abscesses were seen in 12% of cases, and anastomotic leakage of the hepaticojejunostomy and pancreaticojejunostomy occurred in 9% and 12% of cases, respectively. Four percent had no wound-related complications. Nasogastric and nasojejunal tubes were removed postoperatively on median day five and day six, respectively. Clear fluid intake began from median day five and solid food from day seven. The epidural catheter was removed on median day five and abdominal drains on day seven. CONCLUSION: Mortality and postoperative hospital stay after PD were reduced in Denmark from the period 1996-2004 to 2005-2008, but the morbidity remains high. The results suggest a need for adjustment of perioperative care to current evidence-based care standards.

[Lumbar fusion surgery for degenerative conditions in Denmark 2005-2006]. / Lumbal spondylodese for degenerativ ryglidelse i Danmark i 2005-2006.

INTRODUCTION: The indication and use of lumbar spinal fusion surgery for degenerative conditions is being debated. PURPOSE: The objective of this study was to describe recent trends in lumbar fusion surgery for degenerative conditions in Denmark. MATERIAL AND METHODS: A cohort study using a sample from the Danish National Patient Registry was used. RESULTS: In 2005 and 2006, 2,064 and 891 lumbar fusions were performed in 14 public and 6 private hospitals. The annual activity increased from 993 to 1,118 procedures at public hospitals and from 393 to 510 procedures at private hospitals. Lumbar disc arthroplasty was performed in 196 cases, anterior fusion in 162 case, posterior fusion in 2,309 cases, while combined anterior and posterior fusion were performed in 347 cases. The indications for surgery were based on the diagnosis spondylosis in 245 cases, spinal stenosis in 1,174 cases, discuss degeneration in 947 cases, degenerative spondylolisthesis in 600 cases and non-specific lumbar pain in 45 cases. Posterior fusion was performed in 74.3% and 81.9% in public and private hospitals, respectively. Combined anterior and posterior fusion was performed in 12.1% and 10.1% in public and private hospitals, respectively. CONCLUSION: Lumbar fusion rates for degenerative conditions increased from 2005 to 2006 with variation in operative procedures in relation to diagnoses. We propose to monitor data in a database to improve registration of various fusion techniques for various indications and to support further research.

[Organisation and reimbursement of surgical practice in Denmark 2004-2008]. / Udvikling og afregningsmønster for kirurgi i privat og offentligt sygehusregi i Danmark 2004-2008.

INTRODUCTION: The organisation and the reimbursement pattern for surgery in Denmark are relatively unknown. MATERIAL AND METHODS: The organisation and activity of hip and knee replacement, laparoscopic cholecystectomy and inguinal herniotomy, low-back surgery and obesity surgery were analysed together with the surgery reimbursement pattern in Denmark in the 5-year period 2004-2008 based on national register data. RESULTS: During the 4-year period 2004-2007 activity rose for all types of surgery, except laparoscopic cholecystectomy. A predominant part of the increased activity was seen within the private sector, especially in obesity and low-back surgery. A predominant part of the activity in the private sector was financed via public sector funding. CONCLUSION: The results show increased surgical activity in five common operations and call for intensified monitoring of activity and quality to secure research and further development on a nationwide basis.

[Liver surgery in Denmark 2002-2007]. / Leverresektioner i Danmark 2002-2007.

INTRODUCTION: We evaluated the organisation, management and outcome for patients undergoing elective liver resection in Denmark in the period 2002-2007. MATERIAL AND METHODS: Nationwide data based on the National Patient Registry and discharge information from hospital departments in the period 1 January 2002 to 31 December 2007 were analysed. RESULTS: Twenty-three departments performed 818 resections with five departments performing 96% and 18 departments performing 4% of the operations. The amount of non-anatomical resections constituted 30% (248 of 818) of the resections. The median postoperative stay was nine days, and the hospital mortality rate was 3.9%, distributed between 2.4% for non-anatomical resections, 2.9% for segmental resections and 5.2% for right-sided hepatectomy. CONCLUSION: The number of treated patients was too small as was the number referred to highly specialised liver surgery units. Moreover, the amount of non-anatomical resections was too high as was the average postoperative stay and the hospital mortality rate. In future, we propose that liver resections be centralised in 2-3 hospitals each capable of providing all the following services: surgery, hepatology, oncology and interventional radiology.

[Surgical treatment for ovarian cancer in Denmark 2004-2007]. / Operation for ovariecancer i Danmark 2004-2007.

INTRODUCTION: Previous national surveys have demonstrated that surgical treatment for ovarian cancer in Denmark is performed in too many low-volume departments. MATERIAL AND METHODS: Nationwide data from the National Patient Registry from January 1 December 2004-31 December 2007 including all primary operations for ovarian cancer and recording the number of departments, length of hospital stay and mortality. RESULTS: A total of 1,908 women were operated, initially at 47 departments (stage III-IV 31 departments), a number which was reduced to eight departments by 2007 and further reduction to a total of six departments is planned in 2008. The 30-day mortality was constant (about 3.9%) over the 4-year period. CONCLUSION: The organisation of surgical treatment for ovarian cancer has improved since the Danish Health Board in 2001 recommended that operations be performed at five high-volume departments.

[Bariatric surgery in Denmark--are we on the right way?]. / Fedmekirurgi i Danmark--er vi på rette vej?

INTRODUCTION: In 2005 the National Board of Health (NBH) published guidelines on bariatric surgery in Denmark. The aim of the present study was to shed light on the national bariatric effort in relation to these guidelines. MATERIAL AND METHODS: The analysis is based on extraction of the following data from the National Patient Registry in the period from 2005 through 2007: annual number of operations, type of operation, laparoscopic versus open procedure. Furthermore, the centres were compared. RESULTS: A total of 2,098 bariatric procedures were performed in the years 2005 to 2007. Apart from a single operation, all operations were performed at departments selected by the NBH. During the period an increase of approximately 400% in the number of operations was observed, and the rise was largest at the private clinics, which performed approx. 60% of the operations in 2007. Not all public departments fulfilled the recommendation from the NBH of a minimum of 100 annual operations. The proportion of banding procedures performed at private clinics was significantly lower than the proportion performed at public hospitals. Significantly more open operations were performed at private clinics, a tendency which was attributable to the activities of one of the private clinics. CONCLUSION: The frequency with which bariatric surgery is performed follows a strongly increasing trend and the procedures are only performed at the public departments selected by the National Board of Health and at the private centres that have entered into an agreement with Danish Regions. Since the operative access and selection of procedures varies between departments we conclude that research should be a firm requirement for all centres, and that research efforts should comprise cooperation concerning the database recommended by the NBH.

[Organisation and early outcome after radical prostatectomy in Denmark 2004-2007]. / Organisation og tidlige operationsresultater efter radikal prostatektomi i Danmark 2004-2007.

BACKGROUND: The organisation, volume and early morbidity after radical prostatectomy has not been researched in Denmark. MATERIALS AND METHODS: The National Hospital Register was searched for all radical prostatectomies in Denmark from 2004-2007, including mortality and readmissions. RESULTS: In total, 1469 radical prostatectomies were performed, initially in 9 departments, decreasing to 6 departments in 2007. From 2004 to 2007 the number of operations increased by approximately 60%. Median hospital stay was 4 days (mean 5.1 days) without any differences between departments. Mortality was 0.2%. CONCLUSION: There is an increasing rate of radical prostatectomies in Denmark. It is proposed that a national database be established to monitor early and long-term outcomes, including the role of surgical technique (nerve sparing, laparoscopic/robotic surgery, etc.) in order to ensure optimal organisation.

Complications and frequency of redo antireflux surgery in Denmark: a nationwide study, 1997-2005.

BACKGROUND: Outcomes after redo fundoplication (RF) in recurrent gastroesophageal reflux disease (GERD) are debatable, and they may include lower success rates with higher postoperative morbidity and mortality than outcomes after primary fundoplication (PF). However, data from large, nationwide studies are not available. Accordingly, the aim of the present study was to evaluate nationwide Danish data on RF in a nine-year period. METHOD: Data in the period from 1997 through 2005 were extracted from the National Patient Register. The following information was procured: frequency of RF, rate of conversion to open surgery, rate of complications requiring reoperation, and 30-day mortality. Data for RF were compared to PF. RESULTS: A total of 2589 fundoplications were performed in 2465 patients. Thus, 113 patients underwent a total of 124 RF (RF rate = 5.0%). Most RF (84.7%) were performed at high-volume departments. Patients who underwent RF were converted to open surgery more often (16.1% vs. 6.1% in PF) (P < 0.0001). The median postoperative hospital stay was 3 days after RF and 2 days after PF (P = 0.96). Following RF 1.6% of the patients had complications requiring surgery compared with 1.3% after PF (P = 0.79), and 30-day mortality was 0.81% after RF compared with 0.45% after PF (P = 0.57). CONCLUSION: This nationwide Danish study showed a low rate of redo fundoplication and a similar morbidity and mortality rate after redo surgery compared with that of primary surgery.