Expression of cyclin D1a and D1b as predictive factors for treatment response in colorectal cancer.

BACKGROUND: The aim of this study was to investigate the value of the cyclin D1 isoforms D1a and D1b as prognostic factors and their relevance as predictors of response to adjuvant chemotherapy with 5-fluorouracil and levamisole (5-FU/LEV) in colorectal cancer (CRC). METHODS: Protein expression of nuclear cyclin D1a and D1b was assessed by immunohistochemistry in 335 CRC patients treated with surgery alone or with adjuvant therapy using 5-FU/LEV. The prognostic and predictive value of these two molecular markers and clinicopathological factors were evaluated statistically in univariate and multivariate survival analyses. RESULTS: Neither cyclin D1a nor D1b showed any prognostic value in CRC or colon cancer patients. However, high cyclin D1a predicted benefit from adjuvant therapy measured in 5-year relapse-free survival (RFS) and CRC-specific survival (CSS) compared to surgery alone in colon cancer (P=0.012 and P=0.038, respectively) and especially in colon cancer stage III patients (P=0.005 and P=0.019, respectively) in univariate analyses. An interaction between treatment group and cyclin D1a could be shown for RFS (P=0.004) and CSS (P=0.025) in multivariate analysis. CONCLUSION: Our study identifies high cyclin D1a protein expression as a positive predictive factor for the benefit of adjuvant 5-FU/LEV treatment in colon cancer, particularly in stage III colon cancer.

Long-term function after ileal pouch-anal anastomosis - function does not deteriorate with time.

AIM: There are conflicting reports regarding long term function after ileal pouch-anal anastomosis (IPAA). The aim of the present prospective study was to investigate the influence of duration as an independent factor on long-term function results. METHOD: Between 1984 and 2007, 315 patients underwent IPAA and were followed by a standardised interview and endoscopy protocol. There were 1802 interviews. Two hundred and thirty-five patients had three or more visits and these data were analysed by Time-Series-Cross-Section multivariate regression analysis. The mean time follow up was 12 years and the mean interval between visits was 34.5 months. RESULTS: Mean frequency of defecation was 5.2 in the day and 0.55 at night. This did not change with time. Daytime and night incontinence occurred in 13% and 21%. There was no change in incontinence, urgency, soiling or perineal excoriation with time. After 24 years the cumulative incidence of pouchitis was 43.5%. Twenty patients had chronic pouchitis (6.3%). CONCLUSION: The interval from IPAA did not influence the long-term functional outcome.

Failed pelvic pouch substituted by continent ileostomy.

OBJECTIVE: The long-term failure rate of ileal pouch-anal anastomosis (IPAA) is 10-15%. When salvage surgery is unsuccessful, most surgeons prefer pouch excision with conventional ileostomy, thus sacrificing 40-50 cm of ileum. Conversion of a pelvic pouch to a continent ileostomy (CI, Kock pouch) is an alternative that preserves both the ileal surface and pouch properties. The aim of the study was to evaluate clinical outcome after the construction of a CI following a failed IPAA. METHOD: During 1984-2007, 317 patients were operated with IPAA at St Olavs Hospital and evaluated for failure, treatment and outcome. Seven patients with IPAA failure had CI. Four patients with IPAA failure referred from other hospitals underwent conversion to CI and are included in the final analysis. RESULTS: Seven patients had a CI constructed from the transposing pelvic pouch and four had the pelvic pouch removed and a new continent pouch constructed from the distal ileum. Median follow up after conversion to CI was 7 years (0-17 years). Two CI had to be removed due to fistulae. One patient needed a revision of the nipple valve due to pouch loosening. At the end of follow-up, 8 of the 11 patients were fully continent. One patient with Crohn's disease had minor leakage. CONCLUSION: In patients with pelvic pouch failure, the possibility of conversion to CI should be presented to the patient as an alternative to pouch excision and permanent ileostomy. The advantage is the continence and possibly a better body image. Construction of a CI on a new ileal segment may be considered, but the consequences of additional small bowel loss and risk of malnutrition if the Kock pouch fails should be appraised.

Long-term surgical load in patients with ileal pouch-anal anastomosis.

AIM: To evaluate surgical workload and complications in patients who had undergone restorative proctocolectomy, through long-term follow-up in one single institution. METHOD: From 1984 to 2006, 304 consecutive patients underwent Ileal Pouch-Anal Anastomosis (IPAA). There were 182 stapled and 122 hand-sewn anastomoses. A protective loop ileostomy was established in 256 patients (84%), whereas 48 patients (16%) were without a covering stoma. RESULTS: Twenty-nine patients (10%) suffered from early anastomotic leakage. A protective stoma did not prevent early anastomotic dehiscence (P = 0.11) or the number of pelvic abscesses (P = 0.09). Early complications required 20 laparotomies with creation of a diverting stoma in nine patients. There were 16 (6%) complications related to closure of the loop ileostomy. Sixty-six patients needed an additional re-operation related to the IPAA procedure. There were 20 removals of pouches and three permanent diverting stomas. The estimated removal rate at 20 years of a functioning pouch was 11% (CI +/- 6). Altogether 100 (33%) patients had one or more surgical procedures, excluding dilations of anastomotic strictures and closing of a loop ileostomy. These 100 patients underwent 187 surgical procedures. The estimated rate of a first re-operation due to complications was 52% (CI +/- 16) in 20 years. Hand-sewn anastomoses had similar complications and failure rates as stapled anastomoses. CONCLUSIONS: More than half of patients operated with restorative proctocolectomy will need surgical intervention within 20 years and the failure rate is more than 10%. The high risk of complications and failure inherent in the procedure should not be ignored.

Surgical load and long-term outcome for patients with Kock continent ileostomy.

OBJECTIVE: The aim of the study was to evaluate the results of Kock continent ileostomy (CI) during the same period when ileal pouch-anal anastomosis was the preferred operation for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). METHOD: During the period 1983-2002, 50 patients underwent CI. The surgical technique was unchanged during the period. Follow-up included all patients. Forty-eight patients had UC, two of these had the diagnosis later changed to Crohn's disease and two had FAP. RESULTS: Twenty-two patients had 38 reoperations, four (8%) of whom had the pouch removed. The main causes for reoperation included leakage and difficulty in intubation due to sliding of the nipple valve (42%), fistula formation (29%) and stenosis (21%). Seventeen (45%) underwent a revision of the nipple valve and the pouch and nine (24%) a local procedure. The reoperation rate was higher among patients having a conventional ileostomy converted to CI than among those having CI. As a primary procedure (P = 0.016). The risk of a second reoperation was higher for those reoperated within the first year after having a CI, than for those reoperated later (P = 0.007). CONCLUSIONS: The reoperation rate of patients with CI is high but the removal rate of the pouch is low and is not associated with a high rate of revision. CI is a good alternative to conventional ileostomy in patients not suitable for restorative proctocolectomy or where this procedure has failed.

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis.

BACKGROUND: This randomized clinical trial compared long-term outcome after antireflux surgery with acid inhibition therapy in the treatment of chronic gastro-oesophageal reflux disease (GORD). METHODS: Patients with chronic GORD and oesophagitis verified at endoscopy were allocated to treatment with omeprazole (154 patients) or antireflux surgery (144). After 7 years of follow-up, 119 patients in the omeprazole arm and 99 who had antireflux surgery were available for evaluation. The primary outcome variable was the cumulative proportion of patients in whom treatment failed. Secondary objectives were evaluation of the treatment failure rate after dose adjustment of omeprazole, safety, and the frequency and severity of post-fundoplication complaints. RESULTS: The proportion of patients in whom treatment did not fail during the 7 years was significantly higher in the surgical than in the medical group (66.7 versus 46.7 per cent respectively; P=0.002). A smaller difference remained after dose adjustment in the omeprazole group (P=0.045). More patients in the surgical group complained of symptoms such as dysphagia, inability to belch or vomit, and rectal flatulence. These complaints were fairly stable throughout the study interval. The mean daily dose of omeprazole was 22.8, 24.1, 24.3 and 24.3 mg at 1, 3, 5 and 7 years respectively. CONCLUSION: Chronic GORD can be treated effectively by either antireflux surgery or omeprazole therapy. After 7 years, surgery was more effective in controlling overall disease symptoms, but specific post-fundoplication complaints remained a problem. There appeared to be no dose escalation of omeprazole with time.

Rectal cancer treatment of the elderly.

OBJECTIVE: Life expectancy and incidence of rectal cancer have been increasing. The purpose of this study was to evaluate rectal cancer treatment among very old patients. METHODS: This prospective national cohort study includes all 4875 rectal cancer patients in Norway aged over 65 years treated between November 1993 and December 2001. Patients aged 65-74, 75-79, 80-84 and over 85 years were compared for patient-, tumour- and treatment-characteristics and relative survival. Two thousand eight hundred and forty patients treated for cure with major surgery and TME technique were further evaluated for postoperative mortality, five-year local recurrence, distant metastasis and disease-free survival. RESULTS: There were more palliative surgery and local procedures and less surgery for cure (47%vs 77%, P < 0.001) for patients over 85 years compared to younger patients. Five-year relative survival was 36% for patients aged over 85 years compared to 49% for patients 80-84 years and 60% for patients 65-74 years. Among patients treated for cure with major surgery the rate of anterior resection decreased by age (67%vs 46%, P < 0.001). Postoperative mortality increased from 3% to 8% (P < 0.001). There were no significant differences in the rates of five-year local recurrence, distant metastasis or relative survival. CONCLUSION: Although a slight increase in postoperative mortality, major rectal cancer surgery can be performed in very old patients. These patients had similar rates of local recurrence, distant metastasis and relative survival as younger patients.

Changes of gastric mucosal architecture during long-term omeprazole therapy: results of a randomized clinical trial.

BACKGROUND: The impact of long-term acid suppression on the gastric mucosa remains controversial. AIM: To report further observations on an established cohort of patients with gastro-oesophageal reflux disease, after 7 years of follow-up. METHODS: Of the original cohort randomized to either antireflux surgery or omeprazole, 117 and 98 patients remained in the medical and surgical arms, respectively. Gastric biopsies were taken at baseline and throughout the study. RESULTS: Fifty-three antireflux surgery and 39 omeprazole-treated patients had Helicobacter pylori infection at randomization. Eighty-three omeprazole-treated and 60 antireflux surgery patients remained H. pylori negative over the 7 years, and no change was observed in mucosal morphology except for a change in endocrine cell population (linear and diffuse hyperplasia, P = 0.03). During the 7-year study many patients, who were initially H. pylori infected, had the infection eradicated leaving only 13 omeprazole and 12 antireflux surgery patients still infected. In these patients, omeprazole induced a deterioration of the mucosal inflammation scores (P = 0.01) with a numerical increase of glandular atrophy. CONCLUSIONS: Long-term omeprazole therapy does not alter the exocrine oxyntic mucosal morphology in H. pylori-negative patients, but mucosal endocrine cells appear to be under proliferative stimulation; in H. pylori-positive patients there are changes in mucosal inflammation and atrophy.

Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery.

OBJECTIVE: Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS: Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS: Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION: TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level.

BACKGROUND: The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level. METHODS: Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20-29 procedures, group 3 (n = 16) 10-19 procedures and group 4 (n = 28) fewer than ten procedures. RESULTS: The 5-year local recurrence rates were 9.2, 14.7, 12.5 and 17.5 per cent (P = 0.003) and 5-year overall survival rates were 64.4, 64.0, 60.8 and 57.8 per cent (P = 0.105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1.9 (95 per cent confidence interval (c.i.) 1.3 to 2.7); P < 0.001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1.2 (95 per cent c.i. 1.0 to 1.5); P = 0.023). CONCLUSION: The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.

Total mesorectal excision for rectal cancer--what can be achieved by a national audit?

OBJECTIVE: The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986-88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. METHODS: In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. RESULTS: The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow-up the rate of local recurrence was 8%, and 5-year overall survival was 71% for patients younger than 75 years. CONCLUSIONS: An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.

Laparoscopic antiperistaltic versus isoperistaltic gastrojejunostomy for palliation of gastric outlet obstruction in advanced cancer.

The purpose of the study was to compare the impact of the peristaltic orientation of laparoscopic gastrojejunal anastomoses (LGJ) in patients with malignant gastric outlet obstruction (GOO) on postoperative delayed-return gastric emptying (DRGE) rates. GOO was defined as complete holdup of contrast at barium meal and/or failure of gastroscope to pass beyond stricture. DRGE was defined as inability to eat regular diet by day 10. Thirty-four patients undergoing antiperistaltic LGJ were compared with 21 patients undergoing isoperistaltic LGJ at two institutions during the same period. Thirty-day mortality was 5.4%, and median survival was 6.2 months. Thirty-day morbidity was 20%, and conversion rate was 3.6%. DRGE rates were increased after isoperistaltic LGJ (0 vs. 3; P < 0.05), but patient groups were not well matched for type of primary cancer (P < 0.05). All patients with DRGE resumed food intake 12 to 16 days after surgery. There were 21 admissions before death, with a reoperation rate of 11.5% and a recurrent GOO rate of 3.8%. Although no conclusions could be drawn about whether the peristaltic orientation of the anastomosis had a bearing on DRGE rates, LGJ resulted in an overall 6% rate of DRGE.

Reference intervals for procalcitonin and C-reactive protein after major abdominal surgery.

Procalcitonin (PCT). a new marker proposed as a diagnostic tool for bacterial infections, triggers a systemic-inflammatory reaction in the body (sepsis, septic shock) and has potential use in a wide range of patient settings. To interpret the results from PCT measurements, we depend on reference intervals established from relevant populations. PCT and C-reactive protein (CRP) concentrations were analysed in 47 patients with a normal postoperative course after major abdominal surgery. The mean concentration of PCT declines from the first day and reaches half its initial values on the second day after the operation. whereas the mean concentration of CRP increases in the first 48 h and reaches half its maximum value on the fifth day after the operation. We present a continuous reference interval for plasma PCT and CRP concentrations in the first week following major abdominal surgery. For PCT we also present a graphic display of expected mean and expected upper reference limits predicted from the value measured on the first postoperative day.

Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer.

BACKGROUND: Knowledge of prognostic factors following resection of rectal cancer may be used in the selection of patients for adjuvant therapy. This study examined the prognostic impact of the circumferential resection margin on local recurrence, distant metastasis and survival rates. METHODS: A national population-based rectal cancer registry included all 3319 new patients from November 1993 to August 1997. Some 686 patients underwent total mesorectal excision with a known circumferential margin. This shortest radial resection margin was measured in fixed specimens. None of the patients had adjuvant radiotherapy. RESULTS: Following potentially curative resection and after a median follow-up of 29 (range 14--60) months, the overall local recurrence rate was 7 per cent (46 of 686 patients): 22 per cent among patients with a positive resection margin and 5 per cent in those with a negative margin (margin greater than 1 mm). Forty per cent of patients with a positive margin developed distant metastasis, compared with 12 per cent of those with a negative margin. With decreasing circumferential margin there was an exponential increase in the rates of local recurrence, metastasis and death. CONCLUSION: The circumferential margin has a significant and major prognostic impact on the rates of local recurrence, distant metastasis and survival. Information on circumferential margin is important in the selection of patients for postoperative adjuvant therapy.

[Iatrogenic gas embolism]. / Iatrogen gassemboli.

BACKGROUND: Gas embolism may occur as a consequence of lung injury, decompression sickness, surgery or as accidental infusion of gas during various diagnostic procedures. Iatrogenic gas embolism is often not recognised, but can lead to severe morbidity or even death. MATERIAL AND METHODS: We present a case of iatrogenic paradoxical air embolism caused by a defect in a central venous catheter. A review of the literature is given. RESULTS: The patient recovered gradually, but suffered significant neurological deficits. INTERPRETATION: Gas embolism must be considered as a differential diagnosis when a patient presents with unexplained neurological symptoms. Prompt treatment using oxygen at increased pressures (hyperbaric oxygen treatment) may be lifesaving and prevent serious sequelae.

The cost of long term therapy for gastro-oesophageal reflux disease: a randomised trial comparing omeprazole and open antireflux surgery.

BACKGROUND AND AIM: To comprehensively assess the relative merits of medical and surgical therapy for gastro-oesophageal reflux disease (GORD), health economic aspects have to be incorporated. We have studied the direct and indirect costs of medical and surgical therapy within the framework of a prospective randomised multicentre trial. METHODS: After initial treatment of reflux oesophagitis with omeprazole to control symptoms and to heal oesophagitis, 154 patients were randomised to continue treatment with omeprazole (20 or 40 mg daily) and 144 patients to have an open antireflux operation (ARS). In case of GORD relapse, patients allocated to omeprazole were offered ARS and those initially operated on had either a reoperation or were treated with omeprazole. The costs were assessed over five years from randomisation. RESULTS: Differences in cumulative direct medical costs per patient between the two therapeutic strategies diminished with time. However, five year direct medical costs per patient when given omeprazole were still significantly lower than for those having ARS in Denmark, Norway, and Sweden (differences were DKK 8703 (US$1475), NOK 32 992 (US$ 5155), and SEK 13 036 (US$ 1946), respectively). However, in Finland the reverse was true (the difference in favour of ARS amounted to FMK 7354 (US$ 1599)). When indirect costs (loss of production due to GORD related sick leave) were also included, the cost of surgical treatment increased substantially and exceeded the cost of medical treatment in all countries. CONCLUSIONS: The total costs of medical therapy for chronic GORD were lower than those of open ARS when prospectively assessed over a five year period, although significant differences in cost estimates were revealed between countries.

Classification and surgical treatment of incisional hernia. Results of an experts' meeting.

BACKGROUND: The treatment of incisional hernia (IH) is a current problem in modern surgery. Many important aspects of incisional hernia surgery are yet to be answered, especially the choice of surgical technique and its adaptation to the individual patient. The aim of this experts' meeting was to resolve some current questions in incisional hernia surgery and to organise an international hernia register. METHODS: An international panel of ten experts met under the auspices of the European Hernia Society (GREPA) to investigate the classification and therapeutic alternatives for incisional hernia. Prior to the conference, all experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The information from this correspondence was used as a basis for panel discussion. The personal experiences of the participants and other aspects of individualised therapy were also considered. RESULTS: The expert panel suggested a new classification of incisional hernia based on localisation, size, recurrences and symptoms. All experts agreed that the fascia duplication and the fascia adaptation should only be used for small incisional hernias. Fascia duplication is of value only in the horizontal direction. The technical details and the pros and cons of each procedure were discussed for prosthetic implantation using onlay and sublay techniques and the technique of autodermal hernioplasty. CONCLUSIONS: The management of incisional hernia is currently not standardised. In order to answer relevant questions of incisional hernia surgery, an international hernia register should be established.

Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease.

BACKGROUND: The efficacy of antireflux surgery (ARS) and proton pump inhibitor therapy in the control of gastroesophageal reflux disease is well established. A direct comparison between these therapies is warranted to assess the benefits of respective therapies. STUDY DESIGN: There were 310 patients with erosive esophagitis enrolled in the trial. There were 155 patients randomized to continuous omeprazole therapy and 155 to open antireflux surgery, of whom 144 later had an operation. Because of various withdrawals during the study course, 122 patients originally having an antireflux operation completed the 5-year followup; the corresponding figure in the omeprazole group was 133. Symptoms, endoscopy, and quality-of-life questionnaires were used to document clinical outcomes. Treatment failure was defined to occur if at least one of the following criteria were fulfilled: Moderate or severe heartburn or acid regurgitation during the last 7 days before the respective visit; Esophagitis of at least grade 2; Moderate or severe dysphagia or odynophagia symptoms reported in combination with mild heartburn or regurgitation; If randomized to surgery and subsequently required omeprazole for more than 8 weeks to control symptoms, or having a reoperation; If randomized to omeprazole and considered by the responsible physician to require antireflux surgery to control symptoms; If randomized to omeprazole and the patient, for any reason, preferred antireflux surgery during the course of the study. Treatment failure was the primary outcomes variable. RESULTS: When the time to treatment failure was analyzed by use of the intention to treat approach, applying the life table analysis technique, a highly significant difference between the two strategies was revealed (p < 0.001), with more treatment failures in patients who originally were randomized to omeprazole treatment. The protocol also allowed dose adjustment in patients allocated to omeprazole therapy to either 40 or 60 mg daily in case of symptom recurrence. The curves subsequently describing the failure rates still remained separated in favor of surgery, although the difference did not reach statistical significance (p = 0.088). Quality of life assessment revealed values within normal ranges in both therapy arms during the 5 years. CONCLUSIONS: In this randomized multicenter trial with a 5-year followup, we found antireflux surgery to be more effective than omeprazole in controlling gastroesophageal reflux disease as measured by the treatment failure rates. But if the dose of omeprazole was adjusted in case of relapse, the two therapeutic strategies reached levels of efficacy that were not statistically different.

[Hernia surgery in Norway]. / Lyskebrokkirurgi i Norge.

BACKGROUND: Inguinal hernia repair has undergone major changes during the last decade. This study aimed to explore the impact on treatment algorithms used in Norway. METHODS: A questionnaire was sent to all public hospitals in January 1999. RESULTS: 57 of 58 hospitals where inguinal hernia repairs were undertaken responded. Most repairs are undertaken in local/district hospitals, but in the majority of hospitals, surgeons performed a limited number of procedures (one or two per month). The vast majority of hospitals used two different surgical techniques, open mesh techniques being the preferred technique. Most hospitals made limited use of laparoscopic techniques. Sick-leave periods were shorter after surgery with open mesh techniques as compared to traditional techniques. Less than 20% of hospitals had established control regimens. INTERPRETATION: A clear tendency towards standardization of inguinal hernia repair can be observed throughout the country. Open mesh techniques have now replaced the traditional operative methods, whereas laparoscopic technique has not been adopted. Quality assessment of inguinal hernia repair could be improved.