Colorectal Liver Metastases – Different Aspects on Treatment with Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy and on Portal Vein Occlusion

Introduction: For patients with colorectal liver metastases (CRLM), the only treatment with a possibility for long-term survival and cure is radical resection. The majority of patients are at the time of diagnosis not assessed as resectable because they have advanced disease in the liver or unresectable extrahepatic disease or are too frail to withstand liver surgery. Patients who at the time of diagnosis are not assessed as resectable may be treated with conversion chemotherapy to downsize the tumor burden and render the patient eligible for resection. One concern with chemotherapy administered preoperatively has been the potential negative effect on the future liver remnant (FLR), especially for patients with a low volume of the FLR who are undergoing techniques to increase the volume. Established techniques to increase the volume are portal vein occlusion (PVO) and two-staged hepatectomy (TSH). A more recent method is Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). Due to the relative novelty of ALPPS, the long-term oncological results are not known. For patients with CRLM, resection of liver metastases is more favorable from a health economic perspective than palliative treatment and results in a higher quality of life than palliative chemotherapy. For patients undergoing ALPPS as well as TSH, the data are scarce. Aim: The aim of the first study was to determine whether preoperative chemotherapy has a negative impact on the volume increase for patients undergoing ALPPS. The aim of the second study was to analyze the temporal course of the volume increase in the FLR for patients undergoing PVO. The aim of the third study was to study the long-term outcome for patients randomized to ALPPS or TSH. The aim of the fourth study was to perform a health economic analysis of patients randomized to ALPPS or TSH. Methods: The first study was based on data from the ALPPS registry, which is an international registry initiated 2012. All patients included in the registry between 2012 and 2016 were included. The patients were divided into the following four groups: no preoperative chemotherapy, 1 regimen of neoadjuvant chemotherapy, more than 1 regimen, and more than 1 regimen with the addition of monoclonal antibodies. The volume increase between interventions 1 and 2 was analyzed. In the second study, a retrospective analysis was performed of patients randomized to TSH. Forty-eight patients were included. The volume increase of the FLR was analyzed as the kinetic growth rate (KGR). The KGR was calculated from PVO until radical hepatectomy or exclusion, as well as between the first and second radiological evaluations. In the third and fourth studies, patients randomized to ALPPS and TSH were included. In the third study, survival, as well as factors affecting the outcome, were analyzed. In the fourth study, a calculation of resource use was performed, as was an analysis of health-related quality of life (HRQoL) for the groups. Results: In the first study, it was found that chemotherapy had no negative impact on the volume increase for patients undergoing ALPPS. In the second study, it was found that the volume increase of the FLR was largest the first week after ALPPS. In the third study, it was found that patients randomized to ALPPS had a longer survival than those randomized to TSH. Of the factors affecting the outcome, resection of liver metastases had a significant impact. In the fourth study, no significant difference could be found in resource use or HRQoL for patients randomized to ALPPS over TSH. Conclusion: Patients with advanced CRLM undergoing ALPPS should receive preoperative chemotherapy, if indicated. For those undergoing PVO, early evaluation is crucial to evaluate the volume increase, and for those with insufficient increase, additional techniques to increase the volume should be considered. Resection of liver metastases is an important factor to improve the outcome. Further studies are warranted to conclude whether ALPPS or TSH is most effective from a health economic perspective

Förändringar av en rättighetslag

Vi har studerat en laglig rättighet som vissa personer med funktionshinder kan ha en rätt till i Sverige. Dessa rättigheter finns i lag (1993:387) om stöd och service till vissa funktionshindrade. Vi har studerat de förslag till ändringar som kan komma att ske i insatsen personlig assistans. Vi har även studerat den föreslagna insatsen personlig service med boendestöd som är tänkt att ersätta en del av insatsen personlig assistans. Vi frågar oss om dessa insatser, efter en eventuell lagändring, kan anses vara rättigheter samt ingå i en rättighetslag. Vårt material har vi samlat in främst genom fem intervjuer med sex informanter. Vi har även studerat betänkandet SOU 2008:77, remissyttranden samt artiklar som berör vårt ämne. Vår studie visar på en stor skepsism gentemot den föreslagna insatsen personlig service med boendestöd. Överlag finns det tvivel kring SOU 2008:77. Dock fann vi även en del positiva aspekter så som kontroll över assistansanordnare. Vår slutsats är att även om insatsen personlig assistans fortsatt kan ses vara en rättighet efter en eventuell lagändring, så kan inte den föreslagna insatsen personlig service med boendestöd anses vara en rättvis del i en rättighetslag.We have studied a legal privilege that individuals with certain kinds of handicap can have a right to here in Sweden.The rights that individuals with certain kinds of handicap have are written in a law named: law (1993:387) on support and service for certain disabled persons. We have studied the changes with a focus on personal assistance effort. We have also looked at a proposal for a new effort to replace a part of personal assistance. This proposed effort will be named personal service with housing. We are wondering whether these efforts will be of such quality, in case of a possible change, that they can be included in a law of privilege.We have gathered our materials mainly through five interviews with six informants. We have also studied different texts, including the bill, various municipalities’ remarks to the bill and articles.Our study showed a large scepticism towards the proposal on personal service with housing. Overall the opinions we came across were expressing doubt regarding the bill for changes in the law on support and service for certain disabled. Though we also reached the conclusion that there are some positive suggestions within the bill. One of the more positive aspects was a more rigid control of those who hire personal assistants.Our conclusion is that even if the effort personal assistance can still be seen as a right after a possible change, the new proposal on personal service with housing cannot be considered to be a just right for individuals with certain kinds of handicap. Thus the suggested effort of personal service with housing cannot be included in a law of privilege

Förändringar av en rättighetslag

Vi har studerat en laglig rättighet som vissa personer med funktionshinder kan ha en rätt till i Sverige. Dessa rättigheter finns i lag (1993:387) om stöd och service till vissa funktionshindrade. Vi har studerat de förslag till ändringar som kan komma att ske i insatsen personlig assistans. Vi har även studerat den föreslagna insatsen personlig service med boendestöd som är tänkt att ersätta en del av insatsen personlig assistans. Vi frågar oss om dessa insatser, efter en eventuell lagändring, kan anses vara rättigheter samt ingå i en rättighetslag. Vårt material har vi samlat in främst genom fem intervjuer med sex informanter. Vi har även studerat betänkandet SOU 2008:77, remissyttranden samt artiklar som berör vårt ämne. Vår studie visar på en stor skepsism gentemot den föreslagna insatsen personlig service med boendestöd. Överlag finns det tvivel kring SOU 2008:77. Dock fann vi även en del positiva aspekter så som kontroll över assistansanordnare. Vår slutsats är att även om insatsen personlig assistans fortsatt kan ses vara en rättighet efter en eventuell lagändring, så kan inte den föreslagna insatsen personlig service med boendestöd anses vara en rättvis del i en rättighetslag.We have studied a legal privilege that individuals with certain kinds of handicap can have a right to here in Sweden. The rights that individuals with certain kinds of handicap have are written in a law named: law (1993:387) on support and service for certain disabled persons. We have studied the changes with a focus on personal assistance effort. We have also looked at a proposal for a new effort to replace a part of personal assistance. This proposed effort will be named personal service with housing. We are wondering whether these efforts will be of such quality, in case of a possible change, that they can be included in a law of privilege. We have gathered our materials mainly through five interviews with six informants. We have also studied different texts, including the bill, various municipalities’ remarks to the bill and articles. Our study showed a large scepticism towards the proposal on personal service with housing. Overall the opinions we came across were expressing doubt regarding the bill for changes in the law on support and service for certain disabled. Though we also reached the conclusion that there are some positive suggestions within the bill. One of the more positive aspects was a more rigid control of those who hire personal assistants. Our conclusion is that even if the effort personal assistance can still be seen as a right after a possible change, the new proposal on personal service with housing cannot be considered to be a just right for individuals with certain kinds of handicap. Thus the suggested effort of personal service with housing cannot be included in a law of privilege

Treatment intention and outcome in patients with simultaneously diagnosed liver and lung metastases from colorectal cancer

Background: The aim was to assess the likelihood of patients with simultaneously diagnosed liver and lung metastases (SLLM) from colorectal cancer (CRC) to receive the curative treatment decided upon multidisciplinary team meeting (MDT) and to elaborate on the reasons for treatment intention failure and survival outcomes depending on final treatment strategy.Method: The study included a retrospective review of all patients discussed at the MDT at a single centre between 2010 and 2018 to identify all patients presenting with SLLM from CRC. Treatment intention, actual treatment outcome and reasons for treatment failure was documented. Descriptive and survival statistics were applied.Results: Of the 160 patients who had SLLM, resection of all metastatic sites was deemed possible in 107 patients (67%) of whom 39 patients (36%) finalized the curative treatment plan. The most common reason for noncompliance with management recommendations was disease progression or recurrence. Complete resection resulted in longer survival compared to patients who did not undergo resection of all metastatic sites with median survival of 63 and 27 months, respectively (p < 0.001).Conclusion: A low proportion of patients completed the initially intended curative resections. Simulta-neous resection of liver/lung metastases and primary tumour might increase the proportion of fulfilled hepatopulmonary resections.(c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Symptoms and impact of symptoms on function and health in patients with chronic obstructive pulmonary disease and chronic heart failure in primary health care

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) seem to have several symptoms in common that impact health. However, methodological differences make this difficult to compare. AIM: Comparisons of symptoms, impact of symptoms on function and health between patients with COPD and CHF in primary health care (PHC). METHOD: The study is cross sectional, including patients with COPD (n=437) and CHF (n=388), registered in the patient administrative systems of PHC. The patients received specific questionnaires--the Memorial Symptom Assessment Scale, the Medical Research Council dyspnea scale, and the Fatigue Impact Scale--by mail and additional questions about psychological and physical health. RESULTS: The mean age was 70 ± 10 years and 78 ± 10 years for patients with COPD and CHF respectively (P=0.001). Patients with COPD (n=273) experienced more symptoms (11 ± 7.5) than the CHF patients (n=211) (10 ± 7.6). The most prevalent symptoms for patients with COPD were dyspnea, cough, and lack of energy. For patients with CHF, the most prevalent symptoms were dyspnea, lack of energy, and difficulty sleeping. Experience of dyspnea, cough, dry mouth, feeling irritable, worrying, and problems with sexual interest or activity were more common in patients with COPD while the experience of swelling of arms or legs was more common among patients with CHF. When controlling for background characteristics, there were no differences regarding feeling irritable, worrying, and sexual problems. There were no differences in impact of symptoms or health. CONCLUSION: Patients with COPD and CHF seem to experience similar symptoms. There were no differences in how the patients perceived their functioning according to their cardinal symptoms; dyspnea and fatigue, and health. An intervention for both groups of patients to optimize the management of symptoms and improve function is probably more relevant in PHC than focusing on separate diagnosis groups

High resection rate improves overall survival in elderly patients with pancreatic head cancer - A cohort study

Background: There is evidence that a high hospital volume of pancreaticoduodenectomy improves short-and long-term outcomes, but there are few population-based studies on the effect of a high resection rate in the population. The aim of this national, observational study was primarily to investigate differences in overall survival among elderly patients with cancer in the pancreatic head between high and low resection rate groups and secondarily to determine if counties with high resection rates of pancreaticoduodenectomy had more severe complications after surgery. Materials and methods: All patients in the Swedish National Registry for tumours in the pancreatic and periampullary region diagnosed between 2010 and 2018 with pancreatic head cancer were included in this retrospective cohort study. Patients were divided into low and high resection rate groups according to the yearly resection rates in the respective counties. For operative outcomes, all patients who had undergone pancreaticoduodenectomy were included regardless of diagnosis. The primary outcome of the study was overall survival among patients aged >= 70 years with pancreatic head cancer. Results: Among 13 933 patients in the registry, 7661 were 70 years or older, of whom 3006 had pancreatic head cancer. Overall survival was longer in high resection rate groups for patients aged >= 70 years, as for the age subgroups 70-79 years and >= 80 years (all p < 0.001). Among patients who had undergone pancreaticoduodenectomy aged >= 80 years the high resection rate counties showed an increased rate of severe complications, but no increase in 90-day mortality. Conclusion: High resection rate groups show a significantly longer overall survival among elderly patients with pancreatic head cancer in Sweden. This implies that there could be a survival benefit from increasing resections in low resection rate groups. (C) 2021 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd

Åtgärder i transportinfrastrukturen för de stora industriinvesteringarna i Norrbottens län och i Västerbottens län

Näringslivets omställning med investeringar som bidrar till miljömålen och minskad klimatpåverkan sker nu i snabb takt. I Norrbottens län och Västerbottens län har ett antal industriprojekt på senare tid aktualiserats, som kan ge ett väsentligt bidrag till denna gröna omställning. För att industrisatsningarna ska kunna genomföras, och för att de potentialer som finns ska kunna effektueras, behöver ett antal viktiga åtgärder i transportinfrastrukturen prioriteras och tidigareläggas. De företagsetableringar och företagsexpansioner som genomförs eller planeras i Norrbottens län och Västerbottens län kommer att ställa nya krav på transportinfrastrukturen. Regeringen har gett Trafikverket i uppdrag att analysera vilken påverkan detta får för transportinfrastrukturen samt vilka behov av åtgärder som kan väntas uppstå med anledning av denna samhällsomställning

The resection rate of synchronously detected liver and lung metastasis from colorectal cancer is low : a national registry-based study

Population-based data on the incidence and surgical treatment of patients with colorectal cancer (CRC) and synchronous liver and lung metastases are lacking as are real-life data on the frequency of metastasectomy for both sites and outcomes in this setting. This is a nationwide population-based study of all patients having liver and lung metastases diagnosed within 6 months of CRC between 2008 and 2016 in Sweden identified through the merging of data from the National Quality Registries on CRC, liver and thoracic surgery and the National Patient Registry. Among 60,734 patients diagnosed with CRC, 1923 (3.2%) had synchronous liver and lung metastases, of which 44 patients had complete metastasectomy. Surgery of liver and lung metastases yielded a 5-year OS of 74% (95% CI 57–85%) compared to 29% (95% CI 19–40%) if liver metastases were resected but not the lung metastases and 2.6% (95% CI 1.5–4%) if non-resected, p < 0.001. Complete resection rates ranged from 0.7% to 3.8% between the six healthcare regions of Sweden, p = 0.007. Synchronous liver and lung CRC metastases are rare, and a minority undergo the resection of both metastatic sites but with excellent survival. The reasons for differences in regional treatment approaches and the potential of increased resection rates should be studied further