Diverting stomas reduce reoperation rates for anastomotic leak but not overall reoperation rates within 30 days after anterior rectal resection: a national cohort study

Purpose A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma. Methods A 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located<15 cm from the anal verge. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry. Primary end point was relaparotomy or relaparoscopy for anastomotic leak within 30 days from index surgery. Secondary endpoints were postoperative complications including reoperation for any cause. Results Some 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p>0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97–7.24, p<0.001) was associated with increased risk for anastomotic leak. However, there were no diferences in overall reoperation rates following anterior resection with or without diverting stoma (9.3% vs 10.9%, p=0.423), and overall complication rates were similar. Reoperation was associated with increased mortality irrespective of the main intraoperative fnding. Conclusion Diverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not afect overall rates of reoperation or complications within 30 days

The Practically Wise Medical Teacher: Medical Education at the University of Tromsø – A Norwegian Case

Source at https://www.hsj.gr/.This article addresses the issue of teaching quality in medical education and investigates what characterizes a professionally competent or practically wise medical teacher through the use of longitudinal data from interviews with 40 medical students. In discussing the findings, Aristotle’s concepts of episteme, techne and phronesis, and theoretical perspectives on professionalism and quality in teaching are applied. The findings highlight that one is either a practically wise medical teacher or a technical medical teacher. The practically wise medical teacher typically focuses on reflection, experience, participation, formative assessment and discussion in an atmosphere of good relations, which stimulate teaching and learning. The technical medical teacher, on the contrary, knows very little about the students and treats them as onlookers in clinical settings. The analysis results indicate that being a practically wise medical teacher requires a perception of what characterizes professionalism in medical education, the ability to use formative assessment and role model consciousness. These findings underline the importance of a good supervisor–learner relationship, which promotes medical teachers’ teaching competence and knowledge of professionalism. The findings also indicate the importance of faculty development in order to improve teaching quality at both the individual and system levels

Translation and validation of the Norwegian version of the postoperative quality of recovery score QoR-15

Background As patient-centered care gains more attention, assessing the patient's perspective on their recovery has become increasingly important. In response to the need for a reliable and valid patient reported outcome measurement tool for major surgical resections in Norway. The Norwegian Registry for Gastrointestinal Surgery (NORGAST) initiated a project to translate and evaluate QoR-15's psychometric properties for patients going through general, gastrointestinal (GI), and hepato-pancreato-biliary (HPB) resectional surgery. Methods After a translation and adaption of the original version of QoR–15 into Norwegian, the QoR–15NO was psychometrically evaluated including a confirmatory factor analysis to test for unidimensionality, as well as tests for content validity, internal consistency, measurement error, construct validity, feasibility, and responsiveness. This process included cognitive interviews using a structured interview guide. Further, patients who underwent various types of GI/HPB surgery at five hospitals in different parts of Norway completed the QoR-15NO before surgery and on the first or second day after surgery. The impact of surgery was classified according to Surgical Outcome Risk Tool v2 (SORT), in extra major/complex, major, intermediate, and minor. Results This study included 324 patients with 83% return rate with both pre- and postoperative forms. There were negative correlations between duration of surgery and postoperative QoR-15 score and the difference between post- and preoperative score (change score). Individuals who had gone through surgery with major impact had a lower postoperative mean QoR-15 score (97) than their counterparts who had experienced either medium (QoR-15: 110) or minor (QoR15: 119) impact surgery. Cronbach's alpha (0.88) and Omega Alpha Total (ωt = 0.90) indicate that the scale has good to very good internal consistency. Test–retest reliability was measured by Intra-class Correlation Coefficient to ICC = 0.70. Confirmatory factor analyses supported that a one-factor model with correlated residuals had a good fit to data. Conclusion This study supports QoR-15NO as a valid, essentially unidimensional, feasible, and responsive instrument among patients undergoing general, GI, and HPB resectional surgery in Norway. The total QoR-15NO score provides important information that can be used in an everyday clinical setting and integrated into NORGAST

Anal Sphincter Length as Determined by 3-Dimensional Endoanal Ultrasound and Anal Manometry: A Study in Healthy Nulliparous Women

Objectives - The normal female external anal sphincter (EAS) is shorter anteriorly than laterally and posteriorly. Furthermore, the thickness of the very proximal part of the circular EAS is thinner than 50% of the lateral and posterior EAS thickness. The extent of these features is not fully explored. The aim of this prospective study was to assess the normal anal sphincter with 3‐dimensional (3D) endoanal ultrasound (EAUS) and to relate 3D EAUS length measurements to sphincter length determined by anal manometry. Methods - Healthy premenopausal nulliparous women underwent anal manometry and 3D EAUS examinations. Two experienced colorectal surgeons independently assessed all scans, blinded to any patient data. Results - A total of 43 women were included. Four scans were incomplete and excluded from the analysis. Interobserver agreement was fair to very good for the various length measurements. The mean length from the distal border of the puborectal muscle to the very proximal border of the anterior EAS (the anterior gap) was 4.4 (95% confidence interval, 3.9–4.9) mm, whereas the length to the level where the anterior EAS thickness was at least 50% of the lateral and posterior EAS thickness was 7.2 (95% confidence interval, 6.5–7.9) mm. Manometric sphincter length at rest did not correlate with any 3D EAUS length measurements. Conclusions - In the normal anterior female anal canal, the EAS is not present or appears with less than 50% of the thickness of the lateral and posterior EAS for the first 7.2 mm below the distal border of the puborectal muscle

Lower conversion rate with robotic assisted rectal resections compared with conventional laparoscopy; a national cohort study

Background Conversion from laparoscopic to open access colorectal surgery is associated with a poorer postoperative outcome. The aim of this study was to assess conversion rates and outcomes after standard laparoscopic rectal resection (LR) and robotic laparoscopic rectal resection (RR). Methods A national 5-year cohort study utilizing prospectively recorded data on patients who underwent elective major laparoscopic resection for rectal cancer. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and from the Norwegian Colorectal Cancer Registry. Primary end point was conversion rate. Secondary end points were postoperative complications within 30 days and histopathological results. Chi-square test, two-sided T test, and Mann–Whitney U test were used for univariable analyses. Both univariable and multivariable logistic regression analyses were used to analyze the relations between different predictors and outcomes, and propensity score matching was performed to address potential treatment assignment bias. Results A total of 1284 patients were included, of whom 375 underwent RR and 909 LR. Conversion rate was 8 out of 375 (2.1%) for RR compared with 87 out of 909 (9.6%) for LR (p  30. Conversion was associated with higher rates of major complications (20 out of 95 (21.2%) vs 135 out of 1189 (11.4%) p = 0.005), reoperations (13 out of 95 (13.7%) vs 93 out of 1189 (7.1%) p = 0.020), and longer hospital stay (median 8 days vs 6 days, p = 0.001). Conclusion Conversion rate was lower with robotic assisted rectal resections compared with conventional laparoscopy. Conversions were associated with higher rates of postoperative complications.publishedVersio

Laparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort. aparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort

Purpose Although widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort. Methods Data from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures. Results A total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR (p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR (p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0–13.0) after ORR compared to 6.0 (quartiles 4.0–8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days (p < 0.001, 95% CI 2.3–3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups.publishedVersio

Endoscopic full-thickness dissection (EFTD) in the rectum: a case series

Background Rectal endoscopic full- thickness dissection (EFTD) using a fexible colonoscope is an alternative to the wellestablished trans-anal endoscopic microsurgery (TEM) and the trans-anal minimally invasive surgery (TAMIS) techniques for resecting dysplastic or malignant rectal lesions. This study evaluated EFTD safety by analyzing outcomes of the frst patients to undergo rectal EFTD at the University Hospital of North-Norway. Methods The frst 10 patients to undergo rectal EFTD at the University Hospital of North-Norway April, 2016 and January, 2021, were included in the study. The procedural indications for EFTD were therapeutic resection of non-lifting adenoma, T1 adenocarcinoma (AC), recurrent neuroendocrine tumor (NET) and re-excision of a T1-2 AC. Results EFTD rectal specimen histopathology revealed three ACs, fve adenomas with high-grade dysplasia (HGD), one NET and one benign lesion. Six procedures had negative lateral and vertical resection margins and in three cases lateral margins could not be evaluated due to piece-meal dissection or heat damaged tissue. Two patients experienced delayed post-procedural hemorrhage, one of whom also presented with a concurrent post-procedural infection. No serious complications occurred. Conclusion Preliminary results from this introductory trial indicate that EFTD in the rectum can be conducted with satisfactory perioperative results and low risk of serious complications

Molecular differences of adipose-derived mesenchymal stem cells between non-responders and responders in treatment of transphincteric perianal fistulas

Background: Injection of autologous adipose tissue (AT) has recently been demonstrated to be an efective and safe treatment for anal fstulas. AT mesenchymal stem cells (AT-MSCs) mediate the healing process, but the relationship between molecular characteristics of AT-MSCs of the injected AT and fstula healing has not been adequately studied. Thus we aimed to characterize the molecular and functional properties of AT-MSCs isolated from autologous AT injected as a treatment of cryptogenic high transsphincteric perianal fstulas and correlate these fndings to the healing process. Methods: 27 patients (age 45±2 years) diagnosed with perianal fstula were enrolled in the study and treated with autologous AT injected around the anal fstula tract. AT-MSCs were isolated for cellular and molecular analyses. The fstula healing was evaluated by MRI scanning after 6 months of treatment. AT-MSC phenotype was compared between responders and non-responders with respect to fstula healing. Results: 52% of all patients exhibited clinical healing of the fstulas as evaluated 6 months after last injection. Cultured AT-MSCs in the responder group had a lower short-term proliferation rate and higher osteoblast diferentiation potential compared to non-responder AT-MSCs. On the other hand, adipocyte diferentiation potential of AT-MSCs was higher in non-responder group. Interestingly, AT-MSCs of responders exhibited lower expression of infammatory and senescence associated genes such as IL1B, NFKB, CDKN2A, TPB3,TGFB1. Conclusion: Our data suggest that cellular quality of the injected AT-MSCs including cell proliferation, diferentiation capacity and secretion of proinfammatory molecules may provide a possible mechanism underlying fstula healing. Furthermore, these biomarkers may be useful to predict a positive fstula healing outcome

The New National Registry for Gastrointestinal Surgery in Norway: NoRGast

Background and aims: There is an increasing demand for high-quality data for the outcome of health care. Diseases of the gastro-intestinal tract involve large patient groups often presenting with serious or life-threatening conditions. Complications may affect treatment outcomes and lead to increased mortality or reduced quality of life. A continuous, risk-adjusted monitoring of major complications is important to improve the quality of health care to patients undergoing gastrointestinal resections. We present the development of the Norwegian Registry for Gastrointestinal Surgery, a national registry for colorectal, upper gastrointestinal, and hepato-pancreato-biliary resections in Norway. Materials and methods: A narrative and qualitative presentation of the development and current state of the registry. Results: We present the variables and the analysis tools and provide examples for the potential in quality improvement and research. Core characteristics include a strictly limited set of variables to reflect important risk factors, the procedure performed, and the clinical outcomes. Conclusion: A registry with the potential to present complete national cohort data is a powerful tool for quality improvement and research.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The construction of the registry interface and platform and the analysis of data are financed by the University Hospital Northern Norway as this institution also has the judicial responsibility for data safety. The early implementation of the registry was made possible by a dedicated grant from the Centre for Clinical Documentation and Evaluation (SKDE), a national service node to the promotion of registry development.publishedVersio

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast

BACKGROUND: To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome. METHODS: An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat. RESULTS: Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001). CONCLUSIONS: Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome