An analysis of gender differences in treatment and outcome of periampullary tumours in Sweden – A national cohort study

Background: Little is known of possible gender differences in treatment of periampullary tumours and outcome after pancreatoduodenectomy (PD), and the aim of this study was therefore to investigate any variances from national multicentre perspective. Methods: Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients diagnosed with a periampullary tumour from 2012 throughout 2017 was collected. The material was analysed in two groups, men and women, for palliative treatment and curative intended resection. Results: A total of 5677 patients were included, 2906 (51%) men and 2771 (49%) women. Women were older than men, 72 (65–78) years vs. 70 (64–76), p < 0.001. A lesser proportion of women were planned for resection (1131 (41%) vs. 1288 (44%), p = 0.008), but after adjusting for age and tumour location no difference was seen. Postoperative morbidity was equal, but women had significantly better long-term survival than men. The survival was equal for palliative men and women. Conclusion: No gender bias could be established when analysing treatment for periampullary tumours in Sweden, even though less women were offered surgery. Data suggest that even though women were older they tolerate surgery well and hence offering PD at a higher age for women could be suggested

Completeness and Correctness of Cholecystectomy Data in a National Register--Gallriks.

To validate the Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) concerning completeness and correctness of entered data for cholecystectomies and evaluating the effect of repeated audits. It is crucial for any register to obtain a high accuracy in order to be a credible and reliable source for quality evaluation, research, and development

Bile Duct Injuries Associated With 55,134 Cholecystectomies: Treatment and Outcome from a National Perspective.

Bile duct injury (BDI) is a rare complication associated with cholecystectomy, and recommendations for treatment are based on publications from referral centers with a selection of major injuries and failures after primary repair. The aim was to analyze the frequency, treatment, and outcome of BDIs in an unselected population-based cohort

Quality-of-life after bile duct injury : intraoperative detection is crucial. A national case-control study

Background Existing reports on quality-of-life (QoL) after bile duct injury (BDI) are conflicting. Methods Case-control study were QoL assessment was performed using SF-36 (36-item short Form health survey). Patients with BDI were compared to a matched control group (1:2) subject to cholecystectomy. Results In total 168 BDIs (0.3%) were eligible for participation and 64% returned SF-36. Median follow-up was 4.3 years. Intraoperative cholangiography was performed/attempted in 93% of BDI patients and 92% were diagnosed intraoperatively. Lesions <5 mm dominated (59%) and QoL was comparable for BDIs and controls (physical composite score PCS; p = 0.052 and mental composite score MCS; p = 0.478). Patients with an immediate intraoperative repair reported a better PCS than patients subjected to a later repair and/or referral (p = 0.002). No difference in SF-36 was detected when the BDI was repaired by the index compared to non-index surgeon (PCS p = 0.446, MCS p = 0.525). Conclusion QoL after bile duct injury is comparable to uneventful cholecystectomy, as long as the injury is diagnosed intraoperatively. Immediate repair, in this cohort of mainly minor injuries, also performed by the index surgeon, resulted in similar QoL as in the control group. We suggest liberal use of cholangiography for early detection of BDI, and intraoperative repair whenever possible

Routine intraoperative cholangiography during cholecystectomy is a cost-effective approach when analysing the cost of iatrogenic bile duct injuries

Background: The total cost of bile duct injuries (BDIs) in an unselected national cohort of patients undergoing cholecystectomy are unknown. The aim was to evaluate costs associated with treatment of cholecystectomy-related BDIs and to calculate cost effectiveness of routine vs. on-demand intraoperative cholangiography (IOC). Methods: Data from Swedish patients suffering a BDI during a 5 year period were analysed. Questionnaires to investigate loss-of-production and health status (EQ-5D) were distributed to patients who suffered a BDI during cholecystectomy and who underwent uneventful cholecystectomy (matched control group). Costs per quality-adjusted-life-year (QALY) gained by intraoperative diagnosis were estimated for two strategies: routine versus on-demand IOC during cholecystectomy. Results: Intraoperative diagnosis, immediate intraoperative repair, and minor BDI were all associated with reduced direct treatment costs compared to postoperative diagnosis, delayed repair, and major BDI (all p < 0.001). No difference was noted in loss-of-production for minor versus major BDIs or between different treatment strategies. The cost per QALY gained with routine intraoperative cholangiography (ICER-incremental cost-effectiveness ratio) to achieve intraoperative diagnosis was €50,000. Conclusions: Intraoperative detection and immediate intraoperative repair is the superior strategy with less than half the cost and superior functional patient outcomes than postoperative diagnosis and delayed repair. The cost per QALY gained (ICER) using routine IOC was considered reasonable

Major intraoperative bleeding during pancreatoduodenectomy - preoperative biliary drainage is the only modifiable risk factor

Background: Pancreatoduodenectomy is associated with a high risk of complications. The aim was to identify preoperative risk factors for major intraoperative bleeding. Methods: Patients registered for pancreatoduodenectomy in the Swedish National Pancreatic and Periampullary Cancer Registry, 2011 to 2016, were included. Major intraoperative bleeding was defined as ≥1000 ml. Univariable and multivariable analysis of preoperative parameters were performed. Results: In total, 1864 patients were included. The median blood loss was 600 ml, and 502 patients (27%) had registered bleeding of ≥1000 ml. Preoperative independent risk factors associated with major bleeding were male sex (p < 0.001), body mass index (BMI) ≥25 kg/m2 (p < 0.001), preoperative biliary drainage (PBD) (p < 0.001), C-reactive protein (CRP) ≥12 mg/L (p = 0.006) and neo-adjuvant chemotherapy treatment (NAT) (p = 0.002). Postoperative intensive care (p < 0.001), reoperation (p = 0.035), surgical infections (p = 0.036), and bile leakage (p = 0.045) were more common in the group with major bleeding, and the 30-day mortality was higher (4.9% vs 1.6%; p < 0.001). Conclusion: Most predictive parameters for major intraoperative bleeding are not modifiable. PBD is an independent predictor for major intraoperative bleeding and to reduce the risk, patients with resectable periampullary tumors should, if possible, be subject to surgery without preoperative biliary drainage