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Prothrombotic and metabolic variables are decreased after obesity surgery, and fibrin clot lysis is increased. It is unknown how fibrinolytic variables are affected, and whether fibrinolytic and metabolic changes predict the enhanced clot lysis. Study aims were to determine fibrinolytic biomarkers before and 6 months after Roux-en-Y gastric bypass (RYGB) and to identify predictors of the RYGB-induced increase in clot lysis. Women (n = 42) and men (n = 18) with obesity underwent RYGB, and factor XIII (FXIII), thrombin activatable fibrinolysis inhibitor (TAFI), plasminogen and plasmin inhibitor (PI) were measured before and 6 months after surgery. Regression analyses identified determinants of the RYGB-induced increase in clot lysis among changes in fibrinogen and in fibrinolytic and metabolic variables. Results showed that after RYGB, FXIII, TAFI, plasminogen and PI were reduced (P

Background: Obesity is associated with physical inactivity and impaired health-related quality of life (HRQoL). We aim to test the hypothesis that Roux-en-Y gastric bypass (RYGB) followed by supervised physical training improves physical activity (PA) levels and HRQoL. Methods: Sixty patients, qualified for RYGB, were at 6 months post-surgery randomized to 26 weeks of a supervised physical training intervention (INT) or to a control (CON) group. PA was assessed by accelerometry and using the questionnaire RPAQ. HRQoL was measured by the SF-36 questionnaire. All assessments were performed pre-surgery and 6, 12, and 24 months post-surgery. Results: RYGB did not improve objectively or self-reported PA, but improved all domains of SF-36 (all p < 0.01). Objectively measured light PA, moderate to vigorous PA, and step counts tended to increase in INT compared to CON 12 months after RYGB (0.05 < p < 0.09), but the effects failed to persist. The SF-36 domain “general health” increased in INT compared to CON 24 months after RYGB (p = 0.041). Conclusion: RYGB improves HRQoL, but does not increase PA. Supervised physical training intervention improves general health 24 months after RYGB and tends to improve certain domains of PA right after the intervention period, but fails to increase the patients’ overall PA level over time. Clinical Trial Registration Registered at ClinicalTrials.gov—no. NCT01690728.

BACKGROUND: The risk of cardiovascular disease is reduced by bariatric surgery, but it is unknown if exercise after bariatric surgery reduces this risk even further.OBJECTIVE: To investigate if Roux-en-Y-gastric bypass (RYGB) and supervised physical training after RYGB improve cardiovascular disease risk markers within coagulation activation, fibrin clot properties, and fibrinolysis.SETTING: Bariatric center, Hospital of Southwest Jutland, Denmark.METHODS: Sixty obese patients underwent RYGB and 6 months after RYGB were randomized to 26 weeks of physical training or a control group. Biomarkers within coagulation activation, fibrin clot properties, and fibrinolysis were measured presurgery, and 6, 12, and 24 months postsurgery.RESULTS: Six months after RYGB, the endogenous thrombin potential decreased from 1744 (1603-2003) to 1416 (1276-1582) nM × min (PCONCLUSION: We observed favorable long-term reductions in markers of thrombin generation, improved fibrin clot properties, and increases in fibrinolysis after RYGB. Supervised physical training after RYGB further increased fibrinolysis.

Obesity and physical inactivity are major health problems. Roux-en-Y gastric bypass (RYGB) surgery results in significant weight loss and reduces obesity-related morbidity and mortality. Physical activity lowers the risk of cardiovascular disease and premature death. The aims of this study were to elucidate the effects of RYGB followed by 6 months of supervised physical training on physical capacity. In a randomized controlled trial, 60 participants eligible for RYGB were randomized 6 months post-surgery to either two weekly physical training sessions for 26 weeks (INT) or a control group (CON). Aerobic capacity (VO2 max), muscle strength (MS) of the shoulder and hip and physical function were measured pre-surgery and 6, 12 and 24 months post-surgery. RYGB per se decreased MS in all tested muscle groups, had no effects on VO2 max but improved physical function. After the intervention, INT had a significant 0.33 L min-1 increase in VO2 max compared to CON (95% CI: 0.07-0.57, P = 0.013). Furthermore, MS in the hip adductor increased significantly with 13 N (95% CI: 3.6-22.4, P = 0.007) and a between-group difference was found in the Stair Climb Test (0.46 repetitions [95% CI: 0.02-0.91, P = 0.042]). The effects were not maintained at follow-up. Supervised physical training following RYGB improved VO2 max, hip MS and physical function, but the positive effects were not maintained at follow-up. While activities of daily life may become easier as a result of RYGB, the observed extensive post-operative loss of MS requires more attention to increase the patient's physical capacity prospectively.

Background and aims: Obesity and physical inactivity are both associated with low-grade inflammation and endothelial dysfunction. Bariatric surgery improves markers of inflammation and endothelial function, but it is unknown if physical training after bariatric surgery can improve these markers even further. Therefore, we aimed to investigate the effects of Roux-en-Y gastric bypass (RYGB) followed by physical training on markers of low-grade inflammation and endothelial function. Methods: Sixty patients approved for RYGB underwent examinations pre-surgery, 6, 12, and 24 months post-surgery. Six months post-surgery, they were randomized 1:1 to an intervention group or a control group. The interventions consisted of two weekly sessions of supervised moderate intensity physical training for a period of 26 weeks. Fasting blood samples were analyzed for concentrations of interleukin 6 (IL-6), C-reactive protein (CRP), intercellular adhesion molecule 1 (ICAM-1), tissue-type plasminogen activator antigen (t-PA:Ag) and von Willebrand factor (vWF). Results: RYGB markedly improved markers of inflammation (IL-6, CRP) (p < 0.001) and endothelial function (ICAM-1, t-PA:Ag, vWF) (p < 0.05), and the improvements were sustained 24 months post-surgery (p < 0.01), except for the effects on vWF. We found no correlations between the changes in weight or BMI and the changes in markers of inflammation and endothelial function, except that the change in vWF was found to be inversely correlated with the changes in weight and BMI. We observed no effects of supervised physical training on markers on inflammation or endothelial function (p>0.1 for all). Conclusions: RYGB causes substantial and sustained favorable effects on markers of inflammation and endothelial function. Supervised physical training after RYGB did not cause additional improvements.

OBJECTIVE Bariatric surgery results in significant weight loss and reduces cardiovascular morbidity. However, a large variation in postsurgery weight loss is seen. Physical activity promotes weight loss in nonsurgically treated subjects with obesity. The aim of this study was to investigate the effects of 6 months of supervised physical training following Roux-en-Y gastric bypass surgery (RYGB) on body weight and cardiovascular risk markers. METHODS Sixty participants eligible for RYGB were included. Six months post surgery, the participants were randomly assigned to either twice-weekly supervised physical training sessions in a fitness center (INT) or a control group (CON) for 26 weeks. Before surgery and 6, 12, and 24 months after surgery, the participants underwent an examination program that included anthropometric measurements, blood pressure, heart rate, blood samples, and an abdominal computed tomography scan. RESULTS RYGB significantly reduced body weight and improved cardiovascular risk markers (all P

Background Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery. Methods A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration. Results Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two. Conclusion A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Objective To examine 24-h blood pressure (24BP), systemic haemodynamics and the effect of sodium intake on 24BP in obese patients before and after gastric bypass surgery [laparoscopic Roux-en-Y gastric bypass (LRYGB)], and to determine whether weight loss from LRYGB might be related to an increase in plasma concentrations of atrial natriuretic peptide. Methods Twelve hypertensive and 12 normotensive morbidly obese patients underwent LRYGB: 24BP, systemic haemodynamics and mid-regional pro-atrial natriuretic peptide (MRproANP) were assessed before, 6 weeks and 12 months after surgery. The effect of high versus low sodium intake on 24BP was evaluated before and 12 months after LRYGB. Results Six weeks after LRYGB, the average weight loss was 20 kg, with a further 21 kg weight loss 1 year after surgery. In hypertensive patients, 24BP was significantly reduced at 6 weeks, but not 1 year after LRYGB. However, antihypertensive medications were successively reduced from baseline to 1 year after surgery. In normotensive patients, there was no change in 24BP 6 weeks after LRYGB, but a tendency towards a reduction 1 year after the operation. Plasma concentrations of MRproANP were subnormal prior to surgery in hypertensive patients and increased by 77% 1 year after the operation. In normotensive patients, preoperative concentrations were normal and increased only by 6%. High sodium intake induced plasma volume expansion, increased stroke volume and cardiac output, but no significant change in 24BP - neither before nor after LRYGB. Conclusions LRYGB resulted in a significant 24BP reduction and a substantial increase in MRproANP plasma concentrations in hypertensive, obese patients 6 weeks after surgery, suggesting a causal link between obesity-hypertension and altered release/degradation of cardiac natriuretic peptides.

Summary Hiatus hernia is known to be an important risk factor for developing gastroesophageal reflux disease. We aimed to use the endoscopic functional lumen imaging probe (EndoFLIP) to evaluate the functional properties of the esophagogastric junction. EndoFLIP assessments were made in 30 patients with hiatus hernia and Barrett's esophagus, and in 14 healthy controls. The EndoFLIP was placed straddling the esophagogastric junction and the bag distended stepwise to 50 mL. Cross-sectional areas of the bag and intra-bag pressures were recorded continuously. Measurements were made in the separate sphincter components and hiatus hernia cavity. EndoFLIP measured functional aspects such as sphincter distensibility and pressure of all esophagogastric junction components and visualized all hiatus hernia present at endoscopy. The lower esophageal sphincter in hiatus hernia patients had a lower pressure (e.g. 47.7 ± 13.0 vs. 61.4 ± 19.2 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the common esophagogastric junction in controls. In hiatus hernia patients, the crural diaphragm had a lower pressure (e.g. 29.6 ± 10.1 vs. 47.7 ± 13.0 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the lower esophageal sphincter. There was a significant association between symptom scores in patients and EndoFLIP assessment. Conclusively, EndoFLIP was a useful tool. To evaluate the presence of a hiatus hernia and to measure the functional properties of the esophagogastric junction. Furthermore, EndoFLIP distinguished the separate esophagogastric junction components in hiatus hernia patients, and may help us understand the biomechanics of the esophagogastric junction and the mechanisms behind hiatal herniation.

Background The objective of the present study was to evaluate the cost-utility of bariatric surgery in a lifetime horizon from a Swedish health care payer perspective. Methods A decision analytic model using the Markov process was developed covering cardiovascular diseases, type 2 diabetes, and surgical complications. Clinical effectiveness and safety were based on the literature and data from the Scandinavian Obesity Surgery Registry. Gastric bypass, sleeve gastrectomy, and gastric banding were included in the analysis. Cost data were obtained from Swedish sources. Results Bariatric surgery was cost saving in comparison with conservative management. It also led to a substantial reduction in lifetime risk of events: from a 16 % reduction in the risk of transient ischaemic attacks to a 62 % reduction in the incidence of type 2 diabetes. Over a lifetime, surgery led to savings of €8408 and generated an additional 0.8 years of life and 4.1 quality-adjusted life years (QALYs) per patient, which translates into gains of 32,390 quality-adjusted person-years and savings of €66 million for the cohort, operated in 2012. Analysis of the consequences of a 3-year delay in surgery provision showed that the overall lifetime cost of treatment may be increased in patients with diabetes or a body mass index >40 kg/m2. Delays in surgery may also lead to a loss of clinical benefits: up to 0.6 life years and 1.2 QALYs per patient over a lifetime. Conclusion Bariatric surgery, over a lifetime horizon, may lead to significant cost savings to health care systems in addition to the known clinical benefits. Electronic supplementary material The online version of this article (doi:10.1007/s11695-014-1567-5) contains supplementary material, which is available to authorized users.

Purpose The objective of this study was to evaluate the current utilization, the level of endorsement by professional societies, and health technology assessment bodies, as well as the reimbursement levels for bariatric surgery in European countries. Materials and Methods We performed an analysis of the indications for bariatric surgery based on national clinical and commissioning guidelines, current utilization of surgery, characteristics of patients who underwent surgery, and reimbursement tariffs in Belgium, Denmark, England, France, Germany, Italy, and Sweden. Data were obtained from national patient registries, administrative databases, and published literature for the year 2012. Results Despite clear consensus outlined in clinical guidelines, significant differences were found in the eligibility criteria for surgery. Patients with no significant comorbidities were deemed eligible if they had a body mass index (BMI) of 40 or 50 kg/m2 in Denmark. Irrespective of the country, patients with comorbidities were eligible if they had a BMI of 35 kg/m2. The highest utilization of bariatric surgery (number of surgeries per 1 M population) was observed in Belgium (928), Sweden (761), and France (571) while Italy (128), England (117), and Germany (72) had the lowest utilization. There was a strong negative correlation between utilization and average BMI level of the patient population (r = −.909, p = 0.005). The annual per capita spending on surgery differed significantly between countries, ranging from €0.54 in Germany to €4.33 in Belgium. Conclusions There are significant variations in the clinical indications, utilization, and funding of bariatric surgery in European countries. Electronic supplementary material The online version of this article (doi:10.1007/s11695-014-1537-y) contains supplementary material, which is available to authorized users.

Background Ischemic preconditioning (IPC) has been shown to protect the liver against ischemia-reperfusion (I/R) injuries. However, ischemic post-conditioning has received little attention. The aim of the present study was to quantify and compare the hepato-protective properties of IPC and IPO, for the first time, using unbiased design-based stereological methods. Methods We divided 67 rats into four groups: sham, liver ischemia (LI), IPC, and IPO. Rats were subjected to 60 min LI, followed by 4- or 24-h reperfusion. We performed quantification of (NVR) and apoptotic cell profile number. Results We observed no significant differences in NVR between ischemic groups after 4 h. After 24-h reperfusion, NVR had increased to 70% in the LI group, compared with 51% ( P = 0.02) and 49% ( P = 0.01) in the IPC and IPO groups, respectively. After 4-h reperfusion, the apoptotic cell number was significantly higher in all ischemic groups than in the sham group; we detected no difference between ischemic groups. After 24-h reperfusion, we detected a significantly lower number of apoptotic cell profiles in the IPC group than in the LI group ( P = 0.02). The mean number of apoptotic cell profiles decreased insignificantly in the IPO group ( P = 0.06). Liver parameters were at all time comparable between groups. Conclusions After I/R, IPC and IPO reduce the degree of hepatocellular injury. Both methods are equally efficient at preventing hepatocellular necrosis. Furthermore, apoptosis is significantly lower after IPC.

Ischemic pre (IPC)- and postconditioning (IPO) protect the liver against ischemia/reperfusion injuries (IRI). Conditioning involves several different trigger factors, mediators, and effectors, many of which are affected during the early phase of reperfusion, ultimately resulting in decreased liver injuries. The aim of the present study was to investigate the genomic response induced by IPC and IPO in ischemia/reperfusion-damaged rat liver biopsies. Forty-eight male Wistar rats were divided into five groups: sham ( n = 8), IRI ( n = 10), IPC ( n = 10), IPO ( n = 10), and IPC + IPO ( n = 10). The rat livers were subjected to 30 min of ischemia. Liver biopsies and blood samples were taken after 30 min of reperfusion. The biopsies were analyzed using cDNA microarrays with validation by quantitative RT-PCR. The significance analysis of microarray was used to identify genes with changed expression levels. A comparison analysis of the intervention groups showed a highly increased number of genes, with significantly different expression in the conditioned groups compared with the IRI group. A total of 172 genes were identified as the most highly affected, and these genes showed similar patterns with regard to the up- and downregulated expression levels within the conditioned groups. Pathway analysis of the 172 genes identified four networks that were involved in increased gene expression, cellular growth, and proliferation. In conclusion, the present study demonstrated that IPC, IPO, and IPC + IPO had pronounced effects on the expression levels of a large number of genes during early reperfusion. IPC, IPO, and IPC + IPO seem to mediate their protective effects by regulating the same genes and genetic networks. These identified networks are known to be involved in maintaining cellular homeostasis.

Aliment Pharmacol Ther 2011; 33: 1113–1122 Summary Background Many patients with gastro-oesophageal reflux disease (GERD) are hypersensitive to heat and acid and may respond insufficiently to standard treatment. Antagonists of the heat and acid receptor ‘transient receptor potential vanilloid 1’(TRPV1) are a potential drug class for GERD treatment. Aim To investigate the effect of a TRPV1 antagonist (AZD1386) on experimentally induced oesophageal pain. Methods Twenty-two healthy men (20–31 years) participated in this randomised, placebo-controlled, double-blinded, crossover study examining the effects of a single-dose oral AZD1386 (30 and 95 mg). Subjects were block-randomised. On treatment days, participants were stimulated with painful heat, distension, electrical current and acid in the oesophagus. Heat and pressure pain on the forearm were somatic control stimuli. Data analysis: intention-to-treat. Results A total of 21 participants completed the protocol and 1 voluntarily discontinued. In the oesophagus, both 30 and 95 mg of AZD1386 increased pain thresholds to heat stimuli 23% [95% confidence interval (CI): 10–38%] and 28%, respectively (CI: 14–43%). The skin heat tolerance was increased 2.1 °C (CI: 1.1–3.2 °C) after 30 mg AZD1386 and 4.0 °C (CI: 3.0–5.0 °C) after 95 mg. Heat analgesia persisted for 2.5 h. Pain thresholds to the other stimuli were unaffected by AZD1386. 50% reported ‘feeling cold’ and body temperature increased in all subjects exposed to 30 and 95 mg AZD1386 (mean increase 0.4 ± 0.3 °C and 0.7 ± 0.3 °C, respectively, P

Sensory changes are thought to be involved in gastro-esophageal reflux disease (GERD). The esophageal multimodal pain model can be used to investigate sensations in response to distension, heat, electric current and acid.The aim of this study was to provide normal values for this model in the normal state and in the acid induced sensitized state.Fifty-three healthy men (20-38 years old) underwent esophageal stimulation with distension, heat and electrical current before and after sensitization with 0.1 N HCl acid. Stimulus intensities at painful and non-painful thresholds and referred pain areas were measured. The percentage of individual participants sensitized to each modality was calculated. In 22 subjects the pre-acid tests were repeated on three subsequent visits.To reach moderate pain, subjects tolerated mean distension of 29.1 ± 11 mL, heat stimulation time of 141 ± 33 s, and mean current of 17.6 ± 6.4 mA. After acid exposure, significantly reduced thresholds were observed for mechanical (24%), heat (11%) and electrical (14%) stimulation (P values 0.05). The percentage of subjects sensitized, defined as reductions in thresholds of ≥10% or ≥20% after acid perfusion, was as follows: for distension 77%/62%, for heat 48%/28%, and for current 58%/44%. The model showed good reliability (intra-class correlations 0.6).Normal values for healthy young men are now provided for the normal and the sensitized state. The percentage of subjects sensitized after acid stimulation are thoroughly documented, and depends on stimulation type and the cut-off value chosen.

Udgivelsesdato: 2010-Oct Background: During surgery, ischaemic pre- (IPC) and post-conditioning (IPO) protects the liver against ischaemia/reperfusion injuries (I/R-injuries). The impact of ischaemic conditioning on liver regeneration has been less well studied. Angiogenesis is an important part of liver regeneration after hepatectomy. The aim of the present study was to investigate the effect of ischaemia/reperfusion and ischaemic conditioning on the expression of genes with angiogenic potential in a model of rat liver ischaemia. Methods: A model of total liver ischaemia (30 min) and reperfusion (30 min) was employed using Wistar rats. Rats were randomized into five groups: (C) control (IRI) ischaemic, IPC, IPO and IPC + IPO. Liver enzymes were sampled at the end of reperfusion. Liver biopsies were analysed using cDNA microarrays. Results: Alanine aminotransferase (ALT) increased significantly in all the ischaemic groups compared with controls (P= 0.000). Searching databases 99 genes involved in rat liver angiogenesis were identified. Compared with group (C) the number of genes significantly up-regulated was as follows: IRI (n= 5), IPC (n= 24), IPO (n= 33) and IPC + IPO (n= 18). No genes were down-regulated in the four groups compared with controls. Conclusion: Ischaemic conditioning, as demonstrated in the present study, seems to be potent activators of angiogenic genes. This might be favourable to the regenerating liver.

Item does not contain fulltext BACKGROUND & AIMS: Pain is a prominent symptom in chronic pancreatitis (CP), but the underlying mechanisms are incompletely understood. We investigated the role of descending pain modulation from supraspinal structures as well as central nervous system sensitization in patients with pain from CP. METHODS: Twenty-five patients with CP and 15 healthy volunteers were included. Descending pain modulation was investigated by diffuse noxious inhibitory control (a descending inhibitory response after conditioning stimulation). Central pain processing was investigated as the perceptual responses to multimodal (electrical, thermal, and mechanical) stimulations of the rectosigmoid and evoked brain potentials after electrical stimulation of the rectosigmoid. RESULTS: Compared with healthy volunteers, the efficacy of diffuse noxious inhibitory control was reduced in patients with CP (13% +/- 21% vs 39% +/- 22%, respectively; F = 3.8; P = .01); central sensitization was indicated by remote hyperalgesia in the rectosigmoid to electrical stimulation (21 +/- 15 mA vs 27 +/- 15 mA; F = 6.2; P = .02) and heat stimulation (51 degrees C +/- 5 degrees C vs 53 degrees C +/- 4 degrees C; F = 5.9; P = .02). Compared with controls, patients with CP had increased latency of the early P1 peak to rectosigmoid stimulation (85 +/- 21 ms vs 108 +/- 28 ms, respectively; P = .02), possibly reflecting reorganization of central pain pathways. CONCLUSIONS: Patients with CP have impairments in inhibitory pain modulation and evidence of central sensitization. Treatment of their pain therefore should focus not only on the pancreas, but also on descending pain modulation from supraspinal structures and central nervous system sensitization. 01 augustus 2010

To assess the impact of warm-up on laparoscopic performance in the operating room (OR).Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP.Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35).There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up, median 28.5 (range = 18.5-32.0) versus median 19.25 (range = 15-31.5), P = 0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbach's alpha = 0.92).This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources.

Udgivelsesdato: 2010 BACKGROUND: Recently, it has been suggested that nurses can perform diagnostic endoscopy procedures, which traditionally have been a physician's responsibility. The existing studies concerning quality of sigmoidoscopy performed by nurses are small, used assessment tools with insufficient validation and to date there is very little knowledge of the learning curve patterns for physicians and nurses. The aim of a present study was to assess early learning curves on a virtual-reality colonoscopy simulator of untrained residents as compared with that of nurses with and without endoscopy assistance experience. MATERIALS AND METHODS: Thirty subjects were included in the study: 10 female residents (median age 30.5 years) without colonoscopy experience, 10 female nurses (median age 27.5 years) without endoscopy assistance experience and 10 female nurses (median age 42 years) with endoscopy assistance experience. All participants performed 10 repetitions of task 6 from the "Introduction" colonoscopy module of the Accu Touch Endoscopy simulator. Eight experienced colonoscopists performed three repetitions of task 6 in order to provide the reference expert level of performance. RESULTS: All subjects completed the virtual colonoscopy without complications. Significant differences existed between residents and nurses with respect to time to complete the procedure. Residents and nurses showed similar learning curve patterns. There were not significant differences between the groups in terms of volume of insufflated air, percentage of time without discomfort, and percentage of mucosa seen. None of the trainee groups achieved expert proficiency level in terms of time and amount of insufflated air by the tenth repetition. CONCLUSIONS: Nurses performed virtual colonoscopy as accurately and safely as residents. Although the residents performed significantly faster, time differences showed a tendency towards decreasing, and appraisement of the numeric time differences seemed of minor practical importance. From a technical point of view this indicates that nurses may learn to perform colonoscopy after appropriate training.

Introduction: Intraductal papillary mucinous tumours (IPMT) were described as a distinct entity in I982. The extent of surgical resection for this disease remains controversial. Methods: Twelve patients with a diagnosis of IPMT were included in the present retrospective study. Results: Ten out of twelve patients had symptoms suggesting chronic pancreatitis. Two patients were not operated on due to biopsy-verified metastases in the liver. Nine patients were treated with a total pancreatectomy and one with a pancreaticoduodenectomy. In the ten patients operated on for IPMT, histological examination showed eight non-invasive- and two invasive carcinomas. In six cases, multifocal extensive intraductal changes were found, affecting either most of or the whole pancreas. There was no perioperative mortality. Six patients were alive at follow-up without recurrence and four patients were dead, two of them with recurrence. Conclusion: IPMTs represent a subgroup of pancreatic neoplasms with a favourable prognosis, and the resection should aim at removing all dysplastic foci. In cases with diffuse dilatation of the main pancreatic duct, widespread tumour involvement of the duct system can be expected and total pancreatectomy should be the operation of choice.

Udgivelsesdato: 2008-null BACKGROUND/PURPOSE: We investigated the effect of T-tube drainage on the healing of choledocho-choledochostomies in pigs. METHODS: Twenty pigs with a median weight of 56 kg were used for the experiments. The pigs were randomized to two groups of ten. In all pigs the gallbladder was removed and the common bile duct was transected. In both groups continuity was re-established by standardized single-line, interrupted, and inverted sutures. In one group a T-tube for decompression was inserted. On postoperative day 6, a laparotomy was performed. Pigs were investigated for signs of cholascos, and an intraoperative cholangiography was performed. The excised anastomosis was examined for breaking strength and collagen content. Blood samples were drawn prior to the first and the final operations. RESULTS: In both groups standard liver parameters were unaffected by surgery, and cholangiography showed no signs of extrahepatic stenosis or intrahepatic dilatation. The T-tube-drained choledocho-choledochostomies showed a significantly higher breaking strength (P = 0.035) compared to the group which had no drainage. Collagen content per volume was unaffected by T-tube drainage. CONCLUSIONS: T-tube drainage had a significant stimulatory effect on the breaking strength of choledocho-choledochostomies in pigs on postoperative day 6, but was without effect on collagen content.

Udgivelsesdato: 2008-Nov BACKGROUND AND AIMS: Somatosensory hyperalgesia in the referred pain area (RPA) in patients with acute or chronic abdominal pain syndromes may result from the convergence of nerve fibers from visceral and somatic tissues at the spinal and supraspinal levels. Chronic biliary pain in patients with the postcholecystectomy syndrome (i.e., biliary hypersensitivity) may be explained by persistent hyperexcitability of neurons in the central nervous system (CNS). The aim of this study was to evaluate the cutaneous neural sensory perception in the RPA in patients with chronic postcholecystectomy biliary pain and a sphincter of Oddi (SO) dysfunction (SOD). METHODS: Forty-two patients with persistent biliary pain and suspected SOD, 27 age-matched healthy volunteers, and 18 age-matched asymptomatic cholecystectomized controls were prospectively investigated by quantitative sensory testing (Neurometer CPT). The biliary symptoms and the severity of pain were classified on a visual analog pain severity scale system via a previously validated and standardized questionnaire. The patients helped the doctors locate the RPA in the right upper quadrant. The sensory detection threshold was determined noninvasively (Neurometer CPT) with transcutaneous electrical stimulation at 5, 250, and 2,000 Hz, and different current intensities (range from 0.01 to 9.99 mA) applied in a single (patient) blinded method. These three frequencies selectively excite small unmyelinated (C fibers), small myelinated (A-delta), and large myelinated (A-beta) fibers, which transmit dull pain, sharp pain, and touch, respectively. The contralateral region of the abdomen left upper quadrant served as the control area. The sensory current perception threshold ratio (SCPTR) of the data measured in the contralateral area and the RPA was calculated. RESULTS: The SCPTRs in the definite SOD patients with biliary pain, healthy volunteers, the asymptomatic cholecystectomized controls, and the symptomatic cholecystectomized patients but without SOD were 2.32 +/- 1.4 versus 1.06 +/- 0.24 versus 0.97 +/- 0.16 versus 0.83 +/- 0.35 at 2,000 Hz; 2.19 +/- 1.0 versus 1.01 +/- 0.26 versus 1.02 +/- 0.25 versus 0.88 +/- 0.35 at 250 Hz; and 2.19 +/- 1.1 versus 1.12 +/- 0.26 versus 0.99 +/- 0.37 versus 0.84 +/- 0.32 at 5 Hz, respectively. Significant hypersensitivity was detected in the RPA at different stimulation frequencies in the SOD patients with biliary pain versus the cholecystectomized controls: at 5 Hz: P = 0.00001; at 250 Hz: P = 0.00001; and at 2,000 Hz: P = 0.0001, respectively. CONCLUSION: Continuous visceral pain (biliary pain) caused by local inflammatory/sensitizing processes or a CNS malfunction could lead to significant hypersensitivity of the peripheral nociceptive nerve fibers in SOD patients. Postcholecystectomy pain may be explained by persistent hyperexcitability of the nociceptive neurons in the CNS with or without objective motility disorders of the SO.

Udgivelsesdato: 2008-Nov Pain mechanisms in patients with chronic pancreatitis are incompletely understood and probably multifactorial. Recently, evidence from experimental human pain research has indicated that in many of these patients pain processing in the central nervous system is abnormal and mimics that seen in neuropathic pain disorders. The current review focuses on several lines of evidence supporting this hypothesis. Hence, the spontaneous and postprandial pain in chronic pancreatitis may reflect the characteristic pain features seen in patients with neuropathic pain. Biochemical and histopathological findings in tissues from patients with chronic pancreatitis are similar to those observed in patients with other nerve fibre lesions. Experimental studies have shown that patients with chronic pancreatitis show signs of spinal hyper-excitability counter-balanced by segmental and descending inhibition. Changes in the brain with cortical reorganisation to gut stimulation and increased activity in specific electroencephalographic features characteristic for neuropathic pain are also seen in patients with chronic pancreatitis. Finally, principles involved in the treatment of pancreatic pain have many similarities with those recommended in neuropathic pain disorders. In conclusion, a mechanism-based understanding of pain in chronic pancreatitis may have important implications for the treatment.

Udgivelsesdato: 2008 OBJECTIVE: The mechanisms underlying symptom improvement in gastric electrical stimulation (GES) are not fully understood. Modulation of the central nervous system excitability may be involved. The objective of the study was to investigate the central effects of GES, including the possible modulation of the visceral sensory nervous system. MATERIAL AND METHODS: A gastric electrical stimulator was implanted in seven diabetic patients with medically refractory gastroparesis. A double-blinded protocol was used to investigate the patients at baseline and one month after recovery with the stimulator turned on and off (1-month periods). The following assessments were carried out: mechanical, thermal and electrical stimulations with sensory recordings in the esophagus and duodenum, and standardized, self-administered, daily symptom questionnaires. RESULTS: No difference was found between baseline and the on- and off periods in overall gut pain thresholds across all stimulus modalities in the esophagus (p=0.63), duodenum (p=0.19) or esophagus and duodenum combined (p=0.76). No difference in the sensory response to mechanical stimulation was found in the esophagus before (all p>0.31) and after (all p>0.43) smooth muscle relaxation with butylscopolamine. Similar findings were observed in the duodenum. No differences were found in thermal sensitivity (esophagus (p=0.67) and duodenum (p=0.17)), sensory response to electrical stimulation (esophagus (p=0.57) and duodenum (p=0.52)) or induced somatic referred pain areas (esophagus (p=0.75) and duodenum (p=0.51)). No difference was seen in the induced somatic referred pain areas or self-reported symptoms. CONCLUSIONS: No evidence was found for GES-induced modulation of the visceral sensory system and central excitability. However, GES has been proven to modulate the central nervous system in animal studies, necessitating further human experiments in order unambiguously to establish the possible central effects of GES.

Aiming to investigate the natural history of the healing of choledocho-choledochostomies. Fifty-five female pigs of 57 kg median weight were used for the experiments. The gallbladder was removed and the common bile duct transected. Continuity was re-established by standardized single-line, interrupted, and inverted sutures. The pigs had a planned postoperative survival of up to 14 days with a subsequent laparotomy for evaluation. Blood samples were drawn prior to the first and the final operations. During laparotomy the animals were investigated for signs of cholascos, and an intraoperative cholangiography was performed. The excised anastomosis was examined for breaking strength and collagen content. Standard liver parameters were not significantly affected by the surgery, and cholangiography showed no signs of extrahepatic stenosis or intrahepatic dilatation. Breaking strength showed a decrease for the initial 3 postoperative days (PODs), then an increase to a stable level on PODs 6 to 14. Collagen content per volume showed a rise on PODs 0 to 1, then no change until POD 4, followed by a gradual rise until day 6. Subsequently a stable level was reached until POD 14. Two pigs were excluded due to minor cholascos. The present study on pigs shows that choledocho-choledochostomies, judged by breaking strength and collagen content, regain a stable level of strength 6 days after operation.

Unexplained chest/epigastric pain is a common symptom in the general population. However, it has not previously been studied whether such pain could be a marker of subsequent gastrointestinal cancer. We aimed to estimate the risk of gastrointestinal cancers in a Danish 10-year follow-up study among patients with chest/epigastric pain, normal upper endoscopy, and no prior discharge diagnosis of ischemic heart disease (N = 386), compared with population controls (N = 3860). The overall 10-year risk of gastrointestinal cancer (stomach, colorectal, liver, and pancreas) was 2.9% for patients with unexplained chest/epigastric pain vs. 1.5% for controls. The adjusted relative risks or =1 year after upper endoscopy were 8.4 (95% confidence interval [CI], 2.6-27.5) and 1.2 (95% CI, 0.5-2.9), respectively. We found that patients with unexplained chest/epigastric pain have an increased risk of gastrointestinal cancer within the first year after upper endoscopy. Consequently, unexplained chest/epigastric pain might be an early gastrointestinal cancer symptom.

SUMMARY Background No studies have examined the risk of upper gastrointestinal diseases among patients with unexplained chest/epigastric pain (UCEP) and a normal upper endoscopy. Aim To examine the relative risk of peptic ulcer, oesophagitis, pancreatitis or gallstone in UCEP patients. Methods This Danish 10-year cohort study focused on UCEP patients (n = 386), diagnosed in 1992–93. Ten age- and gender-matched controls were selected per patient from Denmark’s Civil Registration System (n = 3860). Kaplan–Meier analysis and Cox’s regression analysis was used to calculate the risk of hospitalization for peptic ulcer, oesophagitis, pancreatitis or gallstone. Results Compared with controls, the adjusted relative risks among UCEP patients

To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4-100%).Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome.Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1-2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5-6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia.Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5-6 weeks. These results suggest a conservative attitude for the first 1-2 months after surgery. The data may also serve as a background for preoperative information to the patients.

There is a need for new methods to study the dynamics of the esophagogastric junction (EGJ). The aims were to verify the efficacy and usefulness of a “functional lumen imaging probe” (FLIP) for the evaluation of the EGJ. Eight healthy volunteers (6 men), median age 26 (21–35) yr, and two achalasia patients underwent the FLIP procedure. The EGJ was located by manometry. The FLIP measured eight cross-sectional areas (CSAs) 4 mm apart together with the pressure inside a saline-filled cylindrical bag. The data showed the geometric profile of the EGJ reconstructed in a video animation of its dynamic activity. A plot of curve-fitted data for the smallest CSA vs. pressure after balloon distension indicated that the pressure increased from 18 cmH2O at a CSA of 38 mm2 to a pressure of 37 cmH2O at a CSA of 230 mm2 for the healthy controls. In one achalasia patient (unsuccessfully treated with dilations), the CSA never rose above the minimal measurable value despite the pressure increasing to 50 cmH2O. In another achalasia patient (successfully treated with dilations), the pressure only reached 15 cmH2O despite opening to a CSA of 250 mm2. In conclusion, FLIP represents the first dynamic technique to profile the function and anatomy of the EGJ. The method can be used practically to evaluate difficult cases of EGJ dysfunction and may provide a role in evaluating patients before and after therapies for diseases affecting the EGJ such as achalasia and gastroesophageal reflux disease.

Background: A combined colorectal and hepatic resection is considered too risky by many surgeons owing to the high risk of postoperative septic complications. The aim of the present study was to investigate the effects of hepatic resection on the healing of left-sided colonic anastomoses in rats on postoperative day 7. Material and Methods: Fifty-four Sprague-Dawley rats were block-randomized into three groups. In each group, 1 cm of the left side of the colon was resected and anastomosed. Additionally, 40 or 70% of the liver was resected in group 2 and 3, respectively. Rats were killed on postoperative day 7. The abdominal cavity was inspected for the presence of complications. The bursting pressure and hydroxyproline content of the anastomoses were measured. Results: The total number of complications was significantly higher in group 3 than in group 2. Anastomotic bursting pressure and hydroxyproline content did not differ significantly among the groups. Conclusions: Increasing the extent of simultaneous hepatic resection did not significantly affect the healing of left-sided colonic anastomoses in rats on postoperative day 7, although there was a tendency towards lower bursting pressure paralleling the extent of liver resection. Excessive hepatic resection with colectomy may increase postoperative complications.

Purpose: To evaluate the efficacy and safety of transcatheter arterial embolization (TAE) in patients with bleeding/rebleeding duodenal ulcers. Material and Methods: Over a 6-year-period, 40 consecutive patients with bleeding/rebleeding after endoscopic therapy and/or surgery for duodenal ulcer were included in the study. Superselective angiographic catheterization and coil embolization were performed by the same interventional radiologist. Results: Lasting hemostasis was achieved in 26 of 40 patients (65%). Transfusion requirement was reduced from median 14 (range 3–35) units of blood before TAE to 2 (range 0–53) units after TAE. Ten patients died, five because of continuous bleeding. No adverse effects as a result of TAE were seen. Conclusion: TAE is an effective and safe treatment in a significant proportion of patients with bleeding duodenal/rebleeding ulcers after therapeutic endoscopy and/or surgery.

In previous comparisons of inflammatory and stress responses to open (OR) and laparoscopic (LR) hernia repair, all operations were performed under general anesthesia. Since local anesthesia is widely used for OR, a comparison of this approach with LR seemed relevant.Patients with recurrent inguinal hernia were randomized to OR under local anesthesia (n = 30) or LR under general anesthesia (n = 31). The magnitude of the surgical trauma was assessed by measuring markers of coagulation (prothrombin fragment 1 + 2), endothelial activation (von Willebrand factor), inflammation [leukocytes, interleukin-6, -8 and -10, granulocyte macrophage colony-stimulating factor, and C-reactive protein (CRP)], and endocrine stress (cortisol) in blood collected before operation, 4 h postincision, and on postoperative day 2.Leukocyte counts and interleukin-6 and CRP levels increased in both groups, with the CRP increase being significantly greater in the OR group. The other markers did not increase significantly.The acute phase response was more pronounced after OR, even when this was done under local anesthesia. Both techniques seemed rather atraumatic.

Patients with non-cardiac chest pain (NNCP) suffer from unexplained and often intractable pain which can pose a major clinical problem. The aim of this study was to investigate nociceptive processing in NNCP patients and their response to experimentally acid-induced oesophageal hyperalgesia using a multimodal stimulation protocol.Ten highly selected patients with NCCP (mean age 43 years, 1 M) were compared with an age- and gender-matched group of 20 healthy subjects. After preconditioning, the distal oesophagus was painfully distended with a balloon using "impedance planimetry". This method assesses the luminal cross-sectional area of the oesophagus based on the electrical impedance of the fluid inside the balloon. The baseline distensions were done before and after pharmacological relaxation of the smooth muscle with 20 mg butylscopolamine. After baseline distensions, a series of up to 10 mechanical stimuli was performed (temporal summation). The stimulations were repeated after sensitization of the oesophagus induced by acid perfusion. The sensory intensities were assessed during the stimulations and the referred pain area was mapped.At baseline distensions, no differences were seen between patients and controls before and after relaxation of the smooth muscles. The patients tolerated fewer repeated distensions than controls (4.8+/-0.5 versus 9.1+/-0.9; p=0.04) and had an increased size of the referred pain areas to the mechanical stimulations (32.9+/-6.2 versus 64.9+/-18.3 cm2; p=0.01). After sensitization with acid, the patients developed hyperalgesia (p0.001), whereas no significant changes were seen in controls.NCCP patients showed facilitated central pain mechanisms (temporal summation and visceral hyperalgesia after sensitization). This could be used in the diagnosis and understanding of the symptoms in these patients.

Our aims were to investigate gender differences to multimodal stimulations of the esophagus after experimentally induced sensitization. Thirty healthy age-matched subjects, 13 males and 17 females, were included. Pain evoked by mechanical and thermal stimuli was assessed before and after perfusion of the lower esophagus with 0.1 N hydrochloric acid. Males were more sensitive to the baseline mechanical stimuli (P < 0.01) and tolerated a lower volume of acid (P = 0.04). After acid perfusion, males were more sensitive than females to distensions (cross-sectional area P = 0.001 and volume P = 0.001). Acid perfusion sensitized both males (P = 0.03) and females (P = 0.04) to heat stimulation but not to cold stimulation (males, P = 0.09; females, P = 0.8). The referral areas for pain evoked by mechanical and thermal stimuli were larger in females compared with males both before and after acid perfusion (P = 0.002). In females only the referred pain area increased to heat stimulations (P = 0.02). Acid infusion resulted in a more hyperreactive esophagus (P = 0.03) but the hyperreactivity was not gender-dependent. In conclusion, males were more sensitive to mechanical and chemical esophageal stimuli and showed acid-evoked mechanical hyperalgesia. Females had significantly larger referred pain areas to the stimulations. The differentiated response to peripheral and central pain mechanisms may explain the gender-related differences seen in several gastrointestinal disorders.

We aimed to investigate the feasibility of robotic-assisted laparascopic reconstruction of the common bile duct (CBD) by way of Roux-en-Y choledochojejunostomy, given an operator with no prior robotic skills.Ten pigs, of 75 kg median weight, were used for the experiments. Three of these animals were used to initialize and adjust the procedure, and seven were scheduled for postoperative survival of a week, and subsequent laparotomy for evaluation. The gallbladder was removed and a Roux-en-Y choledochojejunostomy was done. Blood samples were drawn prior to the first and the final operation. Under laparotomy, the animals were investigated for signs of cholascos and intraoperative cholangiography was performed.All pigs showed competent anastomoses upon evaluation, including two pigs, which died on the fourth and fifth postoperative days, respectively, due to incorrect suspension of the Roux-en-Y sling, resulting in gastric retention. Standard liver parameters were not affected by surgery, and cholangiography showed no signs of extrahepatic stenosis or intrahepatic dilatation.Robotic-assisted Roux-en-Y choledocho-jejunostomy is an easy procedure and accomplishes biliary drainage and intact intestinal flow. Decreasing operating times were experienced, approximating those of a skilled operator.

Background This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. Methods Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. Results No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P = 0·021). Furthermore, those who had VR training showed significantly greater improvement in error (P = 0·003) and economy of movement (P = 0·003) scores. Conclusion Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.

Background and Study Aims: Endoscopic sphincter of Oddi manometry (ESOM) allows direct assessment of motor function in the sphincter of Oddi. However, variations in examination conditions and duodenal motility may have a critical effect on the results of ESOM. The aim of the present study was to develop a new method -sphincter of Oddi video manometry - based on simultaneous ESOM and real-time endoscopic image analysis, and to investigate the usefulness of video manometry for detecting manometric artefacts during ESOM. Patients and Methods: Seven consecutive patients who had undergone cholecystectomy and were referred with a suspicion of sphincter of Oddi dysfunction were investigated. Sphincter of Oddi pressure and endoscopic images (20 frames/s) were recorded simultaneously on a Synectics PC Polygraf computer system with a time-correlated basis, and then compared. Results: On ESOM, 69 sphincter of Oddi phasic contractions were identified, with an average amplitude of 153.9 ± 85.0 mmHg and a duration of 7.9 ± 1.2 seconds. Visual analysis of the real-time endoscopic images, replayed in cine loop by the computer, revealed 236 separate duodenal contractions, with an average frequency of 3.5 ± 2.4/min (range: 1-12/min). On the ESOM tracing, 78% of the duodenal contractions had a corresponding pressure wave with an average duration of 2.8 ± 0.4 seconds and an amplitude of 71.9 ± 16.7 mmHg. Other artefacts on the ESOM tracings, such as catheter movements, pseudocontractions, hyperventilation, or retching, were also easily recognized using simultaneous ESOM and real-time endoscopic image analysis. Conclusions: Video manometry of the sphincter of Oddi is a promising new method for improving the analysis and documentation of ESOM tracings. It has several advantages over the conventional technique, allowing visual detection of duodenal activity and enabling enhanced recognition of other manometric artefacts.

Purpose: To correlate the functional changes of the esophagus determined by manometry and radiography using bread and barium with the severity of esophageal symptoms. Material and Methods: Fifty-seven patients, mean age 44.4 years, suspected of primary esophageal motility disorders underwent simultaneous video-radiography and manometry. Based on interviews the patients were divided into subgroups according to predominant symptom − gastro-esophageal reflux symptoms, dysphagia, or chest pain – and to severity of symptoms, i.e., symptoms with negative or no influence on daily life. The manometric diagnosis and esophageal emptying were based on both liquid and solid swallows. Results: There was significant difference in the incidence of esophageal dysmotility disorders both globally and in the subgroup of patients with dysphagia between patients with and those without severe symptoms, but only after solid swallows. Conclusion: We suggest employment of bread in esophageal function tests to improve the...

Background and aims. To develop a pain model for chemical stimulation of the human gut. Methods. In a double-blind experimental study 10 subjects with a previously performed sigmoidostomy were randomised to receive injections with either isotonic or hypertonic saline in the colonic mucosa. In the hypertonic experimental arm, 0.1 ml of 0.9%, 2%, 4%, and 6% and 0.2 ml of 2% and 4% saline were given. In the placebo arm, six 0.9% saline injections of the same quantities were given. In a separate experiment 0.8 ml 4% saline was infused into the mucosa by a pump over a period of 2 min. The pain intensity was rated on a 0–10 visual analogue scale with 5 as the pain threshold. Results. The hypertonic saline injections resulted in local as well as referred non-painful and painful sensations in 9 out of the 10 subjects. The evoked sensations were mostly described as a smarting sensation with an intensity of median 1 (range 0–5.6) for 0.1 ml 2% saline to median 2.9 (range 0–6.2) for 0.2 ml 4% saline. Seven subjects reported referred sensations to the abdominal skin. Continuous infusion of 4% saline resulted in a consistent sensory response in all subjects, with a median intensity of 4.1 (range 2.1–8.1). This sensory intensity was reproducible in 70% in a retest experiment after median 7 weeks. In the placebo arm a total of 70 isotonic saline injections only resulted in inconsistent, short-lasting non-painful sensations in three subjects. Conclusion. The model represents a safe method for direct chemical activation of the sensory endings in the human gut. The model may be used for pharmacological screening of analgesics and for basic investigations in patients suffering from gastrointestinal diseases.

Objectives: New working time directives reduce the available training hours for futuresurgeons. Laparoscopic training must be more efficient, and deliberate clinical operative training within a short time-frame (module based training) might help achieve this goal. This study set out to measure the effect of such a module based training programme for surgical trainees applied to laparoscopic cholecystectomy. Method: Randomized controlled trial in Danish surgical training hospitals. Thirty-five Danish surgical specialty trainees (registrars) were randomized to either module based training including performance of 20 procedures within 4-8 weeks or standard clinical training. The laparoscopic cholecystectomies were videotaped and blindly rated by three professors/consultants using the validated tool: Global Objective Assessment of Laparoscopic Skills (GOALS). Results: Data show a significant effect of the module based training program on technical skills compared to standard training at one year follow-up despite equal number of performed procedures in the two groups (p=0.010). Due to a large number of drop-outs only ten participants completed the study with the required number of videotaped operations. Inter-rater reliability showed Cronbach’s alpha=0.37. Conclusions: Only few trainees completed the study and inter-rater reliability was low, which highlight some of the challenges in educational randomized studies. Despite this, module based training showed promising effect as an efficient method in clinical skills training of surgical registrars.

OBJECTIVES: Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.DESIGN AND PARTICIPANTS: A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.RESULTS: The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.CONCLUSIONS: Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication.We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies.A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences.Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

Summary Background Proton pump inhibitors (PPI) may potentially modify and decrease the risk for development of oesophageal adenocarcinoma in Barrett's oesophagus (BO). Aim To investigate if the intensity and adherence of PPI use among all patients with BO in Denmark affected the risk of oesophageal adenocarcinoma. Methods We performed a nationwide case–control study in Denmark among 9883 patients with a new diagnosis of BO. All incident oesophageal adenocarcinomas and high-grade dysplasias were identified, and risk ratios were estimated on the basis of prior use of PPIs. Sex- and age-matched BO patients without dysplasia or malignancies in a 10:1 ratio were used for comparison. Conditional logistic regression was used for analysis, adjusting for low-grade dysplasia, gender and medication. Results We identified 140 cases with incident oesophageal adenocarcinomas and/or high-grade dysplasia, with a median follow-up time of 10.2 years. The relative risk of oesophageal adenocarcinoma or high-grade dysplasia was 2.2 (0.7–6.7) and 3.4 (95% CI: 1.1–10.5) in long-term low- and high-adherence PPI users respectively. Conclusions No cancer-protective effects from PPI's were seen. In fact, high-adherence and long-term use of PPI were associated with a significantly increased risk of adenocarcinoma or high-grade dysplasia. This could partly be due to confounding by indication or a true negative effect from PPIs. Until the results from future studies hopefully can elucidate the association further, continuous PPI therapy should be directed at symptom control and additional modalities considered as aid or replacement.

Purpose: Gastro-oesophageal reflux (GOR) is demonstrated by radiography as a supplement to 24-h pH monitoring. Material and Methods: Forty-two patients (mean age 44 years) with suspicion of GOR disease were assessed according to a standard questionnaire. GOR was investigated by 24-h pH-monitoring and by radiography. Oesophageal emptying and the presence of rings or strictures were registered as well. Mucosal biopsies, classified as normal, light oesophagitis, severe oesophagitis, or Barrett's oesophagus, were correlated to age, gender, symptomatology, pH monitoring, and oesophageal emptying. GOR and morphological changes demonstrated by radiography were correlated to pH monitoring and mucosa biopsies. Results: Based on pH monitoring, patients with severe oesophagitis and Barrett's oesophagus had a significantly higher acid exposure compared to patients with normal mucosa and light oesophagitis, with no difference concerning age, gender, and symptoms. Severe oesophagitis, including Barrett's oesophagus, was found only in patients with a positive test for radiologic GOR. Eleven patients had rings or strictures independent of oesophageal mucosal changes. Conclusion: GOR demonstrated by radiography identified patients where complications could be expected, which was not possible by pH monitoring alone.

Purpose: Gastro-oesophageal reflux (GOR) is demonstrated by radiography as a supplement to 24-h pH monitoring.Material and Methods: Forty-two patients (mean age 44 years) with suspicion of GOR disease were assessed according to a standard questionnaire. GOR was investigated by 24-h pH-monitoring and by radiography. Oesophageal emptying and the presence of rings or strictures were registered as well. Mucosal biopsies, classified as normal, light oesophagitis, severe oesophagitis, or Barrett's oesophagus, were correlated to age, gender, symptomatology, pH monitoring, and oesophageal emptying. GOR and morphological changes demonstrated by radiography were correlated to pH monitoring and mucosa biopsies.Results: Based on pH monitoring, patients with severe oesophagitis and Barrett's oesophagus had a significantly higher acid exposure compared to patients with normal mucosa and light oesophagitis, with no difference concerning age, gender, and symptoms. Severe oesophagitis, including Barrett's oesophag...

Background Introduction of the laparoscopic surgical technique has reduced hospital stay after colonic resection from about 8–10 to 4–6 days. In most studies, however, specific attention has not been paid to changes in perioperative protocols required to maximize the advantages of the minimally invasive procedure. In the present study the laparoscopic approach was combined with a perioperative multimodal rehabilitation protocol. Methods After laparoscopically assisted colonic resection, patients were treated with epidural local anaesthesia for 2 days, early mobilization and enteral nutrition. Routine use of morphine and traditional tubes, drains and prolonged bladder catheterization was avoided. Results Laparoscopic resection was intended in 50 consecutive patients, of median age 81 years. The conversion rate to open resection was 22 per cent. In patients in whom the procedure was completed laparoscopically the median hospital stay was 2·5 days; defaecation occurred in 92 per cent of patients within 3 days. Patients were mobilized for more than 8 h daily from day 2. Conclusion Recovery after colonic surgery was improved considerably by combining the use of a laparoscopic technique with a multimodal rehabilitation protocol of pain relief, early mobilization and oral nutrition.

Udgivelsesdato: 2009-Apr BACKGROUND: The study was carried out to determine the learning curve patterns for basic laparoscopic technical skills. METHODS: Thirty-seven surgical residents with limited laparoscopic experience performed 10 repetitions of 6 tasks on a virtual-reality trainer (MIST-VR) with standardized distribution of practice. Assessment was based on time, errors, and economy of motion as measured by MIST-VR. Proficiency levels were established by testing experienced laparoscopic surgeons. RESULTS: Four learning curve patterns were determined. Surgeons in group 1 (5.4%) demonstrated proficiency from the beginning; group 2 (70.3%) achieved predefined expert criteria between 2 and 9 repetitions; group 3 (16.2%) demonstrated improvement but was unable to achieve proficiency within 10 repetitions. Group 4 (8.1%) underperformed and showed no tendency of skills improvement, reflecting a group of subjects who probably are unable to learn laparoscopic technique. CONCLUSIONS: The results indicated that a group of subjects could not reach proficiency in the psychomotor skills relevant for laparoscopy. We believe that this is an important issue that should be addressed in future research.

Purpose: Quantitative hepatobiliary scintigraphy, a noninvasive method frequently used to diagnose several biliary tract disorders, shows abnormalities in bile secretion and outflow. It is well known that there are wide variations in the normal pattern of bile emptying, but the effect of cholecystectomy on the bile flow has not yet been investigated. The goal of the current study was to examine the dynamics and normal variations of bile flow by quantitative hepatobiliary scintigraphy before and after cholecystectomy in a group of patients with uncomplicated gallstone disease. Methods: Twenty patients were evaluated before and after cholecystectomy through cholecystokinin octapeptide-augmented quantitative hepatobiliary scintigraphy, and quantitative parameters of bile emptying (T max : time to peak activity, T 1/2 : half-emptying time before and after cholecystokinin octapeptide and duodenum appearance time) were determined and then compared. Results: Before operation, the bile outflow displayed wide variations, with a moderately delayed common bile duct emptying time in some patients. After cholecystectomy, the T 1/2 of the common bile duct decreased significantly when compared with the preoperative status, with only minor patient-to-patient variation, indicating uniformly faster bile emptying (common bile duct T 1/2 before and after operation: 30.5 ± 14.8 and 18.8 ± 2.6 min, respectively). Cholecystokinin octapeptide administration caused rapid bile outflow from the common bile duct, with a significant decrease in the T 1/2 parameters before and after cholecystectomy. Conclusions: In patients with their gallbladders in situ, the bile emptying rate showed wide variations and may be moderately slow without distal common bile duct obstruction. After cholecystectomy, the rate of bile emptying accelerated and showed only minor variations, thereby increasing the sensitivity of quantitative hepatobiliary scintigraphy for showing partial biliary obstruction.