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Background: Despite the importance of predicting adverse postoperative outcomes, functional performance status as a proxy for frailty has not been systematically evaluated in emergency abdominal surgery. Our aim was to evaluate if the Eastern Cooperative Oncology Group (ECOG) performance score was independently associated with mortality following high-risk emergency abdominal surgery, in a multicentre, retrospective, observational study of a consecutive cohort.Methods: All patients aged 18 or above undergoing high-risk emergency laparotomy or laparoscopy from four emergency surgical centres in the Capitol Region of Denmark, from January 1 to December 31, 2012, were included. Demographics, preoperative status, ECOG performance score, mortality, and surgical characteristics were registered. The association of frailty with postoperative mortality was evaluated using multiple regression models. Likelihood ratio test was applied for goodness of fit.Results: In total, 1084 patients were included in the cohort; unadjusted 30-day mortality was 20.2%. ECOG performance score was independently associated with 30-day mortality. Odds ratio for mortality was 1.70 (95% CI (1.0, 2.9)) in patients with ECOG performance score of 1, compared with 5.90 (95% CI (1.8, 19.0)) in patients with ECOG performance score of 4 (p < 0.01). Likelihood ratio test suggests improvement in fit of logistic regression modelling of 30-day postoperative mortality when including ECOG performance score as an explanatory variable.Conclusions: This study found ECOG performance score to be independently associated with the postoperative 30-day mortality among patients undergoing high-risk emergency laparotomy. The utility of including functional performance in a preoperative risk assessment model of emergency laparotomy should be evaluated.

OBJECTIVE: To study long-term gastrointestinal surgical hospital burden (hospital readmissions and gastrointestinal surgical procedures) after laparoscopic gastric bypass.BACKGROUND: Little is known about gastrointestinal surgical hospital burden after laparoscopic gastric bypass.METHODS: Danish patients undergoing laparoscopic gastric bypass (BMI >35-50) from January 1, 2005 to December 31, 2013 were included (100% follow-up). The nonsurgical reference group were individuals with BMI of ≥ 30 drawn from The Danish National Health Surveys from 2005 to 2013. The primary outcome was gastrointestinal surgical hospital burden. Secondary outcome was mortality. Age, body mass index (BMI), gender, and calendar time (time of surgery and nonsurgical survey), diabetes status was adjusted for in a multivariate Poisson regression model.RESULTS: 13,582 bariatric surgical patients and 45,948 reference individuals were included with a mean follow-up time of 4.7 years (SD 2.4). The incidence rate ratio (IRR) for hospital re-re-admission was 2.17 higher in the intervention group (95% CI 2.04-2.31). Sensitivity analysis showed that patients operated before 2010 had a higher incidence for re-re-admission than after. IRR for surgical gastrointestinal procedures was 6.56 (CI 6.15-6.99) and 3.04 (CI 3.51-4.17) after 1 and 5 years for the intervention group compared with the reference group. Surgery for internal hernia was the most common abdominal procedure. The mortality odds ratio was 0.84 (CI 0.65-0.96).CONCLUSIONS: Gastrointestinal surgical hospital burden was significantly higher in the first 5 years after gastric bypass compared with a matched nonsurgical reference group of obese citizens.

BACKGROUND: Body mass index (BMI) derived from self-reported information is widely used and the validity is therefore crucial. We aim at testing the validity of self-reported height and weight, and to test if the accuracy of self-reported information can be improved by calibration by testing if calibration improved the ability to predict diabetes.METHODS: Data from Danish Health Examination Survey (DANHES) was used. 15 692 participants who had both filled out questionnaire and participated in health examination, and 54 725 participants with questionnaire alone, were included. Data was analyzed using Pearson's R, Cohens Kappa, linear regression and Cox-regression. Self-reported values of height and weight were calibrated using coefficients obtained from linear regression analysis. To evaluate if the calibration improved the ability to predict diabetes, Akaike's information criterion was used.RESULTS: Self-reported height, weight and BMI were highly correlated with measured values (R ≥ 0.92). BMI was under-reported by 0.32 kg m-2 and 0.38 kg m-2 in women and men. The hazard ratio (HR) (95% confidence interval) for diabetes according to measured BMI was 2.09 (1.89-2.27) and for self-reported BMI was 1.60 (1.50-1.70) per 5 kg m-2. Calibrated values of self-reported BMI improved the predictive value of BMI for the risk of diabetes.CONCLUSIONS: Self-reported height and weight correlated highly with physical measurement of height and weight. Measured values of BMI were more strongly associated with diabetes risk as compared to self-reported values. Calibration of the self-reported values improved the accuracy of self-reported height and weight.

Introduction: Undergoing acute high-risk abdominal (AHA) surgery is associated with reduced survival and a great risk of an adverse outcome, especially in the elderly. The primary aim of this study was to investigate the residential status and quality of life in elderly patients undergoing AHA surgery. Methods: From 1 November 2014 to 30 April 2015, consecutive patients (≥ 75 years) undergoing AHA surgery were included for follow-up after six months. The patients included answered a health-related quality-of-life questionnaire and a supplemental questionnaire regarding residential status. The results were compared with an age-matched national control group. Results: A total of 52 patients matched the inclusion criteria. Mortality at six months after surgery was 46%. Out of the 28 survivors, 22 participated in the study. Quality of life was estimated as good in 77% of the survivors and they were willing to undergo surgery again, if necessary. All study participants were admitted from their own home, and 95% had no change in residential status after six months. Conclusions: The self-reported quality of life in elderly survivors six months after AHA surgery was surprisingly good in a small study where all findings should be interpreted with precaution. The majority had no change in residential status. Our study may provide useful information for surgeons advising elderly patients and their families about realistic outcomes following AHA surgery.

BACKGROUND: With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never been validated exclusively in an emergency setting.METHODS: A consecutive prospective single-center cohort study of 355 adults undergoing emergency high-risk abdominal surgery between June 2013 and May 2014 is presented. The primary outcome measure was 30-day mortality. Secondary outcome measures were postoperative major complications, defined according to the Clavien-Dindo scale as well as the American College of Surgeons' National Surgical Quality Improvement Program guidelines, and intensive care unit admission. The SAS was calculated postoperatively. Cochran-Armitage test for trend was used to evaluate the incidence of both outcomes. Area under the curve was used to demonstrate the scores' discriminatory power.RESULTS: One hundred eighty-one (51.0%) patients developed minor or no complications. The overall incidence of major complications was 32.7% and the overall death rate was 16.3%. Risk of major complications, death, and intensive care unit admission increased significantly with decreasing SAS (P < .001). The score's c-statistics were 0.63.CONCLUSIONS: We have demonstrated the SAS to be significantly predictive but weakly discriminative for major complications and death among adults undergoing emergency high-risk abdominal surgery. Despite its predictive value, the SAS cannot in its current version be recommended as a standalone prognostic tool in an emergency setting.

INTRODUCTION: The purpose of this study was to evaluate the relation between preoperative delay and mortality in surgical patients undergoing primary emergency laparotomy (PEL) in an unselected, well-described patient cohort in a university hospital setting.MATERIAL AND METHODS: This study was a retrospective analysis of patient charts and perioperative documentation in an unselected consecutive cohort of 131 patients. Covariates for survival outcomes were evaluated in a multivariate analysis. No external funding and no competing interests were declared. The study was approved by The Danish Data Protection Agency; and in pursuance of national Danish research guidelines concerning retrospective studies, approval from ethics committee was not relevant.RESULTS: PEL was performed in 131 patients in the observation period. The median age of the patients was 68 years. The median time from admission to start of operation for all patients was 9.5 hours. No association between a time to operation exceeding six hours and post-operative mortality was found (adjusted odds ratio (95% confidence interval) = 0.67 (0.25-1.78)). Patients over 75 years of age had a very high mortality (47.8%). Most patients died within 30 days post-operatively.CONCLUSION: Acute admission and emergency laparotomy is associated with a very high mortality, especially in elderly patients. However, delay in the surgical treatment exceeding six hours is not associated with a higher mortality. There may be a considerable potential for improving care and management in these patients through a more systematic approach.

INTRODUCTION: Post-marketing surveillance of drugs relies on spontaneous reporting of adverse drug events to the Danish Health and Medicines Authority. A number of new oral anticoagulants (NOAC) have recently been marketed in Denmark. The purpose of this study was to evaluate the reporting of serious adverse drug events in patients treated with a NOAC and admitted for gastrointestinal bleeding.METHODS: This study is based on an electronic free text search in patient records and a search in the electronic medication records of all patients admitted to the Department of Gastroenterology, Surgical Section, Hvidovre Hospital, during a one-year-period. Patients in treatment with NOAC and admitted for gastrointestinal bleeding were identified. Relevant patients were cross-checked for a reported adverse drug event in the Danish Health and Medi-cines Authority's database on adverse medical events.RESULTS: A total of 20 patients were acutely admitted for gastrointestinal bleeding while in treatment with a NOAC, an adverse medical event was reported for one of these patients (5%; 95% confidence interval: 0-25%).CONCLUSION: Serious adverse events in patients treated with NOAC are underreported which questions the current effectiveness of post-marketing surveillance of adverse drug effects.FUNDING: not relevant.TRIAL REGISTRATION: The study was registered with clin-icaltrials.gov (NCT02107651).

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

The nationwide Danish Hernia Database, recording more than 10,000 inguinal and 400 femoral hernia repairs annually, provides a unique opportunity to present valid recommendations in the management of Danish patients with groin hernia. The cumulated data have been discussed at biannual meetings and guidelines have been approved by the Danish Surgical Society. Diagnosis of groin hernia is based on clinical examination. Ultrasonography, CT or MRI are rarely needed, while herniography is not recommended. In patients with indicative symptoms of hernia, but no detectable hernia, diagnostic laparoscopy may be an option. Once diagnosed, hernia repair is recommended in the presence of symptoms affecting daily life. In male patients with minimal or absent symptoms watchful waiting is recommended. In females, however, repair is recommended also in asymptomatic patients. In male patients with primary unilateral or bilateral groin hernia the preferred method is mesh repair, either at open surgery (Lichtenstein) or laparoscopically, irrespective of age. Conventional tension-producing methods like Bassini, McVay or Shouldice are no longer recommended in a routine elective setting. Whether repair should be done by open or laparoscopic technique, depends on local expertise, economical considerations and patient preference. Compared to the Lichtenstein operation laparoscopic repair is associated with less acute pain and faster recovery. Furthermore, available data suggest less chronic long-term pain after laparoscopic repair. In female patients laparoscopic repair is the recommended method. In patients with recurrent hernia laparoscopic repair is preferred in patients with a previous open repair, while patients with recurrence after laparoscopic repair should undergo open mesh repair. In open repair it is recommended to use a mesh secured with a nonabsorbable monofilament suture. In laparoscopic repair a mesh without a slit and with a minimum size of 15 by 10 cm is used. For mesh fix

The duration of convalescence after inguinal hernia repair is determined by a number of factors, among which are information and recommendations given by the surgeon and the general practitioner, level and duration of postoperative pain, type of repair, level of physical activity at work and during leisure activities and development of complications. The literature provides no evidence to support an increased risk of recurrence with early resumption of physical activity after inguinal hernia repair. Patients should be encouraged to resume full activities immediately after surgery, only limited by pain. Udgivelsesdato: 2009-Sep-28

BACKGROUND: Randomised studies suggest regional anaesthesia to have the highest morbidity and local infiltration anaesthesia to have the lowest morbidity after groin hernia repair. However, implications and results of this evidence for general practice are not known. METHODS: Prospective nation-wide data collection in a cohort of n=29,033 elective groin hernia repairs, registered in the Danish Hernia Database in three periods, namely July 1998-June 1999, July 2000-June 2001 and July 2002-June 2003. Retrospective analysis of complications in discharge abstracts, identified from re-admission within 30 days post-operatively, prolonged length of stay (>2 days post-operatively) or death. RESULTS: Complications after groin hernia repair were more frequent in patients 65+ years (4.5%), compared with younger patients (2.7%) (P<0.001). In patients 65+ years, medical complications were more frequent after regional anaesthesia (1.17%), compared with general anaesthesia (0.59%) (P=0.003) and urological complications were more frequent after regional anaesthesia (0.87%), compared with local infiltration anaesthesia (0.09%) (P=0.006). Seventeen prostatectomies occurred after post-operative urinary retention, but with no case after local anaesthesia. Mortality within 30 days after elective groin hernia repair was 0.12%. Regional anaesthesia was disproportionately more often used in patients dying within 1 week post-operatively. CONCLUSION: Choice of the anaesthetic technique should be adjusted to available procedure-specific scientific evidence and the use of regional anaesthesia in elderly patients undergoing groin hernia repair is not supported by existing evidence Udgivelsesdato: 2008/2

OBJECTIVE: The purpose of this study was to investigate the use of contrast-enhanced ultrasound imaging (CEUS) to detect the first draining lymph node (FDLN) in a swine model and to determine whether the distance from the contrast agent injection site to the FDLN has any affect on the ability to detect contrast-enhanced FDLNs. METHODS: Thirteen swine (25-32 kg) were anesthetized during examinations and euthanized afterward. In every swine, 1 mL of a sulfur hexafluoride microbubble ultrasound contrast agent was bilaterally injected subcutaneously below a mammilla. The examined distances varied from 6 to 36 cm. The contrast-enhanced lymphatic channels were visualized with low-mechanical index CEUS and mapped from the injection site to the FDLN. After CEUS was performed, blue dye was injected in the same locations as the contrast agent, and dye-guided surgery was used to localize the FDLNs. To ensure the lymph node detected with the blue dye technique was the same found with CEUS, it was scanned again to confirm contrast enhancement. RESULTS: After 26 injections, 22 inguinal FDLNs were detected with CEUS and the blue dye technique. After 4 injections in 2 swine, contrast-filled lymphatic channels were identified with a course running toward the neck. In all cases but 1, the FDLNs received the contrast agent within 5 minutes. CONCLUSIONS: In this swine model, it was possible to use CEUS to locate the FDLNs. In these preliminary experiments, the distances from the contrast agent injection site to the FDLN did not affect the ability to detect the contrast-enhanced FDLNs Udgivelsesdato: 2008/8