British Journal of Surgery

Breitholtz, Björn Brännström; Gardfjell, Anna; Åhsberg, Kristina

doi: 10.1093/bjs/znaf149.030pmid: N/A

IntroductionThe use of magnetic resonance imaging (MRI) in preoperative staging of breast cancer remains arbitrary. The high sensitivity together with the somewhat lower specificity of MRI provides a unique balance between finding true extent/new lesions and overdiagnostics/overtreatment. This study aims to assess a cohort of breast cancer patients examined with preoperative MRI and estimate the potential benefits and negative effects.MethodThis retrospective, single center cohort study included patients examined with preoperative MRI before primary surgery for breast cancer between 2019 and 2022.ResultIn total, 94 patients were included. Median age was 54 years, 37.2% were premenopausal and 35.1% had invasive lobular carcinoma. The detection rate of occult contralateral breast cancer was 9.6%. Reoperation rate due to positive margins was 6.4%. Bland-Altman statistics showed higher agreement between estimated extent by MRI and postoperative histopathological extent, compared to estimation by ultrasound or mammography. MRI contributed to correct change of operation method in 18.1%, but also less favorable choice of surgery in 5.3% of patients (such as unnecessary mastectomy). The total mastectomy rate was 54.3%. Unnecessary biopsies of benign lesions after MRI were performed in 11.7% of patients.DiscussionIn this cohort, breast MRI had a clear impact on the surgical treatment of breast cancer, affecting choice of operation method. About a fifth of patients examined with MRI received a benefit with a better management of their breast cancer, however an equally large part received less optimal diagnostics and treatment.

Beka, Ervin; Shabo, Ivan; Fornander, David; Johansson, Kenth; Gimm, Oliver

doi: 10.1093/bjs/znaf149.046pmid: N/A

IntroductionBenign thyroid nodules/goitre are very common. When associated with local symptoms including dysphagia, dyspnoea, dysphonia and pharyngeal discomfort, patients often undergo hemithyroidectomy to improve their symptoms. Whether the improvement of the local symptoms can be predicted is poorly investigated.MethodIn this prospective multicentre study, patients filled in four validated questionnaires before, six weeks and one year after hemithyroidectomy. Furthermore, the size of the thyroid nodule/goitre, the size of the isthmus and its distance to the jugulum were registered.ResultA total of 119 consecutive patients were offered to participate in the study. Of these, 72 patients completed the preoperative and postoperative questionnaires after six weeks and 70 patients completed the 1-year follow-up. Of interest, the reported preoperative symptoms did not correlate at all with the objective measurements. Six weeks after surgery, the majority (95%) of patients reported some sort of dysphonia despite the absence of objective findings like laryngeal nerve palsy. In contrast, a significant proportion (73%) of patients noted symptomatic improvements regarding all other symptoms already six weeks postoperatively. Of note, symptom improvements were even reported of patients with thyroid nodules as small as 1 cm in size. After 1 year, 13% of the patients still experienced some sort of dysphonia. Nevertheless, 89% of the patients would recommend the procedure to other patients with similar symptoms.DiscussionThe vast majority of patients with local symptoms due to benign thyroid nodules/goitre noticed an improvement of their symptoms after hemithyroidectomy. The symptomatic improvements were not predictable based on objective preoperative measurements.

Wetterholm, Erik; Arthursson, Victoria; Thorlacius, Henrik; Rönnow, Carl-Fredrik

doi: 10.1093/bjs/znaf149.077pmid: N/A

IntroductionWhen deciding on treatment for early rectal cancer, available options must be considered based on both the risk for recurrence and the risk of postoperative morbidity. This retrospective registry study aimed to investigate morbidity and mortality following surgical resection of T1 and T2 rectal cancer.MethodPopulation-based registry study using the Swedish Colorectal Cancer Registry, including all pathologically staged T1 and T2 rectal cancer cases between 2011 and 2022 treated with anterior resection with or without diverging ileostomy, abdominoperineal resection or Hartmann’s procedure. Complications were registered according to the Clavien-Dindo (CD) classification and considered severe if CD³III. Patient characteristics were analysed using uni- and multivariate logistic regression to determine risk factors for complications.Result2548 rectal cancer patients, 761 with T1 and 1787 with T2, were included. A total of 922 complications were registered among 694 (27.2%) patients. 300 (11.8%) patients had one or more severe complications. 92 patients (3.6%) required intensive care, and 188 (7.4%) had a reoperation. 1063 (41.7%) patients received a temporary stoma (diverging ileostomy) and 1009 (39.6%) a permanent stoma. Anastomotic leakage occurred in 98 (6.4%) of 1539 patients undergoing anterior resection. 90-day mortality was 36 (1.4%). Male sex (OR 1.73, 95% CI 1.34-2.23), ASA III-IV (OR 1.53, 95% CI 1.18-1.99) and BMI>30 (OR 1.41, 95% CI 1.06-1.86) were significant (p<0.05), independent risk factors for complications.DiscussionSurgical resection of early rectal cancer has a high rate of complications and stomas, which should be considered when deciding between treatment options.

Schalling, Klara; Sartipy, Fredrik; Gillgren, Peter; Lindström, David; Mill, Victor; Smedberg, Christian; Westerlund, Eli; Malmstedt, Jonas

doi: 10.1093/bjs/znaf149.091pmid: N/A

IntroductionPrimary subclavian venous thrombosis (PSVT), affects young patients with an active lifestyle or strenuous occupations. Treated with anticoagulation alone, up to 45% develop post-thrombotic syndrome (PTS). Early treatment with catheter-directed thrombolysis (CDT) followed by first rib resection (FRR) has been shown to reduce PTS in selected cases. We report outcomes when this treatment is implemented in a regional population.MethodPatients with PSVT presenting within 14 days from symptom onset were treated between 2013 and 2024, and followed by clinical visits and duplex ultrasound 1 and 12 months after surgery. Primary outcome was Disabilities of the Arm, Shoulder and Hand (DASH) score and secondary outcome was clinical result according to the Derkash classification. Ethical approval was obtained from the Regional Ethics Board.Result227 patients underwent CDT and FRR, with a median age of 30, (IQR 25-40 years) and 51% were women (n=116). Regular sport activity was performed by 70% (156/227). The median time from symptom onset to start of CDT was six (IQR 4-8) days. 197 patients completed 12 months follow-up. Median DASH-score at baseline was 30 (IQR 13-45) and decreased to 1 (IQR 0-6) at 12 months follow-up. Outcome at 12 months according to the Derkash classification was excellent or good in 98% (n=194/197).DiscussionEarly CDT and FFR in acute PSVT yields good results when implemented at a population level. This study supports that most patients with PSVT in a population can be identified early and offered treatment with early CDT and FFR to avoid PTS.

Ekros, Alice

doi: 10.1093/bjs/znaf149.020pmid: N/A

IntroductionBreast cancer is the most frequent cancer among women, with surgery playing a central role in the treatment. Various surgical approaches exist, including a growing field of oncoplastic techniques. Despite classified as a clean surgery, breast surgery has higher rates of postoperative infections compared to other clean surgeries. The role of prophylactic antibiotics in preventing infections remains indecisive.MethodThis study aimed to investigate the correlation between prophylactic antibiotics and postoperative infections in breast cancer surgery. Secondary objectives included assessing the impact of surgical complexity and demographic factors on infection risk.This study included 578 patients with an invasive breast cancer diagnosis undergoing surgery at Skåne University Hospital during year 2022. Patient records were reviewed in Melior to gather information on demographics, surgical type, prophylactic antibiotic administration and postoperative infections.ResultThe overall postoperative infection rate after breast cancer surgery was 14% and 72% received prophylactic antibiotics. Mastectomy had the highest postoperative infection rate. No significant difference regarding postoperative infection could be observed between the patients who received prophylactic antibiotic treatment and those who did not (p = 0.88). An increased body mass index was significantly correlated with an increased risk of postoperative infection (p = 0.01).DiscussionProphylactic antibiotics were not associated with a decreased risk of developing postoperative infection. The complexity of the procedure may correlate to the risk of developing a postoperative infection but overall no significance was shown in this study. However, demographic factors as higher body mass index was significantly correlated with an increased risk for postoperative infection.

Holmberg, Anna; Lunde, Anna; Lundahl, Helene Nilsson; Johnsson, Folke; Löfvendahl, Sofia; Ahl, Eric; Sundin, Ylva; Huss, Linnea

doi: 10.1093/bjs/znaf149.132pmid: N/A

IntroductionThe objective of this report was to evaluate the disinfection process of flexible endoscopes without working channels using ultraviolet (UV) light, in comparison to the currently recommended reprocessing method, in a clinical setting.MethodA comprehensive search of articles was conducted in November 2024 across Medline, Embase, CINAHL, and CENTRAL databases. Ongoing studies and Health Technology Assessment (HTA) reports were also searched. The selected studies were assessed by at least two independent authors, and inclusion decisions made by consensus. The studies underwent critical appraisal, and relevant data were extracted. Data on the level of disinfection were pooled in a meta-analysis using R software. The certainty of the evidence was evaluated using the GRADE approach.In collaboration with experienced hygiene nurses and a physician involved in the project, organizational issues related to implementation were addressed, and a health economic analysis was conducted.ResultManual pre-cleaning followed by ultraviolet (UV) light disinfection of flexible endoscopes without working channels may offer a slightly higher level of effectiveness compared to the currently employed reprocessing method using an endoscope washer-disinfector.An organizational review indicates that there are benefits to using UVC light, as the disinfection process is faster and requires fewer installations.The health economic analysis supports the use of UV-light disinfection due to lower investment and running costs.DiscussionThis health technology assessment can be used as a decision basis for a preferred desinfection process at units using flexible endoscopes without working channels.

Ibrahim, Ibrahim; Amanoil, Rosette; Sotirova, Ira; Scandavini, Chiara; Yoshino, Jun; Valente, Roberto; Gkekas, Ioannis; Franklin, Oskar; Halimi, Asif

doi: 10.1093/bjs/znaf149.105pmid: N/A

IntroductionPortal venous thrombosis (PVT) is a feared complication following pancreatectomy with venous resection, with reported rates ranging between 5% and 31%. Strategies to reduce PVT risk vary. This study evaluates early PVT incidence in patients undergoing venous resection using a standardized approach involving liberal Cattell Braasch maneuver, preference for end-to-end anastomosis, and intensified anticoagulation, combined with routine ultrasound assessment on postoperative day 1 (POD1).MethodWe conducted a retrospective cohort study of patients undergoing pancreatectomy with SMV and/or portal vein resection between 2020–2023 at Umeå University Hospital. The primary outcome was symptomatic PVT within 30 days. Secondary outcomes included detection of PVT or flow irregularity on POD1 ultrasound, and postoperative morbidity/mortality.ResultA total of 60 patients were included (median age 69.4 years). Most underwent segmental venous resection (85%) and Whipple (48.3%) or total pancreatectomy (45%). The Cattell- Braasch maneuver was used in 88.3% of cases. POD1 ultrasound was performed in 95% (57/60) of patients. Only one patient (1.6%) developed symptomatic PVT—this patient did not undergo POD1 ultrasound. No PVT or flow irregularity was detected on any POD1 ultrasound. Major postoperative complications (Clavien-Dindo ≥3a) occurred in 15%, while 30- and 90-day mortality rates were 5% and 6.6%, respectively.DiscussionA standardized surgical and postoperative protocol involving liberal use of the Cattell- Braasch maneuver, end-to-end anastomosis, and intensified anticoagulation appears to be associated with a low incidence of early PVT after venous resection in pancreatic surgery. POD1 ultrasound may be a valuable tool in early detection, potentially supporting risk stratification and timely intervention.

de la Croix, Hanna; Bengtsson, Jonas; Fledsberg, Stephanie; Park, Jennifer; Åberg, Helena; Hermanson, Maria

doi: 10.1093/bjs/znaf149.065pmid: N/A

IntroductionTiming in surgery for inflammatory bowel disease (IBD) is important, considering risk of complications. This study aimed to compare healthcare resource utilization and costs of delayed elective surgery in patients with IBD.MethodThis is a descriptive and observational study based on retrospectively collected data from Swedish national and regional registries. Patients either waiting for, or who had undergone, elective surgery at Sahlgrenska University Hospital during 2017-2023 with an IBD-diagnosis were identified.ResultIn total, 189 individuals were included, 40 controls (mean age 43.6 years, 18 women) who had surgery within 3 months, and 149 cases (mean age 41.6 years, 46 women), who had been waiting for surgery for at least 6 months. After 24-36 months the cost for the controls was 5470 EUR and for the cases 8510 EUR. Mean household yearly income was 36 027 EUR (CI 27 310–44 743) for the controls and 28 688 EUR (CI 25 844–31 532) for the cases. In total, 90% (n=36) were born in Sweden in the control group vs. 75.2% (n=112) in the case group. There was no difference in terms of sick leaves between the groups.DiscussionHealth care costs for patients with IBD waiting for surgery are similar to those of patients who have had elective surgery within 3 months. Given the additional postoperative costs for patients waiting for surgery, the overall costs are higher for this group. A short period of time between surgical decision and surgical date is therefore advisable.

de la Croix, Hanna; Bengtsson, Jonas; Fledsberg, Stephanie; Åberg, Helena; Hermanson, Maria

doi: 10.1093/bjs/znaf149.072pmid: N/A

IntroductionTiming in surgery for inflammatory bowel disease (IBD) is important considering risk of complications, such as fistulizing disease, severe proctitis and high stoma output. This study aimed to address Health-Related Quality of Life (HRQoL) when waiting for surgery.MethodThis study was a cross-sectional register-based study combined with individual-level collected data on the EQ-5D-5L questionnaire assessing the effects of delayed elective surgery on HRQoL amongst patients with IBD. Patients either waiting for, or who had undergone surgery at Sahlgrenska University Hospital during 2017-2023 with an IBD-diagnosis were identified.ResultOf the 214 patients included in the study (33.64% women, mean age 44.3+16.9 years), 60% of the patients had undergone surgery, while the remainder were still awaiting surgery. The mean EQ VAS for the entire sample was 64.9, with the lowest scores observed when waiting for surgery for more than one year, compared to previous age matched population norms in Sweden, with a mean score of 87.0. The mean EQ-5D-5L index for patients waiting less than 3 months differed from those who waited 12-24 months (p=0.017) and >24months (p=0.012) respectively. Likewise, the mean EQ-5D index for those who waited 3-6 months differed from those waiting >12-24 months (p=0.036) and >24 months (p=0.032), using the Swedish value set.DiscussionThere were significant differences in HRQoL between patients who had undergone surgery within the Swedish health care guarantee (<3 months) and those who had been waiting for at least one year. This indicates that waiting time for surgery may impact HRQoL among patients with IBD.

Mijaljevic, Lidija; Azhar, Najia; Chabok, Abbas; Folkesson, Joakim; Gerdin, Anders; Grönkvist, Rode; Hermus, Linda; Larsson, Charlotta; Martling, Anna; Matthiessen, Peter; Nilsson, Per; Rydbeck, Daniel; Angenete, Eva