Search

Objectives: Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. ‍This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries., Materials and Methods: A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients., Results: Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively., Conclusion: Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.

Background: Pancreatic injuries are rare. Reports are lacking from defined European populations covering all ages and genders and in areas with a low prevalence of penetrating trauma. We aimed to review pancreatic injuries identified within a defined population., Methods: Observational cohort study from a prospectively maintained trauma registry and all patients coded for a pancreatic injury between January 1, 2004 and December 31, 2018., Results: A total of 14 patients with pancreatic injury were identified over a 15-year time period. Pancreatic injuries represented 0,19% (14/7207) of all trauma patients and 3,1% (14/454) of patients with documented abdominal injuries. Nine patients 64% (9/14) were children, representing 1% (9/869) of all injured children in the registry and 11,4% (9/79) of children with documented abdominal injuries. Median age was 10,5 years (range 3-58). Ten were male (71%) and 86% (12/14) suffered blunt trauma. Median AAST-OIS was 2 (1-4). Single organ injury occurred in 43% (6/14). Concomitant liver injury was the most frequent associated intra-abdominal injury found in 29% (4/14). Four patients (29%) had associated injuries in other body regions, all thoracic injuries. Median ISS was 9,5 (4-41).Operative management was needed for four of the pancreatic injuries, one spleen-preserving distal pancreatectomy, one spleen-sacrificing distal pancreatectomy and two peripancreatic drainages. One patient died within 30-days, but the death was unrelated to the pancreatic injury., Conclusions: Incidence of pancreatic injuries is low, even among trauma patients with documented abdominal injuries. Most pancreatic injuries occurred in children. Injuries requiring surgery was rare.

Introduction: Conservative, non-antibiotic and non-surgical management of acute diverticulitis is currently being investigated. To better inform clinical decisions, better understanding of disease mechanisms, disease burden and severity is needed., Methods: Literature search of risk factors, pathophysiology, epidemiology and disease burden/severity reported over the last decade., Results: Acute diverticulitis is a common disease and has a high disease burden. Incidence of hospital admissions is reported around 71 per 100,000 population, with reported increase in several subpopulations over the last decades. The incidence is likely to increase further with the aging populations. Risk factors for left-sided acute diverticulitis include dietary, anthropometric and lifestyle factors. Disease mechanisms are still poorly understood, but a distinction between inflammation and infection is emerging. The integrative and complex role of the gut microbiota has become an interesting factor for both understanding the disease as well as a potential target for intervention using probiotics. Mild, self-limiting events are increasingly reported from studies of successful non-antibiotic management in a considerable number of cases. Risk markers of progression to or presence of severe, complicated disease are needed for better disease stratification. Current risk stratification by clinical, imaging or endoscopic means is imperfect and needs validation. Long-term results from minimal-invasive and comparative surgical trials may better help inform clinicians and patients., Conclusions: Over- and under-treatment as well as over- and under-diagnosis of severity is likely to continue in clinical practice due to lack of reliable, robust and universal severity and classification systems. Better understanding of pathophysiology is needed.

Background: Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers., Methods: A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF., Results: A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained., Conclusions: Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.

Colorectal cancer (CRC) is the third most common cancer worldwide. Survival is largely stage-dependant, guided by the tumor-node-metastases (TNM) system for TNM assessment. Histopathological evaluation, including assessment of lymph node status, is important for correct TNM staging. However, recent updates in the TNM system have resulted in controversy. A continued debate on definitions resulting in potential up- and downstaging of patients, which may obscure survival data, has led the investigators to investigate other or alternative staging tools. Consequently, additional prognostic factors have been searched for using the regular light microscopy. Among the factors evaluated by histopathology include the evaluation of tumor budding and stromal environment, angiogenesis, as well as involvement of the immune system (including the 'Immunoscore'). We review the current role of histopathology, controversies in TNM-staging and suggested alternatives to better predict outcome for CRC patients in the era of genomic medicine.

Objective: While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences., Methods: From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded., Results: Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure., Conclusions: Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.

Objective: Novel imaging modalities have supplanted endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of hepatobiliary pancreatic diseases, but the use of ERCP as a diagnostic and therapeutic tool in current clinical practice is not well known. The main objective of this study was to describe and evaluate contemporary use of ERCP in Norway., Material and Methods: Prospective and consecutive data were collected between January 2007 and December 2009 from voluntary institutional reports of ERCP activity at participating hospitals in the Gastronet database., Results: A total of 3840 procedures at 14 hospitals were registered during the study period. Data from 3809 procedures (53% females) were available for evaluation. Patients were ≥60 years of age in 2567 (67%) procedures. High co-morbidity (ASA score ≥3) was present in 32% of patients. The main indication for ERCP was evaluation and therapy of bile duct-related disorders. Successful bile duct cannulation was achieved in 93%. Pre-cut sphincterotomy was performed in 5% of procedures, and a guide wire to facilitate duct access was employed in 63%. Sphincterotomy, treatment for common bile duct stones (CBDS), and an insertion or change of bile duct stents were the most commonly employed procedures. Complications occurred in 10% of the patients, with a procedure-related mortality of 1%., Conclusions: In Norway, ERCP is predominantly performed for CBDS and biliary strictures in elderly patients with associated co-morbidity. Patient selection, indications, and procedures are in concert with international guidelines and recommendations. Disease patterns in Norway differ slightly from those observed in central Europe and North America.

Objective: The introduction of non-invasive imaging for biliary-pancreatic diseases has changed the indications and volumes of endoscopic retrograde cholangiopancreatography (ERCP) over time. This study aimed to provide national figures on ERCP in Norway over the last decade., Material and Methods: Data from four national surveys on ERCP activity collected from 1998 to 2009 at the surgical and medical departments of all Norwegian hospitals were analyzed for variations in volumes among centers, regions, and specialties over time., Results: A total of 42,260 procedures were reported (average 3842 procedures per year, range 3492-4632). The number of hospitals with ERCP decreased from 41 to 35 and the annual number of procedures decreased by 13% (from 4632 to 4036), but the number of ERCP endoscopists remained stable at ~100. The proportion of procedures performed by surgeons decreased from 40% to 32% (p < 0.001) during the first half of the study period; the number of gastrointestinal surgeons performing ERCP remained stable in the latter half (46% and 48% for 2004 and 2008, respectively). In 2004, 15 endoscopists signed up for a formal ERCP training program, including 8 (53%) surgeons. This number increased to 21 (48%) in 2008. A non-significant decrease in referrals (49% in 2002 vs. 35% in 2005) between various ERCP centers was reported. Regional variation in ERCP volumes leveled off during the study period., Conclusions: Though the number of both procedures and hospitals performing ERCP in Norway decreased, the proportion of low-volume and high-volume centers remained steady. The proportion of procedures by gastroenterological surgeons decreased significantly, yet roughly half of the endoscopists in ERCP training programs are surgeons. Regional variation in the ERCP numbers appears to have diminished.

Objective: Endoscopy has been endorsed and introduced in most surveillance programs following curative surgery for colorectal cancer (CRC), yet little data are available to support its use in terms of patient selection, efficacy and frequency of surveillance., Material and Methods: A literature search in the English language using the PubMed/Medline database for the MeSH terms "colorectal cancer", "surveillance", and "endoscopy", with focus on sporadic CRC, excluding CRC developed on a hereditary or inflammatory bowel disease background. Focus on results from the past 5 years was applied., Results: Recent systematic reviews, meta-analyses, randomized trials and prospective studies made the backbone of the article, supported by population-based findings and recent reports on tumor biology. Hard evidence to support a survival benefit from endoscopy alone is lacking. Definitions of "synchronous", "interval", and "metachronous" cancers are not uniform and hampers comparison of studies. The number of metachronous cancers (usually 2-4%) that develop after curative CRC surgery is small, and better patient-tailored surveillance could improve the diagnostic yield. Compliance with endoscopy is low compared to other modalities. Age and socio-demographic factors influence on the surveillance coverage and need to be addressed in any given program. The majority of local recurrences occur within the first 3 years after surgery independent of stage, and microsatellite instable (MSI) tumors appear to be at higher risk., Conclusions: Endoscopy in surveillance after curative surgery for CRC is a resource demanding procedure. A tailored approach according to factors associated with an increased risk for metachronous cancer/local recurrence would increase efficiency.

Objective: Pancreatic cancer is the second most frequent gastrointestinal cancer in the Western world. Few reports on concomitant trends in pancreatic cancer incidence, diagnosis, mortality and survival exist at the national level. This study provides a baseline overview of the temporal patterns in these four indicators over the past four decades in Norway., Material and Methods: We analysed trends in incidence, basis of diagnosis, relative survival and mortality from the Cancer Registry of Norway for the period 1965-2007., Results: Included were 21,663 patients with pancreatic cancers. Incidence and mortality rates remained at around 6-8 per 100,000 over the study period. Diagnoses based on clinical examination alone dropped from 12.5% (in the 1950s) to <1% (in the 2000s), while use of imaging techniques, such as CT and MRI, increased from 3.6% to >30%. Previously high rates of autopsy-verified diagnosis and non-therapeutic surgery decreased accordingly. Consistently more primary tumours (from 12.9% to 19.4%) and metastases (from 12.5% to 22.4%) had histological examination, and use of endoscopy increased to approximately 10%. Relative survival after diagnosis of pancreatic cancer remains very low. However, in recent years, a modest improvement in short-term survival has been noted, with 1-year survival rates of 18% and 16% for males and females, respectively., Conclusions: The incidence and mortality for pancreatic cancer remain largely unchanged, with few 5-year survivors. Improved short-term survival may reflect more aggressive use of surgery and chemotherapy. Further elucidation of risk factors in pancreatic cancer is needed to enable effective prevention, early detection and improved treatment strategies.

Of all the body systems, the gastrointestinal (GI) tract is the most exposed to proteinases. Proteolytic activity must thus be tightly regulated in the face of diverse environmental challenges, because unrestrained or excessive proteolysis leads to pathological GI conditions. The protease-activated receptor-2 (PAR-2) is expressed in numerous cell types within the GI tract, suggesting both multiple functions and numerous modes of receptor activation. Although best known as a pancreatic digestive enzyme, trypsin has also been found in other tissues and various cancers. Of interest, trypsin and PAR-2 act together in an autocrine loop that promotes proliferation, invasion and metastasis in neoplasia through various mechanisms. Trypsin and PAR-2 seem to act both directly and indirectly through activation of other proteinase cascades, including metalloproteinases. PAR-2 activation can participate in inflammatory reactions, be protective to mucosal surfaces, send or inhibit nociceptive messages, modify gut motility or secretory functions, and stimulate cell proliferation and motility. Several studies point to a role for the PARs in disease processes of the GI tract and pancreas ranging from inflammatory bowel disease, symptoms associated with irritable bowel syndrome, pain in pancreatitis, development of colon and other GI cancers, and even infectious colitis. Proteinases should not only be considered from the traditional view as digestive or degradative enzymes in the gut, but additionally as signalling molecules that actively participate in the spectrum of physiology and diseased states of the GI tract.