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Hereditary ventricular polyposis in the form of gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is a rare condition characterised by a typical distribution of polyps in the stomach and risk of gastric cancer at a young age. Prophylactic gastrectomy may be indicated. The condition is not thought to be associated with increased risk of colon cancer, but the evidence base is limited.

Background: We wished to assess our experiences with laparoscopy used in curative resection for gastric cancer., Material and Method: All patients with gastric cancer who underwent curative-intent surgery, irrespective of access, in the period 1 May 2015-28 February 2018 at Oslo University Hospital Ullevål were included. The patient care pathway and oncological results were registered continuously and analysed retrospectively., Results: A total of 93 patients underwent surgery, 48 of whom were women. Median age was 73 (32-89) years, and 16 patients were 80 years of age or above. The duration of the procedure was 265 (125-644) minutes. Altogether seven patients underwent laparotomy, one was planned and six were converted to open surgery. Standardised lymph node dissection was performed in 88 patients. Complications were recorded in 48 patients, of which 11 were serious. A total of six patients had anastomotic leakage. Three died within 30 days/during hospitalisation. Postoperative hospitalisation was 12 (5-78) days. A total of 86 patients underwent radical surgery, five had tumour infiltration in the resection margins, and two had indeterminate resection status. The median number of lymph nodes identified was 18 (0-53). Tumours were locally advanced in 56 patients., Interpretation: Laparoscopic gastric resection with standardised lymph node dissection can be performed in most patients with gastric cancer who undergo curative-intent surgery. The method has become standard in our department.

BACKGROUND Surgery is considered necessary to achieve a cure for oesophageal cancer. Minimally invasive oesophageal resection is increasingly performed with the aim of reducing the number of complications compared with open surgery. The purpose of this study was to investigate postoperative complications, mortality and long-term survival following hybrid oesophageal resection by laparoscopy and thoracotomy.MATERIAL AND METHOD Patients with oesophageal cancer who underwent hybrid resection with curative intent at Oslo University Hospital Ullevål from 1 November 2007 to 1 June 2013 were included (n = 109). Complications were graded according to the Clavien-Dindo classification and survival figures were recorded.RESULTS Median age was 65 years, 79 % were men. Altogether 118 complications were recorded in 70 patients (64.2 %). Distribution of complications was 1.8 % for stage I, 29.4 % for stage II, 22.1 % for stage III and 11.0 % for stage IV. Anastomotic leakage occurred in 4.6 %. There was no postoperative mortality. The proportion of R0 resections with microscopic radicality was 91 % (n = 100). For the entire patient population, the estimated 5-year survival rate was 48 % (95 % CI 36 - 60 %), for R0 resection 51 % (38 - 63 %) and for R1-2 resection 0 %. Estimated median survival with R0-2, R0 and R1-2 resection was 55, 55 and 10 months (0 - 28 months), respectively. R status and stage had a significant bearing on survival.INTERPRETATION There was a low percentage of serious complications, no mortality and few anastomotic leakages after hybrid resection for oesophageal cancer. The 5-year survival rate was good.

Background: Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the department's results for surgical treatment of this rare and distressing condition., Material and Method: In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery., Results: There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery., Interpretation: Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.

Background: Neutropenic enterocolitis is a life-threatening complication that usually occurs in connection with chemotherapy for acute leukemias. Our experience with diagnosis and treatment of these patients is presented., Material and Methods: Medical records from patients treated for neutropenic enterocolitis at Ullevaal University Hospital in the period 2000-2008 were retrospectively reviewed., Results: 16 patients with median age 33 years were treated for neutropenic enterocolitis. Induction chemotherapy was given for acute myelogenic (n = 9) or lymphatic (n = 4) leukemia, myelomatosis (n = 2) or lymphoma (n = 1). The patients developed aplasia five days (median) after start of chemotherapy. All patients were first treated conservatively with broad-spectrum antibiotics, fluids and electrolyte supplementation; nine of them recovered without complications. Four underwent surgery for perforation or ileus and these had the longest period with aplasia (median 31 days). Surgery for perforation is mainly limited resection and construction of ileostomy reservoirs (one or two). Three patients died. These were only treated conservatively; aplasia occurred quicker in these patients (after median two days) and they had the largest number of affected bowel segments (median nine)., Interpretation: Neutropenic enterocolitis is a heterogeneous condition and the treatment is mainly conservative. Surgical intervention is mandatory in patients with free intraabdominal air, ileus and intractable intestinal bleeding. The prognosis seems to worsen when aplasia develops after a short time and when there is a large number of affected bowel segments.

Background: Esophageal perforation is a serious condition with a high mortality. Treatment is both surgical and conservative., Material and Methods: Records were retrospectively reviewed for 22 patients (17 men), with median age 64 (30-85) years, that had been treated for esophageal perforation at Ullevaal University Hospital in the period 2000-2006., Results: Perforation was cervical in two (9%) patients, thoracic in 19 (86%) and abdominal in 1 (5%) of the patient(s). The etiology was iatrogenic in 11 (50%) patients, emetic in 8 (36%) and caused by a foreign body in 3 (14%) patients. Five patients with an iatrogenic etiology had oesophageal cancer. Diagnosis after onset of symptoms was evident within 24 hours in 41% patients, during 24-72 hours in 14% and later than 72 hours in 45% of the patients. Half of the patients (11) were treated surgically, including two that had been initially treated conservatively. Five patients (23%) died of thoracic perforations during hospitalization and there were no other deaths. Median hospital stay was 54 (3-174) days. At the end of follow-up median survival was 113 (12-660) days and 10 of the 22 patients were dead (45%)., Interpretation: Our impression is that early surgery of oesophageal perforation in fit patients can improve the outcome.

Background: The purpose of this study was to chart changes in surgical treatment of inguinal or femoral hernia in Norway from 1990-91 to 1999-2003., Methods: Data were compiled from the Norwegian Patient Registry based on procedure coding for inguinal and femoral hernia repair., Results: The annual number of femoral hernia repair procedures was constant throughout the study period. From 1990-91 to 2003, the mean age dropped from 66 for both sexes to 63 among men and 62 among women. The female-to-male ratio was constant at 2/1. Emergency admittances went down from 56% to 43% and mean hospitalisation was down from five to four days. The use of mesh repairs increased from 3% (1990-91) to 37% (2003). Incidence rates for inguinal hernia repair increased throughout the period, from 1.8 to 2.3 per 10,000 women and from 20.6 to 32.1 per 10,000 men. Mean age was as down from 63 (both sexes) to 59 among men and 57 among women. The female-to-male ratio remained constant at 1/12. Emergency admittances dropped from 13% to 6%. Mean days of hospitalisation fell from 4 in 1990-91 to 1 in 2003. Two out of three inguinal hernia repairs were done ambulatory in the last year of the study period. The use of mesh repairs increased from 1% in 1990-91 to 78% in 2003. Laparoscopic procedures were rarely used (2% in 2003)., Interpretation: In 2003, the majority of inguinal hernia repairs were performed as day surgery with open mesh techniques, in line with European guidelines.

Background: The purpose of this study was to evaluate the results of surgery and stenting for operable and inoperable oesophageal cancer., Material and Methods: Retrospective patient materials with resection (n = 65, 1983-2002) or stenting (n = 59, 1994-2003) for primary oesophageal cancer., Results: Mortality after surgery was 11% and 15% of the patients were re-operated. 36 (55%) had complications such as respiratory failure (n = 33), anastomotic dehiscence/perforation (n = 4), chylothorax (n = 1), haemorrhage (n = 3), wound rupture (n = 1), septicaemia (n = 2), arrhythmia (n = 4) and wound infection (n = 5). Median survival after surgery was 11 months. Survival after three years was 17%, after five years 8%. The stent procedure was without mortality but haemorrhage (n = 1) and stent dislocation (n = 2) occurred. 8 patients (14%) were re-stented for tumour stenosis (n = 6), fistula (n = 2) and dislocation (n = 1). Median survival after stenting was 78 days. Survival after 30 days was 80%, after one year 7%., Interpretation: Resectable oesophageal cancer should be operated in fit patients, as survival is improved and some patients can be cured. Stenting is the main option in inoperable patients.

Background: About 25% of patients with acute pancreatitis progress into severe pancreatitis with local and systemic complications. Local complications include oedema, necrosis, haemorrhage, infections, abscesses and pseudocysts. Systemic complications frequently involve the lungs and the kidneys in addition to cardiovascular dysfunction with hypotension and shock. Multi-organ failure is caused by a systemic inflammatory response commonly seen in necrotising pancreatitis, a severe condition with high mortality (about 30%). Similar pathogenesis is seen in sepsis or severe burns., Methods: We report a young woman with acute pancreatitis and have used available literature to discuss the clinical picture and the pathogenesis, with an emphasis on the systemic complications., Results and Interpretation: Systemic complications like multi-organ failure are frequently reported in acute severe pancreatitis characterised by pancreatic oedema and necrosis. Our patient had abdominal pain and mild pancreatitis without radiological manifestations. She developed systemic complications with respiratory failure not previously reported in mild pancreatitis. Early identification of systemic complications in acute pancreatitis is important in order to start treatment and reduce the risk of a fatal outcome.

Background: The purpose of this study was to investigate cholecystectomy incidence and laparoscopy rates in Norway (1990-2002)., Methods: Data were compiled from the Norwegian Patient Registry based on codes for cholecystectomy., Results: From 1990 to 2000-02, age-adjusted incidence rate (per 10,000 inhabitants) for cholecystectomy increased from 2.9 to 4.1 for men and from 7.0 to 11.8 for women. Incidence rates varied between counties. The proportion undergoing laparoscopic surgery increased from 1% in 1990 to 89% in 2000-02. Over the same period the length of postoperative inpatient stay decreased from 7.3 days to 3.3 days. 94% of electively admitted patients were operated by laparoscopic technique in 2000-02. Among patients admitted on an emergency basis, women below 50 were more often operated by laparoscopic technique than older women and men., Conclusion: Substantial changes in the treatment of gallstone disease occurred in Norway over the period 1990 -2002. Increased incidence rates for cholecystectomy and reduced length of postoperative inpatient stay were observed after the introduction of cholecystectomy by laparoscopic technique.

Background: Increased awareness of post-hernia repair pain motivated a study of pain and rehabilitation after day surgery., Material and Methods: Forty male patients were prospectively randomized to conventional (McVay) or open mesh repair. Self-assessment of postoperative pain was based on a four-step verbal scale. Patients and the physicians conducting the study were blinded to the surgical method. Clinical follow-up was performed twice, after four weeks and median 21 months., Results: The open mesh technique generated less pain during the first postoperative week. Chronic light to moderate pain occurred in 20% of patients irrespective of surgical method. A sick leave of one to three weeks was sufficient in 20 out of 27 patients., Interpretation: The study showed no clinical advantage of a tension-free method in terms of rehabilitation and post-hernia repair after the first postoperative week. Because of the relatively high incidence of late treatment-related pain, non-symptomatic adult patients should not be referred for inguinal hernia surgery. The primary sick leave period should not exceed three weeks.

Background: Internal rectal intussusception, usually occurring in women, causes constipation and incomplete evacuation of stool., Materials and Methods: Twenty-one women and one man (median age 48) were operated with suture rectopexy and sigmoid resection. The patients were examined with anoscopy and defecography, and symptomatic outcome, patients' satisfaction and morbidity were evaluated. Outcome was based mainly on the validated KESS score for constipation., Results: There was a significant reduction in all ten symptoms. Faecal incontinence improved in the two afflicted patients after operation. The number of patients with constipation was reduced from 20 to 8 (p < 0.01); none became constipated. Mean (95 % CI) colonic transit times in ten constipated patients was reduced from 5.3 (4.1-6.4) to 4.0 (2.6-5.4) days (p = 0.08); seven of these patients had a reduction of transit time as well as constipation score., Interpretation: Rectopexy with sigmoid resection improved symptoms, including constipation and feeling of incomplete rectal emptying.

Background: Anal fissure is very painful; surgery is warranted when medical treatment fails., Material and Method: We present a retrospective study of 34 patients (median age 42; 19-63) treated by subcutaneous lateral internal sphincterotomy (n = 27) and anal dilatation (n = 7) from 1992 to 2002, carried out by a questionnaire on pain, anal incontinence, and treatment result., Results: There were no complications or treatment for recurrence of anal fissure. Median pain score before surgery was 7.3 on a scale from 0 (no pain) to 10 (worst imaginable pain), median 73 months (4-124) after surgery the median score was 0 (0-5) (p = 0.00). For sphincterotomy (n = 27), the median score was 7.8 before surgery and 0 (0-5) after (p = 0.00), for anal dilatation 6 (3-10) before surgery and 2 (0-2) (p = 0.01) after. All patients had reduced pain scores after surgery but their incontinence scores remained unchanged. Two patients (7%) who had previously been dilated or irradiated developed faecal incontinence after sphincterotomy. More patients became asymptomatic after sphincterotomy (n = 18; 67%) than after anal dilatation (n = 4; 57%)., Interpretation: Compared to anal dilatation, sphincterotomy offers better pain relief for anal fissure. Doing a shorter sphincterotomy corresponding to length of the fissure reduces the risk of anal incontinence.

Background: The purpose of this study was to examine the incidence of appendicitis and appendectomy in Norway from 1990 to 2001., Methods: Data were compiled from the Norwegian Patient Registry based on ICD-9 and ICD-10 codes for appendicitis and appendectomy. Re-admissions after appendectomy were selected based on institution and allocation numbers for hospitalisation., Results: Age-adjusted incidence rates for appendectomy were 117 per 100 000 for men and 116 per 100 000 for women. Incidence rates were highest among patients aged 10-29. Diagnostic accuracy increased from 81% to 86% in men and from 60% to 71% in women over the study period. Perforation ratio increased from 12% to 21% in men and from 9% to 17% in women. Appendectomy by laparoscopic technique increased during 1998 to 2001 from 5% to 10% of cases for men and from 9% to 15% of cases for women. The proportion of laparoscopic appendectomy was considerably higher in two counties (50% and 28% in 2000-2001). Length of hospital stay was shorter after laparoscopy (median two days) than after open surgery (median three days), with no difference in the rate of re-admission of 4%., Interpretation: Diagnostic accuracy and perforation ratio increased over the 1990s. Patients operated upon with laparoscopic technique had shorter hospital stays and the same re-admission rate compared to patients undergoing conventional surgery. Though the proportion of appendectomies done by laparoscopy doubled from 1998 to 2001, the procedure is not in commonly use in Norway.

Background: The prevalence of anal sphincter rupture at vaginal delivery is from 0.5 to 2.5 %. More than 50 % of these patients may need a secondary anterior sphincteroplasty because of anal incontinence., Materials and Methods: We present prospective series of 29 women (median age 45 years) operated with an overlapping anterior sphincteroplasty from 1996 to 2001. The patients were examined with anal ultrasonography (n = 23), manometry (n = 19) and neurophysiologically (n = 13), and divided into group 1 (n = 19) with anal sphincter rupture and group 2 (n = 10) with sphincter rupture as well as pudendal neuropathy. All patients (n = 29) were examined with the Cleveland Clinic incontinence score before and median eight (2-64) months after operation., Results: Median incontinence score before and after operation was 11.0 (0-22) versus 5.0 (0-16) (p = 0.002) for group 1; 18.0 (15-24) versus 15.5 (11-24) (p = 0.034) for group 2. There was also a significant difference between the groups concerning incontinence scores both preoperatively (p = 0.045) and postoperatively (p = 0.028). An improvement of continence was seen in 15 (79 %) of the patients in group 1 compared to 4 patients (40 %) in group 2. In group 1 a significant increase of median resting and squeeze pressures was seen., Interpretation: Anterior sphincteroplasty improves anal continence considerably in patients with isolated sphincter rupture. However, patients with evidence of pudendal neuropathy must be informed that they should expect only a minor improvement in continence after operation.

Background: Laparoscopic procedures in gastrointestinal surgery have increasingly been used over the last ten years. This study explores the use of various common laparoscopic procedures in Norway., Methods: A questionnaire was sent to all 59 public hospitals in Norway in January 1999, of which all but one responded. Laparoscopic surgery was performed in 54 out of 58 hospitals., Results: Most hospitals perform between 11 and 20% of all gastrointestinal operations with laparoscopic technique. Laparoscopic cholecystectomies and anti-reflux surgery have generally replaced open procedures in all hospitals. Appendectomy by the laparoscopic technique accounts for approximately 10% of cases and has become the preferred technique in only one of ten hospitals. Laparoscopic hernia repairs are done in less than 10% of cases. Overall, surgeons' satisfaction with laparoscopy is good and seems slightly higher in district and central hospitals than in university hospitals. Half of all surgical departments plan to use more laparoscopic procedures., Interpretation: Laparoscopic procedures have replaced conventional open surgical procedures for some procedures but is less used than expected ten years ago. A slow and gradual increase may be expected in the years ahead.

Background: Inguinal hernia repair has undergone major changes during the last decade. This study aimed to explore the impact on treatment algorithms used in Norway., Methods: A questionnaire was sent to all public hospitals in January 1999., Results: 57 of 58 hospitals where inguinal hernia repairs were undertaken responded. Most repairs are undertaken in local/district hospitals, but in the majority of hospitals, surgeons performed a limited number of procedures (one or two per month). The vast majority of hospitals used two different surgical techniques, open mesh techniques being the preferred technique. Most hospitals made limited use of laparoscopic techniques. Sick-leave periods were shorter after surgery with open mesh techniques as compared to traditional techniques. Less than 20% of hospitals had established control regimens., Interpretation: A clear tendency towards standardization of inguinal hernia repair can be observed throughout the country. Open mesh techniques have now replaced the traditional operative methods, whereas laparoscopic technique has not been adopted. Quality assessment of inguinal hernia repair could be improved.

Background: The aim of this study was to examine whether the functional result of restorative proctocolectomy for ulcerative colitis deteriorated by postponing follow-up from three to eight years after pouch surgery., Material and Methods: All patients (n = 58) operated for ulcerative colitis from 1984-97, who still had intact reservoir, responded to a questionnaire on defecating pattern, stool leakage, perianal irritation, urinary function, workload, sexual life, social life, and the patient's opinion on outcome. The results for the first 29 patients were compared to last 29 patients operated. Median follow-up was eight for the first 29 patients and three years for the last 29., Results: There were no significant difference in functional outcome and patient opinion after pouch surgery between the first 29 and last 29 patients (n = 58). Respective figures for median 24-hour stool frequency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defecation 86% and 97%, perianal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) had improved for 11 (19%) and deteriorated for seven patients (12%). Potency was reduced in five (15%) and ejaculation in four patients (12%), one of whom (3%) had retrograde ejaculation. Three (5%) had received a disability pension and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and three (6%) felt worse because of frequent bowel emptying (n = 3), perianal eczema (n = 1) and pouch fistula (n = 1)., Interpretation: The results do not demonstrate any significant deterioration of functional outcome after pouch surgery for ulcerative colitis by postoperative increase of follow-up from three to eight years.

Continence-preserving coloproctectomy for ulcerative colitis is technically demanding and is relatively often afflicted with complications. We have retrospectively reviewed the files of all patients being operated for ulcerative colitis at Ullevål Hospital from 1992 to 1997 (n = 53). Most of the patients (n = 50) were examined clinically; 12 patients had anal manometry before and after operation. 44 patients were operated with continence-preserving coloproctectomy with J-pouch and handsewn anastomosis; of these, 42 were followed more than six months. Eight had pouchitis, four perianal abscess/fistula, three septicaemia and three were operated for ileus. Two had anastomotic leakage and pelvic abscess that required transanal drainage. One had the pouch removed six years after operation due to chronic pouchitis and pouch-vaginal fistula. There was no deterioration of anal maximal resting and squeezing pressures on pre- and post-operative anal manometry. Mean number of stools from the reservoir per 24 hours were 6.2 (range 3-11); 11 patients had leakage of air and loose stool, three at day-time and eight at night. Two patients (4%) died from colorectal cancer and three (7%) had Crohn's disease. Nine patients were unfit for pouch surgery and underwent coloproctectomy (n = 7) or subtotal colectomy (n = 2). Our results indicate that pouch surgery for ulcerative colitis is a good option for most patients.

During the period 1982-91, 52 patients were treated for rectal prolapse. We present the results for 25 treated with Delorme's operation and 14 with rectopexy, all of whom were observed for more than 12 months after operation. Four patients who had internal prolapse were treated with rectopexy. Eight (15%) of 52 patients had postoperative complications, including six in the Delorme group and two in the rectopexy group. A 75 year-old woman operated with rectopexy died from peritonitis. Eight patients (32%) developed recurrent prolapse after Delorme's operation. Five of these were successfully reoperated. No patients in the rectopexy group had a recurrent prolapse. Incontinence and bleeding were reduced in both groups. Despite a relatively high rate of recurrence, we consider Delorme's operation to be a good alternative, also for old debilitated patients, and to involve a minimal risk of serious complications. If recurrence occurs, reoperation can be carried out with good results.

In October 1992 all Norwegian hospitals were asked whether or not they currently performed laparoscopic cholecystectomy. 36 hospitals performed laparoscopic surgery, 15 did not and 20 hospitals did not reply. During 1990 six hospitals began to use the laparoscopic technique. The number had increased to 21 hospitals in 1991. Altogether 497 cholecystectomies were performed laparoscopically i 1991, comprising 36% of all cholecystectomies in the 51 responding hospitals. In October 1992 the number of hospitals performing laparoscopic cholecystectomy had increased to 36, and the mini-invasive technique was used in 920 cases, i.e. in 68% of the total number of cholecystectomies. Only approximately 7.5% of all appendectomies were performed laparoscopically in 1992 as well as in 1991. Until 1992, cholecystectomy was the only operation where the mini-invasive technique is widely used in Norway.

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology. Markers of activity include elevated serum ACE levels, interleukin 2-receptors, hypercalcemia, hypercalciuria, intrathoracic uptake of radioactive gallium, retinal vascular leakage, and an increased T4/T8 ratio in bronchoalveolar lavage fluid. The three main pathological features of sarcoidosis are alveolitis, granuloma formation and fibrosis. The cells harvested by bronchoalveolar lavage in sarcoidosis are representative of the local inflammatory reaction seen in the lung. Alveolar macrophages have the potential to synthesize the components of the functional alternative and terminal pathways of complement. The alveolar macrophages from sarcoidosis patients produce more complement than their healthy counterparts. Complement participates in the normal metabolism of immune complexes and has the ability to modulate immune responses via complement receptors present on virtually all cell types. On the other hand, through enhanced levels of complement factors, an increased number of activated macrophages in the lung may contribute to a changed immune response, which may be of significance for the granulomatous inflammation seen in sarcoidosis and may also contribute to the tissue damage seen in sarcoid fibrosis.