Search

Background: In the absence of unequivocal standardized indications for surgery, socioeconomic background and gender may have a major impact on the decision to perform surgery for cholecystolithiasis. The purpose was to assess how decisions to perform surgery in Sweden are influenced by patient-related factors and how this affects the epidemiology of gallstone disease., Materials and Methods: This study is based on the Swedish Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), which covers >90% of surgical units, including 98% of all procedures performed. All procedures performed during 2005-2009 were included. Data on socioeconomic background were obtained from Statistics Sweden. The influence of gender and age on decision to perform surgery was tested in multivariate linear regression analysis., Results: Up to the age of 40 years, women were 6 times more likely than men to undergo surgery for biliary colic. On the other hand, there was a relative preponderance of men undergoing cholecystectomy for jaundice, cholecystitis, bile duct stone or pancreatitis in the elderly population (p < 0.001). Socioeconomic background did not have any significant impact on the decision to operate., Conclusion: Presentations of gallstone disease differ between men and women, as does the decision to perform surgery. The higher incidence of surgery for secondary complications in older men could be explained by a higher prevalence of gallstones resulting from a lower incidence of surgery at a younger age. Whether or not wider indications for surgery in young patients reduce the risk for gallstone complications requiring surgery should be explored in future studies.

Background: Treatment of common bile duct stones has changed. Open surgery has gradually been replaced by endoscopic and laparoscopic procedures. The aims of this study were to see how common bile duct stones have been treated in Sweden, to establish whether there were differences in morbidity and mortality between these approaches, and to identify factors influencing mortality., Methods: All persons undergoing inpatient common bile duct exploration or endoscopic retrograde cholangiopancreatography (ERCP) during 1965-2009 in the Swedish Hospital Discharge Registry, but without a diagnosis of malignancy in the Swedish Cancer Registry, were included. The outcome death was identified by cross-linkage to the Causes of Death Registry. Registry data on possible risk factors for mortality were collected., Results: A total of 126 885 procedures were performed in 110 119 patients. Open surgery was initially the only available method, but during the 1990s ERCP became predominant. Later, laparoscopic bile duct clearance became an established but uncommon method. A 90-day mortality rate of 0·2 per cent after open surgery, 0·8 per cent after ERCP, 0 per cent after laparoscopic exploration and 0·7 per cent after combined procedures was recorded. After adjustment for confounding, there was no difference in mortality between open surgery and ERCP. Biliary reintervention within 90 days was identified as a risk factor for death, whereas a concomitant diagnosis of pancreatitis reduced the risk., Conclusion: The laparoscopic technique had the lowest mortality and morbidity rates. After adjustment for confounding factors, there was no difference in mortality after open surgery and ERCP. The favourable outcome for laparoscopy may have been due to selection bias, owing to treatment of younger, healthier subjects with less severe disease., (Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Epidemiological data on characteristics of patients undergoing open or laparoscopic cholecystectomy are limited. In this register study we examined characteristics and mortality of patients who underwent cholecystectomy during hospital stay in Sweden 2000 - 2003., Methods: Hospital discharge and death certificate data were linked for all patients undergoing cholecystectomy in Sweden from January 1st 2000 through December 31st 2003. Mortality risk was calculated as standardised mortality ratio (SMR) i.e. observed over expected deaths considering age and gender of the background population., Results: During the four years of the study 43072 patients underwent cholecystectomy for benign biliary disease, 31144 (72%) using a laparoscopic technique and 11928 patients (28%) an open procedure (including conversion from laparoscopy). Patients with open cholecystectomy were older than patients with laparoscopic cholecystectomy (59 vs 49 years, p < 0.001), they were more likely to have been admitted to hospital during the year preceding cholecystectomy, and they had more frequently been admitted acutely for cholecystectomy (57% Vs 21%, p < 0.001). The proportion of women was lower in the open cholecystectomy group compared to the laparoscopic group (57% vs 73%, p < 0.001). Hospital stay was 7.9 (8.9) days, mean (SD), for patients with open cholecystectomy and 2.6 (3.3) days for patients with laparoscopic cholecystectomy, p < 0.001. SMR within 90 days of index admission was 3.89 (3.41-4.41) (mean and 95% CI), for patients with open cholecystectomy and 0.73 (0.52-1.01) for patients with laparoscopic cholecystectomy. During this period biliary disease accounted for one third of all deaths in both groups. From 91 to 365 days after index admission, SMR for patients in the open group was 1.01 (0.87-1.16) and for patients in the laparoscopic group 0.56 (0.44-0.69)., Conclusion: Laparoscopic cholecystectomy is performed on patients having a lower mortality risk than the general Swedish population. Patients with open cholecystectomy are more sick than patients with laparoscopic cholecystectomy, and they have a mortality risk within 90 days of admission for cholecystectomy, which is four times that of the general population. Further efforts to reduce surgical trauma in open biliary surgery are motivated.

Background & Aims: Results concerning an association between cholecystectomy and right-sided colon cancer are inconsistent. Little is known about the relation between cholecystectomy and small bowel cancer. Therefore, we evaluated cholecystectomy and risk of bowel cancer., Methods: Cholecystectomized patients, identified through the Swedish Inpatient Register, from 1965 through 1997, were followed up for subsequent cancer. The standardized incidence ratio (SIR) estimated relative risk., Results: In total, 278,460 cholecystectomized patients, contributing 3,519,682 person-years, were followed up for a maximum of 33 years after surgery. Cholecystectomized patients had an increased risk of proximal intestinal adenocarcinoma, which gradually declined with increasing distance from the common bile duct. The risk was significantly increased for adenocarcinoma (SIR, 1.77; 95% confidence interval [CI], 1.37-2.24) and carcinoids of the small bowel (SIR, 1.71; 95% CI, 1.39-2.08), and right-sided colon cancer (SIR, 1.16; 95% CI, 1.08-1.24). No association was found with more distal bowel cancer. The gradient was further pronounced when surgery of the common bile duct was included. The associations remained increased up to 33 years after cholecystectomy. No differences between sexes were found., Conclusions: Cholecystectomy increases the risk of intestinal cancer, a risk that declines with increasing distance from the common bile duct. Changes in the intestinal exposure to bile might be the underlying biological mechanism.

The purpose of this study was to compare cholecystectomy in Sweden (pop. 8.9 million) 1989 to 1994 when the diffusion of laparoscopic cholecystectomy (LC) was completed, focusing on long hospital admissions as a proxy indicator of adverse events. This was an observational study of all patients operated on with cholecystectomy in 1989 and 1994 (n = 19,432) from the National Inpatient Registry. The risk of a long admission was analyzed by multivariate analyses. Odds ratios of long admissions were computed considering gender, age groups, acute or chronic gallstone disease, 1989 and 1994, county level of operations per 1000 inhabitants, and hospital categories. Stratified analyses were performed by acuteness of disease, and year. Long admissions were defined as lasting longer than 20 days in 1989 and 14 days in 1994. Odds ratios of a long admission increased steeply with age and acute gallstone disease. The county level of operations per 1000 inhabitants had no influence on risk nor did hospital category. The absolute number of those operated on with an acute gallstone disease changed little between 1989 and 1994, whereas operations for chronic disease increased significantly. Stratification revealed that their risk of a long admission was increased both in 1989 and 1994, particularly for women. Those with chronic gallstone disease had no increased risk. After the introduction of the laparoscope and a rise in the number of cholecystectomies, patients with chronic gallstone disease seem to have a constant risk of long hospital stay. However, because patients with acute disease had an increased risk in both 1989 and 1994, further longitudinal analyses are needed to analyze the level of complications in this group.

The Swedish laparoscopy registry prospectively recorded 11,164 laparoscopic cholecystectomies during the years 1991-1993 with the aim of monitoring bile duct injuries and other complications of the new technique. In total 57 bile ducts were injured; 35 of these were merely incision of the common bile duct. Serious injuries with tissue loss occurred in 11 cases and clipping or electrocautery damage in another 11.

Objective: To investigate the incidence of port site metastases from unsuspected gallbladder cancer after laparoscopic cholecystectomy., Design: Retrospective national multicentre study, 1991-94., Setting: All 8 university and 24 central hospital, Sweden., Subjects and Interventions: All 32 hospitals were interviewed by means of a written questionnaire. The registers of all Swedish Oncological Centres and the registers of the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for cholecystectomy. To detect laparoscopic interventions incorrectly registered as open operations, all cholecystectomies registered as open were matched against the Swedish Registry of Laparoscopic Cholecystectomy for the years 1991-93 and all patients records for 1994 were scrutinised., Results: Replies were obtained from 30/32 clinics (94%) and 11976 laparoscopic cholecystectomies were done. Of 447 patients with verified gallbladder carcinoma 270 had their gallbladders removed, 55 (20%) laparoscopically. 9 of these (16%) developed port site metastases and 6 died from their disease at a median of 18 months (range 5-22). Two patients are alive, 54 and 45 months after cholecystectomy. One patient has been lost to follow-up., Conclusions: Port site metastases from gallbladder cancer may be more common than previously thought. A laparoscopic procedure should not be done if cancer of the gallbladder is suspected.

Objective: To study the diffusion of laparoscopic biliary surgery in Sweden, 1992-93., Design: A prospective survey of all biliary surgery for gallstone disease recorded for 8 weeks in 1992 and the same period in 1993., Setting: All surgical departments in Sweden., Subjects: A consecutive series of 1938 patients in 1992 and 1748 patients in 1993., Main Outcome Measures: The changing indications, diffusion, morbidity, mortality, postoperative and hospital stay after laparoscopic cholecystectomy (LC) in Sweden in 1992 compared with 1993., Results: Despite the spread of LC, the indications did not change between 1992 and 1993 (p=0.31). The total number of cholecystectomies decreased from 1938 in 1992 to 1748 in 1993. The overall percentage of laparoscopic cholecystectomies (LCs) increased from 74.7% to 81.2% (p <0.001) between 1992 and 1993. Postoperative morbidity and mortality after LC did not differ between 1992 and 1993, but the total morbidity was 9.0% in 1992 and 7.0% in 1993 (p=0.02). Mortality for all cholecystectomies did not change over the periods, being 0.6% in 1992 and 0.2% in 1993 (p=0.07). The numbers of LCs done in any hospital were divided in two groups, 20 or fewer and 21-80. In the smaller group, the postoperative morbidity was 7.1% and in the larger group it was 7.0%, (p=0.9). The postoperative mortality was 0.1% in both groups. The postoperative and total hospital stays of all cholecystectomies decreased from 3.4 days in 1992 to 2.9 days in 1993 (p=0.001) and from 5.0 in 1992 to 4.4 days in 1993 (p < 0.001), respectively. The postoperative and total hospital stays of LCs decreased from 2.0 in 1992 to 1.8 days in 1993 (p=0.009) and from 3.3 in 1992 to 2.9 days in 1993 (p=0.007), respectively., Conclusion: Despite the introduction and diffusion of the new technology, LC, the indications for surgery did not change and the number of cholecystectomies did not increase from 1992 to 1993. The morbidity and mortality of LC and the mortality of all cholecystectomies were unchanged between 1992 and 1993, but the morbidity for all cholecystectomies decreased. The number of LC or all cholecystectomies done in any particular hospital were not related to morbidity or to mortality.