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Background: Common bile duct stone (CBDS) is a common condition the rate of which increases with age. Decision to treat in particular elderly and frail patients with CBDS is often complex and requires careful assessment of the risk for treatment-related cardiovascular complications. The aim of this study was to compare the rate of postoperative cardiovascular events in CBDS patients treated with the following: ERCP only; cholecystectomy only; cholecystectomy followed by delayed ERCP; cholecystectomy together with ERCP; or ERCP followed by delayed cholecystectomy. Methods: The study was based on data from procedures for gallstone disease registered in the Swedish National Quality Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2006–2014. ERCP and cholecystectomy procedures performed for confirmed or suspected CBDS were included. Postoperative events were registered by cross-matching GallRiks with the National Patient Register (NPR). A postoperative cardiovascular event was defined as an ICD-code in the discharge notes indicating myocardial infarct, pulmonary embolism or cerebrovascular disease within 30 days after surgery. In cases where a patient had undergone ERCP and cholecystectomy on separate occasions, the 30-day interval was timed from the first intervention. Results: A total of 23,591 underwent ERCP or cholecystectomy for CBDS during the study period. A postoperative cardiovascular event was registered in 164 patients and death within 30 days in 225 patients. In univariable analysis, adverse cardiovascular event and death within 30 days were more frequent in patients who underwent primary ERCP (p < 0.05). In multivariable analysis, adjusting for history of cardiovascular disease or events, neither risk for cardiovascular complication nor death within 30 days remained statistically significant in the ERCP group. Conclusions: Primary ERCP as well as cholecystectomy may be performed for CBDS with acceptable safety. M

Background: The risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) could be related to technical or patient-related factors. The aim of this study was to assess whether clinical variables and co-morbidities influence the risk of developing PEP. Methods: Data were retrieved from the Swedish GallRiks registry, including all ERCP procedures performed in 2006-2014 for common bile duct stones. A total of 15 800 procedures were identified and cross-checked. Univariable and multivariable logistic regression analyses were conducted with the endpoint of PEP using the following co-variables: age, sex, ASA grade, previous history of acute pancreatitis, diabetes, hyperlipidaemia, hypercalcaemia, kidney disease and liver cirrhosis. Results: Women (odds ratio (OR) 1.33, 95 per cent c. i. 1.14 to 1. 55), patients aged less than 65 years (OR 1. 68, 1. 45 to 1. 94), patients with hyperlipidaemia (OR 1. 32, 1. 02 to 1. 70) and those with a previous history of acute pancreatitis (OR 5. 44, 4. 68 to 6. 31) had a significantly increased risk of PEP. In a subgroup analysis of patients with a previous history of acute pancreatitis, the mean time from previous pancreatitis to ERCP 4423 days in patients who developed PEP vs 6990 days in patients who did not (P = 0. 037). However, when the previous episode of pancreatitis had occurred more than 30 days before ERCP, this association was no longer significant (P = 0. 858). Patients with diabetes had a decreased risk of PEP (OR 0. 64, 0. 48 to 0. 85). Conclusion: Age, sex, hyperlipidaemia and previous history of recent acute pancreatitis increase the risk of PEP. The reduced risk of PEP in patients with diabetes should be explored in future studies.

OBJECTIVE: : The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. BACKGROUND: : Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. METHODS: : Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. RESULTS: : Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). CONCLUSIONS: : Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537).

In recent years, several synthetic cannabinoid compounds have become popular recreational drugs of abuse because of their psychoactive properties. This paper presents toxicological findings of synthetic cannabinoids in whole blood from some cases of severe intoxication including quantitative data from recreational users and a fatal intoxication. Samples were analyzed by liquid chromatography-tandem mass spectrometry in a scheduled multiple reaction mode after a basic liquid extraction. Twenty-nine synthetic cannabinoids were included in the method. In our data set of similar to 3000 cases, 28% were found positive for one or more synthetic cannabinoid(s). The most common finding was AM-2201. Most of the analytes had median concentrations of andlt;0.5 ng/g in agreement with other published data. The emerging drugs MAM-2201 (n = 151) and UR-144 (n = 181) had mean (median) concentrations of 1.04 (0.37) and 1.26 (0.34), respectively. The toxicity of the synthetic cannabinoids seems to be worse than that of natural cannabis, probably owing to the higher potency and perhaps also to the presence of several different cannabinoids in the smoked incense and the difficulties of proper dosing. The acute toxic effects may under certain circumstances contribute to death.

Purpose: To compare clinical outcomes following sutureless Parietex (TM) ProGrip (TM) mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. Methods: This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex (TM) ProGrip (TM) precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. Results: Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. Conclusion: Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

Background: Postoperative chronic pain is a major drawback of inguinal hernia repair. The current objective was to compare the frequency of chronic pain after laparoscopic (Totally Extraperitoneal Patch – TEP) and open (Lichtenstein) repairs. Methods: A randomized multicentre study with five years follow-up was conducted on male patients with a primary inguinal hernia. This report concerns chronic pain which was categorized as mild, moderate or severe by blinded observers. A subgroup analysis was performed on patients who had experienced moderate or severe pain at any time during follow-up. Results: Overall, 1370 of 1512 randomised patients underwent surgery, 665 in the TEP and 705 in the Lichtenstein group. The total incidence of chronic pain in the TEP and the Lichtenstein groups, respectively, was: 11.0 versus 21.7 per cent (one year), 11.0 versus 24.8 per cent (two years), 9.9 versus 20.2 per cent (three years) and 9.4 versus 18.8 per cent (five years) (P < 0.001). After five years, 1.9 per cent of patients in the TEP and 3.5 per cent in the Lichtenstein group reported moderate or severe pain (P = 0.092). Of the 121 patients who had reported moderate or severe pain 72 patients (60.0%) no longer reported pain after a median period of 9.4 (6.7-10.8) years after operation. Conclusion: Five years after surgery only a few per cent of patients still reported moderate to severe chronic pain. Laparoscopic inguinal hernia repair led to less chronic pain than open repair.

Concentrations of the illicit drug gamma-hydroxybutyrate (GHB) were determined in femoral venous blood and urine obtained at autopsy in a series of GHB-related deaths (N = 49). The analysis of GHB was done by gas chromatography after conversion to gamma-butyrolactone and quantitation of the latter with a flame ionization detector. The cutoff concentration of GHB in femoral blood or urine for reporting positive results was 30 mg/L. The deceased were mainly young men (86%) aged 26.5 +/- 7.2 years (mean +/- SD), and the women (14%) were about 5 years younger at 21.4 +/- 5.0 years. The mean, median, and highest concentrations of GHB in femoral blood (N = 37) were 294, 190, and 2,200 mg/L, respectively. The mean urine-to-blood ratio of GHB was 8.8, and the median was 5.2 (N = 28). In 12 cases, the concentrations of GHB in blood were negative (less than 30 mg/L) when the urine contained 350 mg/L on average (range 31-1,100 mg/L). Considerable poly-drug use was evident in these GHB-related deaths: ethanol (18 cases), amphetamine (12 cases), and various prescription medications (benzodizepines, opiates, and antidepressants) in other cases. Interpreting the concentrations of GHB in postmortem blood is complicated because of concomitant use of other psychoactive substances, variable degree of tolerance to centrally acting drugs, and the lack of reliable information about survival time after use of the drug.

Objectives: To compare a laparoscopic (totally extraperitoneal patch (TEP)) and an open technique (Lichtenstein) for inguinal hernia repair regarding recurrence rate and possible risk factors for recurrence. Summary Background Data: Laparoscopic hernia repair has been introduced as an alternative to open repair. Short-term follow-up suggests benefits for those patients operated with a laparoscopic approach compared with open techniques; ie, less postoperative pain and a shorter convalescence period. Long-term results, however, are less well known. Methods: The study was conducted as a multicenter randomized trial with a 5-year follow-up. A total of 1512 men aged 30 to 70 years, with a primary unilateral inguinal hernia, were randomized to either TEP or Lichtenstein repair. Results: Overall, 665 patients in the TEP group and 705 patients in the Lichtenstein group were evaluable. The cumulative recurrence rate was 3.5% in the TEP group and 1.2% in the Lichtenstein group (P = 0.008). Test for heterogeneity revealed significant differences between individual surgeons. The exclusion of 1 surgeon, who was responsible for 33% (7 of 21) of all recurrences in the TEP group, lowered the cumulative recurrence rate to 2.4% in this group, which was not statistically different from that of the Lichtenstein group. Conclusions: The recurrence rate for both TEP and Lichtenstein repair was low. A higher cumulative recurrence rate in the TEP group was seen at 5 years. Further analysis revealed that this could be attributable to incorrect surgical technique.

BACKGROUND: The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence. METHODS: This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique. RESULTS: A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group. CONCLUSION: The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

Background: Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique. Methods: A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded. Results: Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 per cent of die patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P < 0.001), consumed fewer analgesics (P < 0.001), had a shorter period of sick leave (7 versus 12 days; P < 0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P < 0.001). Conclusion: The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.

Background: Laparoscopic surgery has emerged as a new treatment modality for inguinal hernia. It is important to analyse its long-term costs in relation to other methods. Methods: A randomized multicenter study comparing totally extraperitoneal laparoscopic repair (TEP) with open repair according to Lichtenstein was performed on men with a primary inguinal hernia. Long-term follow-up collecting data on recurrences and complications up to five years after operation was carried out. Taking treatment costs into consideration, a cost-minimisation analysis was conducted. Results: Altogether 1370 patients were operated, 665 in the TEP and 705 in the Lichtenstein group. The total hospital cost for the index operation was €710.6 higher for TEP (P<0.001). Including costs for recurrences and complications, this difference increased to €795.1 (P<0.001). Taking community costs into account, the difference decreased with €503.1 to €292.0 (P=0.024). Conclusion: With five-year follow-up including complication, reoperation and community costs, there was a small but significant difference in total costs between the two methods.