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Background and aims Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but outcome evaluation has often been limited to Eckardt score (ES). The present study was aimed to improve knowledge about outcome evaluation and predictive outcome factors by performing a comprehensive objective evaluation of achalasia patients treated by POEM. Methods This single centre prospective study reports outcome data 12 months after POEM in treatment-naive achalasia patients. A predefined follow-up protocol included ES, high resolution manometry, 24-h pH measurement, upper endoscopy and timed barium esophagogram (TBE). Univariate and multivariate regression analyses were performed to analyze association between post-POEM variables and identify predictive factors for objective outcome. Results Fifty patients were included with a drop-out rate of 3 cm after POEM was associated with treatment failure assessed by ES (p = .04) and TBE (p = .03). Advanced achalasia stage (p = .02) and long symptom duration (p = .04) were identified as independent predictive factors for poor outcome assessed by TBE. Conclusions The present study confirms that POEM is an efficient therapy for achalasia. The comprehensive objective evaluation after POEM demonstrates that long symptom duration and major changes in oesophageal anatomy at diagnosis imply poor treatment outcome, and a post-POEM dilated oesophagus is associated with treatment failure.Key messagesPeroral endoscopic myotomy (POEM) is established as a safe and effective therapy for achalasia.Timed barium esophagogram offers objective variables that are valuable in treatment response evaluation.Advanced achalasia stage and long symptom duration are predictive factors for poor objective treatment response after POEM.

Source at https://doi.org/10.1186/s13049-017-0457-y . Background: Non-operative management of splenic injuries has become the treatment of choice in hemodynamically stable patients over the last decades. The aim of the study is to describe the incidence, initial treatment and early outcome of patients with splenic injuries on a national level. Methods: All hospitals in Norway admitting trauma patients were invited to participate in the study. The study period was January through December 2013. The hospitals delivered anonymous data on primarily admitted patients with splenic injury. Results: Three of the four regional trauma centers and 26 of the remaining 33 acute care hospitals delivered data on a total of 151 patients with splenic injury indicating an incidence of 4 splenic injuries per 100,000 inhabitants/year, and a median of 4 splenic injuries per hospital per year. A total of 128 (85%) patients were successfully treated non-operatively including 20 patients who underwent an angiographic procedure. The remaining 23 (15%) patients underwent open splenectomy or spleen-preserving surgery. Conclusion: Most patients with splenic injuries are managed non-operatively. Despite the low number of splenic injuries per hospital, the results indicate satisfactory outcome on a national level.

Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14.We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively.Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period.Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.

Background Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14. Material and method We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively. Results Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period. Interpretation Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.

BackgroundAlthough non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality?MethodsWe performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008.Results583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%–24%; pDiscussionChanges in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome.Level of evidenceIV.

BACKGROUND: The justification and safety of splenic angiographic embolization (SAE) as an adjunct to nonoperative management (NOM) in high-grade splenic injuries are matters of controversy. At Oslo University Hospital-Ulleval, mandatory SAE was introduced in hemodynamically stable Organ Injury Scale (OIS) Grades 3 to 5 injuries in 2002. From October 2008, mandatory SAE was restricted to OIS Grade 4 injuries or higher. The aim of the present study was to evaluate clinical outcome in patients with high-grade splenic injuries and further define the role of SAE. METHODS: All patients 17 years or older with splenic injury admitted from August 1, 2002, to July 31, 2010, were included. Patient charts, computed tomographic scans, and trauma registry data were reviewed. The OIS Grade 3 protocol was amended on October 1, 2008. RESULTS: A total of 296 patients with splenic injuries (mean splenic OIS grade, 3.0) resulted in a 70% attempted NOM rate, with 96% success rate. NOM was attempted in 64 (70%) of 91 patients with Grades 4 and 5 injuries, with a 95% success rate.Comparing OIS Grade 3 injuries admitted before (n = 81) and after (n = 35) October 2008, we found similar admission physiology and Injury Severity Score (ISS). Despite the reduction in SAE rate (from 49% to 26%), the NOM rate remained unchanged, as did NOM failure rate (3% vs. 4%), rate of rebleeding, complications, and mortality. CONCLUSION: A protocol with mandatory SAE in OIS Grades 4 and 5 injuries resulted in an overall 95% success rate among the 70% eligible for NOM. In OIS Grade 3 splenic injuries, mandatory SAE does not seem justified. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Background Although nonoperative management (NOM) has become standard care, optimal treatment of liver injuries in children is still challenging since many of these patients have multiple injuries. Moreover, the role of angiography remains poorly defined, and a high index of suspicion of complications is warranted. This study reviews treatment and outcomes in children with liver injuries at a major Scandinavian trauma centre over a 12-year period. Methods Patients

BACKGROUND: The terrorist attacks in Norway on July 22, 2011, consisted of a bomb explosion in central Oslo, followed by a shooting spree in a youth camp. We describe the trauma center response, identifying possible success factors and suggesting improvements for institutional major incident plans. METHODS: The in-hospital response is analyzed. Data on triage, patient flow, injuries, treatment, resources, and outcome were collected. RESULTS: The explosion caused a total of 98 casualties and 8 died at scene. Ten patients were triaged to the trauma center, with the first patient arriving 18 minutes after the explosion and 7 patients within the next 19 minutes. The shooting caused 68 deaths at the scene and 61 injured. The trauma center received a total of 21 patients from the shooting incident.Surgical leadership was divided between emergency department triage with control of personnel and communication as well as control and supervision of treatment with retriage and optimal use of trauma surgical resources (dual command). Surge capacity was never exceeded in the emergency department, operating rooms, or intensive care units.Of the 31 patients treated at the trauma center, 20 had an Injury Severity Score of more than 15 and 25 required repeated operation, for a total of 125 operations during the first 4 weeks. One patient died, for a critical mortality of 5%. CONCLUSION: A trauma center can handle many patients with severe injury, with low critical mortality when protected from a large number of walking wounded. Limited specific trauma surgical competence was managed by the adoption of a dual surgical command model. LEVEL OF EVIDENCE: Therapeutic/care management study, level V. Language: en

BackgroundThere is still considerable controversy about the importance and method of preserving splenic function after trauma. Recognition of the immune function of the spleen and the risk of overwhelming postsplenectomy infection led to the development of spleen-preserving surgery and non-operative management. More recently angiographic embolization has been used to try to reduce failure of conservative management and preserve splenic function.MethodsA literature review was performed of the changing treatment of splenic injury over the last century, focusing on whether and how to maintain splenic immune function.ResultsNon-operative management continues to be reported as a successful approach in haemodynamically stable patients without other indications for laparotomy, achieving high success rates in both children and adults. Except for haemodynamic instability, reported predictors of failure of conservative treatment should not be seen as absolute contraindications to this approach. Angiographic embolization is generally reported to increase success rates of non-operative management, currently approaching 95 per cent. However, the optimal use of angioembolization is still debated. Splenic immunocompetence after angioembolization remains questionable, although existing studies seem to indicate preserved splenic function.ConclusionNon-operative management has become the treatment of choice to preserve splenic immune function. Current knowledge suggests that immunization is unnecessary after angiographic embolization for splenic injury. Identifying a diagnostic test of splenic function will be important for future studies. Most importantly, in efforts to preserve splenic function, care must be taken not to jeopardize patients at risk of bleeding who require early surgery and splenectomy.

RESULTS A total of 57 out of the 65 course participants were included in the study. The participants’ scores were significantly higher for all three practical exercises after course completion, compared with the pre-course score (p < 0.001). The self-evaluations indicated that the participants felt more competent after the course. INTERPRETATION The study indicates that the BSS course provides better basic surgical skills. In view of the lack of equivalent courses at core surgical training, consideration should be given to introducing this as a compulsory part of the surgical training in Norway.

The Basic Surgical Skills (BSS) course provides an introduction to basic surgical techniques. The course was held in Norway for the first time in 2009. This study was carried out to evaluate the learning outcomes of the course.The participants from four consecutive courses were invited to take part in the study and were tested in three practical exercises immediately before and after the course. Their performance was measured using an Objective Structured Assessment of Technical Skills (OSATS) for two of the exercises and by time needed to complete the third exercise. The participants also undertook two self-evaluations of competence on each exercise, one prior to and one after completing the course.A total of 57 out of the 65 course participants were included in the study. The participants' scores were significantly higher for all three practical exercises after course completion, compared with the pre-course score (p0.001). The self-evaluations indicated that the participants felt more competent after the course.The study indicates that the BSS course provides better basic surgical skills. In view of the lack of equivalent courses at core surgical training, consideration should be given to introducing this as a compulsory part of the surgical training in Norway.

Background Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study. Methods A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell–Jolly bodies (H–J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen. Results On average 4.6 years after SAE (range 1–8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H–J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls. Conclusion This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.

Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010.Patients aged17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed.Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3-5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included - bleeding (n=8), pseudoaneurysms (n=2), contrast extravasation (n=2), high OIS injury grade (n=8) and prophylactic due to specific disease (n=2). NOM was successful in all but one case (98%). For the patients aged ≤ 14 years, extravasation on initial CT scan correlated to delayed bleeding (p0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae.After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤ 14 years.

Background After introducing splenic artery embolisation (SAE) in the institutional treatment protocol for splenic injury, we wanted to evaluate the effects of SAE on splenic function and assess the need for immunisation in SAE treated patients. Methods 15 SAE patients and 14 splenectomised (SPL) patients were included and 29 healthy blood donors volunteered as controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears from all patients and controls were examined for Howell–Jolly (H–J) bodies. Abdominal doppler, gray scale and contrast enhanced ultrasound (CEUS) were performed on all the SAE patients. Results Leukocyte and platelet counts were elevated in both SAE and SPL individuals compared to controls. The proportion of memory B-lymphocytes did not differ significantly from controls in either group. In the SAE group total IgA, IgM and IgG levels as well as pneumococcal serotype specific IgG and IgM antibody levels did not differ from the control group. In the SPL group total IgA and IgG Pneumovax® (PPV23) antibody levels were significantly increased, and 5 of 12 pneumococcal serotype specific IgGs and IgMs were significantly elevated. H–J bodies were only detected in the SPL group. CEUS confirmed normal sized and well perfused spleens in all SAE patients. Conclusion In our study non-operative management (NOM) of high grade splenic injuries including SAE, was followed by an increase in total leukocyte and platelet counts. Normal levels of immunoglobulins and memory B cells, absence of H–J bodies and preserved splenic size and intraparenchymal blood flow suggest that SAE has only minor impact on splenic function and that immunisation probably is unnecessary.