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Complicated gallstone disease in Sweden 1988-2006: a register study
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background The gallstone prevalence in the western world is 10-20%. Most gallstones are silent, but symptoms and complications appear in 20-40%. The incidence of symptom development in patients with silent gallstones is 2-4% per year. The indication for surgical (including endoscopic) treatment of gallstones is symptoms of certain magnitude, and no contraindications. During the past three decades an intense technical development in imaging (ultrasound, computerised tomography and magnetic resonance imaging), endoscopic therapy, and surgery has taken place. The aim of this thesis is to scrutinize changes in management of complicated gallstone disease on a population-based level, using national register data. Have the new methods improved the treatment of acute pancreatitis, common bile duct stones and acute gallbladder disease?

Methods Data is collected from National Patient Register (NPR) run by The Swedish National Board of Health and Welfare. NPR collects discharge data from every admission from every Swedish hospital. Mortality is calculated as standardised mortality ratio (SMR) using age-, gender-, and calendar year specific survival estimates. We have studied both general trends in admissions and treatment alternatives and outcomes in defined patient cohorts. Length of hospital stay, readmission, and mortality has been used as proxy indicators of the effectiveness of treatment strategies used.

Results During the study period mortality in acute pancreatitis (SMR within 90 days of admission) improved and hospital stay for all patients with acute pancreatitis decreased. Cholecystectomy rate at or shortly after index stay for mild acute biliary pancreatitis increased from 14.5 % to 22.7 %. Of all patients with acute pancreatitis 68.4 % of the patients had no aetiological diagnosis in the register. The incidence of bile duct interventions increased 27.8% from 1988 through 2006. The favoured treatment of bile duct stones changed from open choledocholithectomy to endoscopic sphincterotomy with stone extraction during the same period. However, in 2006, still 19.6% of bile duct interventions for stones were performed as choledochotomy and in the great majority of these cases as open surgery. This indicates a continuing need of education in open bile duct surgery. Mean hospital stay for treatment of common bile duct stones decreased significantly (4.5 days) during the period studied. The mortality (SMR) diminished although without statistical significance during the time period, and there was no significant difference in SMR between choledochotomy and endoscopic sphincterotomy. For acute gallbladder disease a moderate increase of admissions occurred from 1988 through 2006. The relation between acute cholecystectomies versus all cholecystectomies did not change during this period. Of all patients admitted with acute gallbladder disease 32.3 % were cholecystectomised during their first hospital stay, whereas 20.3 % underwent elective cholecystectomy and 6.1 % emergency cholecystectomy within two years of first admission. 41.4 % of patients were not operated on for gallbladder disease within two years of first admission with this diagnosis. Mortality from first admission and 90 days onwards was elevated three-fold during the entire period without time trend, without statistical difference between age groups, and between patients who had cholecystectomy at first admission or later.

Conclusion During the audit period treatment of acute pancreatitis improved. However, etiological classification and timing of cholecystectomy in mild acute biliary pancreatitis fell below accepted guidelines. Interventions on the common bile duct for gallstone disease increased significantly. Common bile duct clearance has been separated from cholecystectomy, and cholecystectomy often not done. Only one third of all patients with acute gallbladder disease underwent cholecystectomy at first admission. There is room for improvement in treatment of complicatedgallstone disease, and, gallstone surgeons still need good knowledge in open biliary surgery.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2011. , 67 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1424
Keyword [en]
Gallstone disease, acute pancreatitis, acute biliary pancreatitis, common bile duct stones, acute cholecystitits, acute gallbladder disease, cholecystectomy, ERCP, endoscopic papillotomy, choledochotomy
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-43279ISBN: 978-91-7459-218-4OAI: oai:DiVA.org:umu-43279DiVA: diva2:412742
Public defence
2011-05-20, Sal B, 9 tr, byggnad 1D, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-04-28 Created: 2011-04-26 Last updated: 2012-10-01Bibliographically approved
List of papers
1. First attack of acute pancreatitis in Sweden 1988 - 2003: incidence, aetiological classification, procedures and mortality - a register study
Open this publication in new window or tab >>First attack of acute pancreatitis in Sweden 1988 - 2003: incidence, aetiological classification, procedures and mortality - a register study
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2009 (English)In: BMC Gastroenterology, ISSN 1471-230X, Vol. 9, 18- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Population-based studies suggest that the incidence of first attack of acute pancreatitis (FAAP) is increasing and that old age is associated with increased mortality. Because nationwide data are limited and information on standardized mortality ratio (SMR) versus age is lacking, we wanted to describe incidence and mortality of first attack acute pancreatitis (FAAP) in Sweden.

METHODS: Hospital discharge data concerning diagnoses and surgical procedures and death certificate data were linked for patients with FAAP in Sweden. Mortality was calculated as case fatality rate (CFR), i.e. deaths per 1000 patients and SMR using age-, gender- and calendar year-specific expected survival estimates, and is given as mean with 95% confidence intervals. Data are presented as median values with 25% and 75% percentiles, means and standard deviations, or proportions. Proportions have been compared using the chi square test, Poisson-regression test or Fisher exact test. Location of two groups of ratio scale variables were compared using independent samples t-test or Mann-Whitney U-test.

RESULTS: From 1988 through 2003, 43415 patients (23801 men and 19614 women) were admitted for FAAP. Age adjusted incidence rose from 27.0 to 32.0 per 100000 individuals and year. Incidence increased with age for both men and women. At index stay 19.7% of men and 35.4% of women had biliary diagnoses, and 7.1% of men and 2.1% of women alcohol-related diagnoses. Of 10072 patients who underwent cholecystectomy, 7521 (74.7%) did so after index stay within the audit period. With increasing age CFR increased and SMR decreased. For the whole period studied SMR was 11.75 (11.34-12.17) within 90 days of index admission and 2.03 (1.93-2.13) from 91 to 365 days. Alcohol-related diagnoses and young age was associated with increased SMR. Length of stay and SMR decreased significantly during the audit period.

CONCLUSION: Incidence of FAAP increased slightly from 1988 to 2003. Incidence increased and SMR declined with increasing patient age. Although the prognosis for patients with FAAP has improved it remains an important health problem. Aetiological classification at index stay and timing of cholecystectomy should be improved.

Place, publisher, year, edition, pages
BioMed Central, 2009
National Category
Gastroenterology and Hepatology Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-22372 (URN)10.1186/1471-230X-9-18 (DOI)000265762400001 ()19265519 (PubMedID)
Note

The study was supported by the County Councils of Northern Sweden (Norrlandstingens Regionforbund). The funding body had no influence on study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Available from: 2009-05-06 Created: 2009-05-06 Last updated: 2013-08-22Bibliographically approved
2. Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study
Open this publication in new window or tab >>Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study
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2009 (English)In: BMC Gastroenterology, ISSN 1471-230X, Vol. 9, 80- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Gallstones represent the most common cause of acute pancreatitis in Sweden. Epidemiological data concerning timing of cholecystectomy and sphincterotomy in patients with first attack of mild acute biliary pancreatitis (MABP) are scarce. Our aim was to analyse readmissions for biliary disease, cholecystectomy within one year, and mortality within 90 days of index admission for MABP.

METHODS: Hospital discharge and death certificate data were linked for patients with first attack acute pancreatitis in Sweden 1988-2003. Mortality was calculated as case fatality rate (CFR) and standardized mortality ratio (SMR). MABP was defined as acute pancreatitis of biliary aetiology without mortality during an index stay of 10 days or shorter. Patients were analysed according to four different treatment policies: Cholecystectomy during index stay (group 1), no cholecystectomy during index stay but within 30 days of index admission (group 2), sphincterotomy but not cholecystectomy within 30 days of index admission (group 3), and neither cholecystectomy nor sphincterotomy within 30 days of index admission (group 4).

RESULTS: Of 11636 patients with acute biliary pancreatitis, 8631 patients (74%) met the criteria for MABP. After exclusion of those with cholecystectomy or sphincterotomy during the year before index admission (N = 212), 8419 patients with MABP remained for analysis. Patients in group 1 and 2 were significantly younger than patients in group 3 and 4. Length of index stay differed significantly between the groups, from 4 (3-6) days, (representing median, 25 and 75 percentiles) in group 2 to 7 (5-8) days in groups 1. In group 1, 4.9% of patients were readmitted at least once for biliary disease within one year after index admission, compared to 100% in group 2, 62.5% in group 3, and 76.3% in group 4. One year after index admission, 30.8% of patients in group 3 and 47.7% of patients in group 4 had undergone cholecystectomy. SMR did not differ between the four groups.

CONCLUSION: Cholecystectomy during index stay slightly prolongs this stay, but drastically reduces readmissions for biliary indications.

Place, publisher, year, edition, pages
BioMed Central, 2009
Keyword
gallstone pancreatitis, endoscopic sphincterotomy, surgical-management, 1st attack, guidelines, cholelithiasis, classification, cholangitis
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:umu:diva-30598 (URN)10.1186/1471-230X-9-80 (DOI)000271901500001 ()19852782 (PubMedID)
Note

The study was supported by the County Councils of Northern Sweden (Norrlandstingens regionforbund). The funding body had no influence on study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Available from: 2010-01-08 Created: 2010-01-08 Last updated: 2013-08-22Bibliographically approved
3. Treatment of Common Bile Duct Stones in Sweden 1989-2006: An Observational Nationwide Study of a Paradigm Shift
Open this publication in new window or tab >>Treatment of Common Bile Duct Stones in Sweden 1989-2006: An Observational Nationwide Study of a Paradigm Shift
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2012 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 36, no 9, 2146-2153 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden. METHODS: All patients with hospital care for benign biliary diagnoses 1988-2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis. RESULTS: Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n = 26,815), 60.0 % underwent cholecystectomy during the first hospital admission in 1989-1994, compared to 30.1 % in 2001-2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission. CONCLUSIONS: Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.

Place, publisher, year, edition, pages
New York: Springer-Verlag New York, 2012
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-57257 (URN)10.1007/s00268-012-1648-3 (DOI)000307397000024 ()22610264 (PubMedID)
Available from: 2012-07-10 Created: 2012-07-10 Last updated: 2013-07-12Bibliographically approved
4. Surgery for acute gallbladder disease in Sweden 1989-2006: A register study
Open this publication in new window or tab >>Surgery for acute gallbladder disease in Sweden 1989-2006: A register study
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2013 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, Vol. 48, no 4, 480-486 p.Article in journal (Refereed) Published
Abstract [en]

Objective. Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure. Material and methods. Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality. Results. Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years. Conclusions. Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.

Place, publisher, year, edition, pages
London: Informa Healthcare, 2013
Keyword
biliary, case fatality rate, elective cholecystectomy, emergency cholecystectomy, hospital admission, standardized mortality ratio
National Category
Surgery Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-43277 (URN)10.3109/00365521.2012.763177 (DOI)000316699600012 ()23356689 (PubMedID)
Note

Former title in manuscript form "Surgery for acute gallbladder disease in Sweden 1990 - 2004: A register audit"

Available from: 2011-04-26 Created: 2011-04-26 Last updated: 2013-05-28Bibliographically approved

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