The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Transanal total mesorectal excision for rectal cancer has been suspended in Norway

Background

Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates.

Methods

Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan–Meier estimates were used to compare local recurrence.

Results

In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent.

Conclusion

Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast

BACKGROUND

To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome.

METHODS

An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat.

RESULTS

Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001).

CONCLUSIONS

Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

The New National Registry for Gastrointestinal Surgery in Norway: NoRGast

Background and Aims:

There is an increasing demand for high-quality data for the outcome of health care. Diseases of the gastro-intestinal tract involve large patient groups often presenting with serious or life-threatening conditions. Complications may affect treatment outcomes and lead to increased mortality or reduced quality of life. A continuous, risk-adjusted monitoring of major complications is important to improve the quality of health care to patients undergoing gastrointestinal resections. We present the development of the Norwegian Registry for Gastrointestinal Surgery, a national registry for colorectal, upper gastrointestinal, and hepato-pancreato-biliary resections in Norway.

Materials and Methods:

A narrative and qualitative presentation of the development and current state of the registry.

Results:

We present the variables and the analysis tools and provide examples for the potential in quality improvement and research. Core characteristics include a strictly limited set of variables to reflect important risk factors, the procedure performed, and the clinical outcomes.

Conclusion:

A registry with the potential to present complete national cohort data is a powerful tool for quality improvement and research.

The outcome and the frequency of pathological complete response after neoadjuvant radiotherapy in curative resections for advanced rectal cancer: a population-based study

AIM

Pathological complete response (ypCR) after neoadjuvant treatment for rectal cancer is associated with favourable survival and a low rate of local recurrence. The aim of the study was to assess the incidence of ypCR among patients with advanced rectal cancer treated with neoadjuvant chemoradiotherapy and curative resection and to explore factors associated with survival.

METHOD

From 2000 to 2009, 1384 patients enrolled in the national population- based colorectal cancer registry of Norway with advanced T3 and T4 rectal cancer with N0-2, M0 received neoadjuvant long-course (chemo)radiation. The duration of follow-up was a median of 5 years.

RESULTS

ypCR was achieved in 147 (10.6%) patients. The estimated 5-year overall survival rate was 87% (confidence interval ± 5.4) among ypCR and 67% among non-ypCR (confidence interval ± 2.7) (P < 0.0001). Distant metastasis developed in 12 (8%) of 147 and 328 (26.5%) of 1237 patients respectively (P < 0.001). In a Cox proportional hazards ratio model the effect of ypCR on survival was adjusted for age [hazard ratio (HR) 1.056, P = 0.0001], metachronous metastasis (HR 4.7, P = 0.0001), local recurrence (HR 4.3, P = 0.0001) and surgical procedure (HR 1.48, P = 0.0001). The independent effect of ypCR (HR 0.65, P = 0.041) on survival almost disappeared compared with the univariate analysis.

CONCLUSION

The rate of ypCR in advanced rectal cancer was about 10%. This phenomenon seems to occur in tumours with a low risk of metastasizing. The contribution of neoadjuvant therapy to ypCR on survival was small or absent.

Impact of perioperative chemotherapy on oncological outcomes after gastric cancer surgery

BACKGROUND

Perioperative chemotherapy has become standard care for resectable gastric cancer. However, available evidence is based on a limited number of trials, and the outcomes in routine clinical practice and in unselected patients are scarcely reported.

METHODS

The study included a consecutive series of patients with resectable gastric cancer treated between 2001 and 2011 in Central Norway. Before 2007, patients with resectable gastric cancer did not receive perioperative chemotherapy. Since 2007, medically fit patients with resectable gastric cancer and aged 75 years or less have been offered this. Response rates were evaluated by CT, and tolerability was assessed by the frequency of hospital admission, need for dose reduction or treatment discontinuation. The two time intervals were compared on an intention-to-treat basis for patients aged no more than 75 years for any impact on resection rates, surgical morbidity, postoperative mortality and long-term survival.

RESULTS

About two-thirds (259) of the 419 patients registered were aged 75 years or less at diagnosis. Ninety-five of 136 patients in the later interval were eligible for chemotherapy, of whom 90 actually received the specified regimen, and 78 (87 per cent) were able to complete the preoperative course. Only 40 (44 per cent) completed all scheduled preoperative and postoperative cycles. Thirty-eight (43 per cent) of 89 evaluable patients showed a definite response on CT. Chemotherapy had no impact on postoperative morbidity or mortality. The 5-year survival rate on an intention-to-treat basis was 40·7 (95 per cent c.i. 30·7 to 50·7) per cent in the first interval, compared with 41·7 (31·5 to 51·9) per cent after the introduction of perioperative chemotherapy (P = 0·765). After adjustment for other risk factors, based on comparisons of the two time intervals, there were no differences in oncological outcomes with the use of perioperative chemotherapy.

CONCLUSION

Perioperative chemotherapy was completed in less than half of the patients with resectable gastric cancer. An observed tumour response to chemotherapy did not translate into any long-term survival benefit compared with surgery alone.

Identification of serum microRNA profiles in colon cancer

Background:

microRNAs (miRNAs) exist in blood in an apparently stable form. We have explored whether serum miRNAs can be used as non-invasive early biomarkers of colon cancer.

Methods:

Serum samples from 30 patients with colon cancer stage IV and 10 healthy controls were examined for the expression of 375 cancer-relevant miRNAs. Based on the miRNA profile in this study, 34 selected miRNAs were measured in serum from 40 patients with stage I–II colon cancer and from 10 additional controls.

Results:

Twenty miRNAs were differentially expressed in serum from stage IV patients compared with controls (P<0.01). Unsupervised clustering revealed four subgroups; one corresponding mostly to the control group and the three others to the patient groups. Of the 34 miRNAs measured in the follow-up study of stage I–II patients, 21 showed concordant expression between stage IV and stage I–II patient. Based on the profiles of these 21 miRNAs, a supervised linear regression analysis (Partial Least Squares Regression) was performed. Using this model we correctly assigned stage I–II colon cancer patients based on miRNA profiles of stage IV patients.

Conclusion:

Serum miRNA expression profiling may be utilised in early detection of colon cancer.

Long-term function after ileal pouch-anal anastomosis - function does not deteriorate with time

AIM

There are conflicting reports regarding long term function after ileal pouch-anal anastomosis (IPAA). The aim of the present prospective study was to investigate the influence of duration as an independent factor on long-term function results.

METHOD

Between 1984 and 2007, 315 patients underwent IPAA and were followed by a standardised interview and endoscopy protocol. There were 1802 interviews. Two hundred and thirty-five patients had three or more visits and these data were analysed by Time-Series-Cross-Section multivariate regression analysis. The mean time follow up was 12 years and the mean interval between visits was 34.5 months.

RESULTS

Mean frequency of defecation was 5.2 in the day and 0.55 at night. This did not change with time. Daytime and night incontinence occurred in 13% and 21%. There was no change in incontinence, urgency, soiling or perineal excoriation with time. After 24 years the cumulative incidence of pouchitis was 43.5%. Twenty patients had chronic pouchitis (6.3%).

CONCLUSION

The interval from IPAA did not influence the long-term functional outcome.

Failed pelvic pouch substituted by continent ileostomy

OBJECTIVE

The long-term failure rate of ileal pouch-anal anastomosis (IPAA) is 10-15%. When salvage surgery is unsuccessful, most surgeons prefer pouch excision with conventional ileostomy, thus sacrificing 40-50 cm of ileum. Conversion of a pelvic pouch to a continent ileostomy (CI, Kock pouch) is an alternative that preserves both the ileal surface and pouch properties. The aim of the study was to evaluate clinical outcome after the construction of a CI following a failed IPAA.

METHOD

During 1984-2007, 317 patients were operated with IPAA at St Olavs Hospital and evaluated for failure, treatment and outcome. Seven patients with IPAA failure had CI. Four patients with IPAA failure referred from other hospitals underwent conversion to CI and are included in the final analysis.

RESULTS

Seven patients had a CI constructed from the transposing pelvic pouch and four had the pelvic pouch removed and a new continent pouch constructed from the distal ileum. Median follow up after conversion to CI was 7 years (0-17 years). Two CI had to be removed due to fistulae. One patient needed a revision of the nipple valve due to pouch loosening. At the end of follow-up, 8 of the 11 patients were fully continent. One patient with Crohn's disease had minor leakage.

CONCLUSION

In patients with pelvic pouch failure, the possibility of conversion to CI should be presented to the patient as an alternative to pouch excision and permanent ileostomy. The advantage is the continence and possibly a better body image. Construction of a CI on a new ileal segment may be considered, but the consequences of additional small bowel loss and risk of malnutrition if the Kock pouch fails should be appraised.

Performance of clinical guidelines compared with molecular tumour screening methods in identifying possible Lynch syndrome among colorectal cancer patients: a Norwegian population-based study

Background:

The aim of this study was to assess the performance of the Revised Bethesda Guidelines (RBG) and the accuracy of the Amsterdam II criteria (AM II) in identifying possible Lynch syndrome (LS) compared with the results of molecular tumour testing.

Methods:

Tumours from 336 unselected colorectal cancer patients were analysed by three molecular tests (namely microsatellite instability (MSI), BRAF mutation and methylation of mismatch-repair genes), and patients were classified according to the RBG and AM II criteria.

Results:

A total of 87 (25.9%) patients fulfilled the RBG for molecular tumour analyses (MSI and/or immunohistochemistry), and the AM II identified 8 (2.4%) patients as having possible LS. Molecular tests identified 12 tumours (3.6%) as probable LS. The RBG identified 6 of the 12 patients (sensitivity 50%), whereas 5 of the 8 patients who fulfilled the AM II criteria were not likely to be LS, based on molecular tests (predictive value of positive test, 38%).

Interpretation:

Assuming a fairly high accuracy of molecular testing, the performance of the RBG in identifying patients with possible LS was poor, and the AM II criteria falsely identified a large proportion as having possible LS. This favours the use of molecular testing in the diagnosis of possible LS.

Long-term surgical load in patients with ileal pouch-anal anastomosis

AIM

To evaluate surgical workload and complications in patients who had undergone restorative proctocolectomy, through long-term follow-up in one single institution.

METHOD

From 1984 to 2006, 304 consecutive patients underwent Ileal Pouch-Anal Anastomosis (IPAA). There were 182 stapled and 122 hand-sewn anastomoses. A protective loop ileostomy was established in 256 patients (84%), whereas 48 patients (16%) were without a covering stoma.

RESULTS

Twenty-nine patients (10%) suffered from early anastomotic leakage. A protective stoma did not prevent early anastomotic dehiscence (P = 0.11) or the number of pelvic abscesses (P = 0.09). Early complications required 20 laparotomies with creation of a diverting stoma in nine patients. There were 16 (6%) complications related to closure of the loop ileostomy. Sixty-six patients needed an additional re-operation related to the IPAA procedure. There were 20 removals of pouches and three permanent diverting stomas. The estimated removal rate at 20 years of a functioning pouch was 11% (CI +/- 6). Altogether 100 (33%) patients had one or more surgical procedures, excluding dilations of anastomotic strictures and closing of a loop ileostomy. These 100 patients underwent 187 surgical procedures. The estimated rate of a first re-operation due to complications was 52% (CI +/- 16) in 20 years. Hand-sewn anastomoses had similar complications and failure rates as stapled anastomoses.

CONCLUSIONS

More than half of patients operated with restorative proctocolectomy will need surgical intervention within 20 years and the failure rate is more than 10%. The high risk of complications and failure inherent in the procedure should not be ignored.

Awareness of heredity in colorectal cancer patients is insufficient among clinicians: a Norwegian population-based study

OBJECTIVE

The assessment of family history and medical data is crucial in identifying families with Lynch syndrome (LS). Among consecutive colorectal cancer (CRC) patients, we aimed at identifying all patients with a hereditary predisposition, and to study a possible discrepancy with assessments made by the responsible clinicians.

METHOD

All consecutively diagnosed patients with CRC from two Norwegian hospitals were included, and information on family history was collected in a detailed interview. We assessed information in medical records, and tumours were examined for LS-associated histopathological features.

RESULTS

Among 562 patients, there was no documentation of family history in 388 (69.0%) medical records, and in 174 (31.0%) patients, there was no clinical assessment of the information that was collected on family history. Based on detailed interviews and extended pathological examination, we found that 137 (24.4%) of the 562 patients could be classified as possible LS according to the Revised Bethesda Guidelines (RBG); and that 46 (33.6%) of these patients could be identified by family history alone.

CONCLUSION

Family history and relevant information in patient records can identify patients with possible LS. However, clinicians often fail to include information on hereditary factors and to assess relevant data in medical records. Familial CRC is therefore not acknowledged, and genetic counselling is not offered.

Low Local Recurrence Rates after Rectal Cancer Resection with Limited Use of Preoperative Radiotherapy

Background:

Local recurrence rates after curative rectal resection for rectal cancer have decreased after introduction of TME. In order to achieve even further reduction in local recurrence rates, several hospitals increase the use of preoperative radiotherapy. Thus, radiotherapy-related side effects will increase. The aim of the study was to evaluate the results of the TME-technique with minimal use of radiotherapy.

Materials and Methods:

A prospective observational study from 1993 to 2000 of 137 consecutive patients treated for rectal cancer at the Department of Surgery, Nordland Hospital HF, Bodø, Norway.

Results:

115 patients underwent curative resections (84%). Eight patients (6.4 %) received peri-operative radiotherapy: three preoperatively (2.4%) because of clinically fixed tumours and five patients (4%) postoperatively; four with pR1-resections and one patient after perforation of the rectum. The local recurrence rate was 3.4 % with an observation time of 5 years. The total survival rate was 74% in curative group. In 22 patients the treatment was palliative. Only one of these patient survived 5 years.

Conclusion:

With TME-technique it is possible to achieve low recurrence rates and high survival rates with a high curative rate with minimal use of additional radiotherapy.

Surgical load and long-term outcome for patients with Kock continent ileostomy

OBJECTIVE

The aim of the study was to evaluate the results of Kock continent ileostomy (CI) during the same period when ileal pouch-anal anastomosis was the preferred operation for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP).

METHOD

During the period 1983-2002, 50 patients underwent CI. The surgical technique was unchanged during the period. Follow-up included all patients. Forty-eight patients had UC, two of these had the diagnosis later changed to Crohn's disease and two had FAP.

RESULTS

Twenty-two patients had 38 reoperations, four (8%) of whom had the pouch removed. The main causes for reoperation included leakage and difficulty in intubation due to sliding of the nipple valve (42%), fistula formation (29%) and stenosis (21%). Seventeen (45%) underwent a revision of the nipple valve and the pouch and nine (24%) a local procedure. The reoperation rate was higher among patients having a conventional ileostomy converted to CI than among those having CI. As a primary procedure (P = 0.016). The risk of a second reoperation was higher for those reoperated within the first year after having a CI, than for those reoperated later (P = 0.007).

CONCLUSIONS

The reoperation rate of patients with CI is high but the removal rate of the pouch is low and is not associated with a high rate of revision. CI is a good alternative to conventional ileostomy in patients not suitable for restorative proctocolectomy or where this procedure has failed.

[Preoperative parathyroid scintigraphy in primary hyperparathyroidism]

BACKGROUND

The primary benefit of preoperative scintigraphy in patients with primary hyperparathyroidism not previously surgically explored seems to be the possibility of unilateral or limited access surgery in selected patients.

MATERIAL AND METHODS

We studied the accuracy of scintigraphy using 99mTc sestamibi and dual phase imaging protocol combined with thyroid scintigraphy using 99mTc pertechnetate before conventional neck exploration and histologic verification in 78 consecutive patients.

RESULTS

In 65 patients with solitary, focal uptake on scintigraphy, we found a solitary adenoma in 61 patients (94%), a solitary adenoma on the contralateral side in one patient, two adenomas on the indicated side in one patient, bilateral adenomas in one and hyperplasia in one patient. In 13 patients with a negative or equivocal scintigraphic result, eight had a solitary adenoma and five hyperplasia.

INTERPRETATION

These result may support a limited unilateral surgical approach when scintigraphy shows a localized focal uptake and this is confirmed perioperatively. In experienced hands the risk of overlooking an adenoma will be small. However, it is mandatory to have an experienced parathyroid surgeon prepared to proceed with full neck exploration when this is necessary.

[Cholecystectomy in the laparoscopic era]

Since 1991 laparoscopic cholecystectomy has been performed on 323 patients; 47 patients underwent conversion to open surgery. In the same period, 46 patients were primarily selected for open cholecystectomy. Half the patients were operated on because of gallbladder colic (the sole symptom). Conversion to open operation (14%) occurred not so much because of peroperative complications, but rather because of anatomical problems. On the fourth postoperative day, one patient died of septicaemia caused by iatrogenic diathermy damage to the duodenum. One patient developed a stricture of the choledochus as a result of ischemia. This was caused by dissecting the choledochus, having mistaken it for the ductus cysticus which was missing in this anatomic variant.

[Laparoscopic sigmoidectomy]

The laparoscopic approach has emerged as an alternative to trephine stoma construction. In the present series, eight patients underwent laparoscopic faecal diversion. We performed two endsigmoidostomies and six sigmoid loop ostomies. Indications for diversion included inoperable obstructing pelvic carcinoma in three patients, perianal fistulas in another three--and faecal incontinence in one patient. A temporary loop-sigmoidostomy was performed in one patient after anal sphincteroplasty. Three or four ports were used. After mobilisation, the sigmoid colon was pulled through the abdominal wall. When an end-sigmoidostomy was performed the bowel was transected intra-abdominally. There were no operative complications and all stomas functioned early and well. Laparoscopic sigmoidostomy is safe and allows intra-abdominal exploration and mobilisation of the colon without the inconvenience of a mid-line surgical wound.

[Stomach cancer. A 10-year material with emphasis on early cancer]

Between 1982 and 1991, 112 patients were treated for gastric cancer at Harstad Hospital in Northern Norway. Early gastric cancer accounted for 20% of all the adenocarcinomas (110), which is high compared with figures from other western studies. The role of endoscopy for detecting early gastric cancer is discussed. The five year survival rate after radical surgery was found to be significantly higher for patients with early gastric cancer than for patients who underwent curative surgery for either infiltrative or regional cancer. For patients with a tumour that had invaded the regional lymph nodes the five year survival rate was only 10%. This result can be improved by more extended lymph node dissection. The perioperative mortality rate (8%) was usually a result of severe cancer cachexia or underlying cardial disease, and not anastomotic leakage. The results as regards the cure of early gastric cancer are comparable with those described in other studies.

The Harstad Injury Prevention Study: evaluation of hospital-based injury recording and community-based intervention for traffic injury prevention

In a quasi-experimental study, hospital-treated traffic accident injuries were recorded prospectively for 7 1/2 years in the two Norwegian cities, Harstad and Trondheim. In Harstad the recorded data were used actively in analysis, planning, and implementation of a community-based injury prevention program. Trondheim was the nonequivalent control city. The intervention was divided into three periods, each of 30 months duration. Preventive efforts were implemented to some extent in period 1, increasingly in period 2 and period 3. Traffic safety was promoted in an extensive community program based on the Ottawa charter for health promotion. A 26.6% overall reduction of traffic injury rates was found in Harstad from period 1 to period 3 (p < 0.01), whereas a corresponding significant increase was found in the comparison city. Analysis of data from other sources were not conclusive in supporting the Trondheim data as showing the national trend. Alternative explanations for the injury rate reduction in Harstad were assessed by means of other available relevant data. The exact mechanisms that brought about the reduction of injury rates were hard to elucidate because so many intervention elements were implemented at the same time. It is concluded that at least some of the reduction was due to behavioural and structural changes brought about by health promotion. Important factors for the effect of and participation in the prevention program were local relevance and continuous feedback of accident injury data.

[Calcitonin treatment of metabolic bone disease induced by parenteral nutrition]

After a near total small bowel resection for an acute thrombosis of the mesenterial artery, a 61 year-old man was treated with total parenteral nutrition at home for five years. The treatment was complicated by episodes of sepsis, anaemia and uremia. After four years he developed pain in long bones and the back and grave hypercalcuria. Roentgenogram showed demineralisation. There was no hyperparathyroidism and serum phosphate and serum calcium were normal. His chronic metabolic acidosis was treated continuously with enteral acetate. He received basal amounts of vitamin D and amino acids. By administering calcitonin we were able to cure his progressive bone pains and normalize his calcium urinary output. No side effects were observed. Therefore, calcitonin may contribute to the treatment of bone disease associated with total parenteral nutrition.

[Surgical treatment of acute intestinal ischemia. Successful treatment with embolectomy of the superior mesenteric artery]

We describe a patient with acute intestinal ischemia successfully treated with embolectomy of the superior mesenteric artery. Over the last four years, 11 patients with the same disease were treated with bowel resection at Nordland Regional Hospital. The mortality rate after bowel resection was 45%. Long duration of symptoms, and high frequency of associated cardiovascular disease was characteristic. In elderly patients with acute abdominal pain and cardiovascular disease, a diagnosis of acute mesenterial ischemia should be seriously considered. In patients with acute mesenteric ischemia and no bowel necrosis, embolectomy must be considered in preference to bowel resection.

[Surgical treatment of abdominal aortic aneurysms. Risk factors and complications]

Between January 1985 and April 1991 156 patients underwent surgery for abdominal aortic aneurysm at Nordland Regional Hospital. Of these, 90 underwent elective surgery; 36 were operated on for symptomatic aneurysm; 30 for ruptured aneurysm. The mortality rates were respectively 10%, 14% and 47%. Surgery for aortic aneurysm is on the increase. Advanced age, and associated serious cardiac disease predispose to postoperative complications and death. To reduce mortality better preoperative evaluation and treatment are essential.

[Surgical treatment of aortic occlusion and obliterating aorto-iliac arteriosclerosis]

From 1985 to March 1991, 83 patients with the diagnosis aortoiliac obliteration and aortic occlusion were operated on at the Department of Surgery, Nordland Central Hospital. The main symptom was claudicatio intermittens. 16 patients had pain while at rest, and two had gangrene. The surgical technique was either Y-prosthesis or thrombendarterectomy. Four patients (4.8%) died postoperatively, three of myocardial infarction and one of intestinal ischemia and peritonitis. In our study 66 patients with aortoiliacal atherosclerosis were compared with 17 patients with aortic occlusion. Patients with aortoiliacal atherosclerosis demonstrated by angiography had much more severe infrainguinal arterial pathology. In the occlusion group the postoperative outcome, as measured by ankle/brachial index, was significantly better (p < 0.01). The study included four female patients less than 50 years of age with total infrarenal aortic occlusion. Their symptoms and signs are discussed.

[Abdominal aortic surgery. Transperitoneal or retroperitoneal approach?]

During the past five years a retroperitoneal approach was used in 34 patients and the transabdominal route in 49 patients for treatment of abdominal aortosclerosis. Both groups were identical with respect to age, sex and preoperative morbidity. In patients with previous laparotomy the retroperitoneal approach was always chosen. There was no significant difference with regard to postoperative complications. The only significant difference between the two groups after the operation was a trend towards earlier defecation among the patients treated by the retroperitoneal approach. We can not demonstrate any important advantage or disadvantage of the retroperitoneal approach. The transabdominal approach provides an opportunity to examine the abdominal organs for malignancy. We found one asymptomatic gastric cancer. The retroperitoneal approach is particularly suitable in patients who have undergone laparotomy before for expected severe abdominal adhesions.

[Hip fractures in Troms and Oslo in 1989. Risk development 1978-89]

We studied the incidence of hip fractures in the county of Troms. This was compared with the incidence in a district of the city of Oslo. In both regions, the incidence increased almost exponentially with age both for men and for women. Since 1978, age-adjusted incidence has increased. This is most pronounced for men and for the county of Troms. In 1978 there was a marked difference between Oslo and Troms as regards risk of hip fracture. In 1989 this difference had diminished and persisted only among very old people. Risk factors other than postmenopausal and senile osteoporosis are discussed in an attempt to explain this development.

[Early complications in treatment of femoral neck fractures. Experiences with Olmed screws]

Postoperative secondary displacement of displaced femoral neck fractures is a major problem in the treatment of this fracture. In a study of 232 femoral neck fractures operated at the Department of Surgery, Harstad Hospital and at the Departments of Surgery and Orthopaedics, Tromsø University Hospital, the reduction was lost in 12% of the displaced fractures within three months. The fractures were fixated with two 6 mm screws (Olmed). The deep infection rate was 3.4%. There were significant differences between the hospitals. The rate of redisplacement was 5% at Harstad Hospital and 29% at the Tromsø University Hospital (p less than 0.001), the rate of deep infection was 1.8% versus 7.5% (p less than 0.05). Early complications are caused by poor quality of reduction and incorrect positioning of the screws. The surgeons' lack of experience in treating these fractures gives rise to a high rate of complications. The main reason for the low rate of complications in the material from Harstad Hospital is continuous and prospective quality control of femoral neck fractures. Such continuous feedback, and an interest intreating these fractures among the surgical staff, obviously improves the results. When the Olmed method of fixation is used correctly the rate of early complications is small.

[Bicycle injuries. Hospital based registration of injuries during 1985-89]

We analyze the results of 4 1/2 years of prospective registration of accidents to cyclists. 252 injured were treated at our hospital some as in-patients, some as out-patients. About 30% of all traffic injuries relate to cyclists. The true amount of these injuries is more than ten times the figure in the Norwegian official statistics. Most injuries occur in childhood and early adolescence, because these groups cycle most. Head injuries, wounds and fractures dominate. Two out of three of the injured are males. Accidents involving motor vehicles are more serious than other types of accidents and constitute about 17% of all injuries to cyclists. A lot of helmets have been sold, but no reduction in head injuries has been observed. The classical spoke injuries continue.

[Injuries in nursing homes. Hospital-based registration of injuries of patients in nursing homes]

109 patients were registered in a prospective study of accidents occurring in geriatric nursing homes and treated in Harstad Hospital. In more than 50% the seriousness of the injury was so high that in-patient treatment was necessary. More than 90% of the patients had fallen and 50 patients had suffered fracture of the proximal femur. The incidence of injury is higher than the estimated 13% average, and the seriousness of the injury is substantially higher than the average for all age groups.