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<p>Kirurgiska ingrepp ökar då antalet sjukdomar och befolkningens livslängd ökar. Fler operationer utförs i världen och högre krav ställs på hälso- och sjukvården. Ibland kan en operation leda till omfattande skador, komplikationer eller dödsfall. Förebyggande arbete för att höja patientsäkerheten sker internationellt och nationellt.</p><p>Världshälsoorganisationen (WHO) har utarbetat en checklista för att förbättra patientsäkerheten för att säkerställa kvaliteten på vården genom att använda en beprövad mall. Europarådet, Sveriges kommuner och landsting (SKL), Landstingens Ömsesidiga Försäkringsbolag (LÖF) och Socialstyrelsen arbetar alla med frågor kring patientsäkerheten. En litteraturstudie utfördes med syfte att undersöka om och på vilket sätt en checklista kan påverka patientsäkerheten perioperativt. Resultatet visar att en checklista reducerar komplikationer och dödsfall för patienter i den perioperativa vården, är effektiv och inte tidskrävande. Det visar också att kommunikation, samarbete och utbildning i operationslaget blir bättre genom en checklistediskussion. Alla komplikationer går inte att förhindra men med en checklista kan onödiga misstag undvikas med ett strukturerat och säkert arbetssätt. Framtida studier bör undersöka implementering av en checklista och anpassas lokalt efter operationsavdelningens förutsättningar. En standardmall behöver utvecklas, införas, och utvärderas. Forskning kring hygieniska aspekter som hur luften i en operationssal påverkas när checklistan diskuteras hade varit intressant för framtiden.</p>

Kirurgiska ingrepp ökar då antalet sjukdomar och befolkningens livslängd ökar. Fler operationer utförs i världen och högre krav ställs på hälso- och sjukvården. Ibland kan en operation leda till omfattande skador, komplikationer eller dödsfall. Förebyggande arbete för att höja patientsäkerheten sker internationellt och nationellt. Världshälsoorganisationen (WHO) har utarbetat en checklista för att förbättra patientsäkerheten för att säkerställa kvaliteten på vården genom att använda en beprövad mall. Europarådet, Sveriges kommuner och landsting (SKL), Landstingens Ömsesidiga Försäkringsbolag (LÖF) och Socialstyrelsen arbetar alla med frågor kring patientsäkerheten. En litteraturstudie utfördes med syfte att undersöka om och på vilket sätt en checklista kan påverka patientsäkerheten perioperativt. Resultatet visar att en checklista reducerar komplikationer och dödsfall för patienter i den perioperativa vården, är effektiv och inte tidskrävande. Det visar också att kommunikation, samarbete och utbildning i operationslaget blir bättre genom en checklistediskussion. Alla komplikationer går inte att förhindra men med en checklista kan onödiga misstag undvikas med ett strukturerat och säkert arbetssätt. Framtida studier bör undersöka implementering av en checklista och anpassas lokalt efter operationsavdelningens förutsättningar. En standardmall behöver utvecklas, införas, och utvärderas. Forskning kring hygieniska aspekter som hur luften i en operationssal påverkas när checklistan diskuteras hade varit intressant för framtiden.

Bakgrund: Övervikt och fetma är ett globalt problem som har fördubblats under de senaste 20 åren. Ett flertal sjukdomar är direkt relaterade till övervikt. Många väljer i dag att genomgå viktreducerande kirurgi i sin kamp mot fetma och fetmarelaterade sjukdomar. Syfte: Syftet var att beskriva hur hälsan påverkades av viktreducerande kirurgi. Metod: En systematisk litteraturstudie genomfördes vilken inkluderade nio artiklar varav fyra artiklar var kvalitativa, fyra kvantitativa samt en kvalitativ/kvantitativ. Artiklarnas kvalitet granskades utifrån granskningsmallar. Analysen utgick från två teman och resulterade i sex kategorier. Resultat: Patienter som led av fetmarelaterade sjukdomar blev markant bättre efter viktreducerande operation vilket resulterade i förbättrad hälsa. Flertalet patienter upplevde dock någon form av fysisk eller psykisk komplikation. Ett antal patienter trodde att operationen och efterföljande viktnedgång skulle lösa flertalet problem vilket det inte gjorde. Detta ledde i vissa fall till en försämrad hälsa då patienterna hamnade i ett missbruk av alkohol och droger istället för mat. Slutsats: Både positiva och negativa erfarenheter präglade patienternas upplevelser av viktreducerande kirurgi. Majoriteten av patienterna var trots negativa bieffekter nöjda med operationen. Precis som Eriksson anser bör omvårdnaden präglas av värme, omtanke och förståelse för problematiken.   Nyckelord: Upplevelse, överviktsreducerande kirurgi, hälsa

Diss. (sammanfattning) Stockholm : Karol. inst., 2001. / Härtill 6 uppsatser.

<p>Roux-en-Y gastric bypass (RYGBP) sustains weight loss and ameliorates diseases common in the morbid obese (BMI>40 kg/m²), but leaves the stomach and duodenum inaccessible. Morbidly obese patients have increased operative risks and in other fields minimal surgery is known to facilitate the postoperative course.</p><p>The aim of this thesis was to evaluate hand-assisted laparoscopy in RYGBP and develop techniques to study the excluded stomach.</p><p>The hand-assisted technique was developed in 13 patients and subsequently compared to open surgery in a blinded, prospective, randomised trial of 50 patients.</p><p>Hand-assistance was feasible with a low need for conversions or re-operations. The duration of surgery was longer (150 versus 85 minutes) and postoperative results were similar to those in open surgery. Thus, the patients did not appear to derive benefits from hand-assisted laparoscopy. Interventional radiology accessed the excluded stomach and allowed endoscopy, barium studies and acid measurements. Chronic gastritis and low acid production were found. After RYGBP, 8 of 22 patients (36%) had duodenogastric bile reflux (DGBR), when studied by HIDA-scintigraphy. No DGBR was seen among controls. The gastric mucosa was evaluated by serology</p><p>(pepsinogen I (PGI), H. pylori and H,K-ATPase) in 64 patients before and 1-4 years after operation. RYGBP, in contrast to gastric restriction, had reduced PGI levels postoperatively. According to serology, the mucosa is atrophic or in a resting state.</p><p>This study focuses on safety in RYGBP. Hand-assisted laparoscopy was feasible, but not favourable compared to an optimised open procedure. The excluded stomach is no longer inaccessible and characterised by chronic gastritis, low acid production and frequent bile reflux.</p>

<p>The aims of the thesis were to</p><p>• explore whether radical prostatectomy is beneficial compared with watchful waiting in survival and disease progression</p><p>• find possible effect modifiers</p><p>• evaluate a protocol of multiple biopsies and investigate if men with previous benign prostate biopsies are a group at risk for later prostate cancer</p><p>• inquire into patients’ and clinicians’ experiences of randomization in order to find out what made this study possible to conduct, and thereby contribute to improve randomization in the future</p><p>The background material was a large randomized clinical trial, the Scandinavian Prostatic Cancer Group Study Number 4, or SPCG-4, which was open for inclusion from February 1989 through December 1999. It comprised 695 men in Sweden, Finland and Iceland who had localized prostate cancer and were randomized to either radical prostatectomy or watchful waiting. </p><p>After a mean follow-up time of 6.2 years the first analyses, according to intention-to-treat, showed that radical prostatectomy reduced disease specific mortality, risk of metastases and risk of local progression but did not statistically significantly reduce overall mortality. </p><p>The second analyses confirmed our earlier findings and furthermore, at ten years, radical prostatectomy also statistically significantly reduced overall mortality. Age appeared as an independent effect modifier that will be further investigated.</p><p>A total of 547 men, with a suspicion of prostate cancer that had undergone multiple biopsies, and whose biopsies had benign histology were later compared with the background population to evaluate whether they were a group at risk of developing prostate cancer. Within six years of follow-up, there was no increased risk of prostate cancer.</p><p>Patients as well as clinicians used individual strategies to cope with the situation. The randomizing clinician has to understand the patient’s strategy and his expectations in order to individualize the information accordingly.</p>

<p>The thesis concerns the epidemiology, current and possible future treatment of urothelial cancer of the urinary bladder. The Swedish National Quality Registry for Bladder Cancer 1997-2001 was used to explore epidemiology, current therapies and outcome. More common in men, the incidence for Ta and T1 tumours peaks in the age range 70-79 years. There were differences in treatment activity between the reporting regions. An increasing activity was seen. Older patients received less intravesical treatment, which was also a tendency for women. The five year relative survival for all stages (Ta-T4) was 70%; 93% for Ta and 75% for T1. For Ta or T1 survival did not differ significantly between regions. Because the registry has only been running since 1997 a long term follow-up (ten years) of 250 patients comparing Bacillus Calmette-Guerin and Mitomycin-C, was performed. No differences regarding complementary treatment, progression or survival (overall or disease specific) were shown. Looking for new drugs, gemcitabine was tried for intravesical instillations. Patients were randomised to one of three dose schedules. The effect on a marker tumour lesion was evaluated after nine weeks. The overall complete response rate was 31% (9/29). Side effects were more common in women but generally mild; the most common was nausea. One patient stopped instillations (nausea and fever). No patients were excluded due to pathological changes in laboratory parameters. For metastasised disease, over-expression of the growth factor receptor HER2 on urothelial cancer cells was explored in primary tumours and metastases, aiming at radionuclide target therapy. With a new antigen retrieval procedure and evaluation protocol 80% of primary tumours overexpressed the receptor and 72% remained so in the metastases. In conclusion current therapies were increasingly used by clinicians. Superiority for BCG could not be proven. Prerequisites for new therapies have been explored and the way has been paved for future studies.</p>

Roux-en-Y gastric bypass (RYGBP) sustains weight loss and ameliorates diseases common in the morbid obese (BMI&gt;40 kg/m2), but leaves the stomach and duodenum inaccessible. Morbidly obese patients have increased operative risks and in other fields minimal surgery is known to facilitate the postoperative course. The aim of this thesis was to evaluate hand-assisted laparoscopy in RYGBP and develop techniques to study the excluded stomach. The hand-assisted technique was developed in 13 patients and subsequently compared to open surgery in a blinded, prospective, randomised trial of 50 patients. Hand-assistance was feasible with a low need for conversions or re-operations. The duration of surgery was longer (150 versus 85 minutes) and postoperative results were similar to those in open surgery. Thus, the patients did not appear to derive benefits from hand-assisted laparoscopy. Interventional radiology accessed the excluded stomach and allowed endoscopy, barium studies and acid measurements. Chronic gastritis and low acid production were found. After RYGBP, 8 of 22 patients (36%) had duodenogastric bile reflux (DGBR), when studied by HIDA-scintigraphy. No DGBR was seen among controls. The gastric mucosa was evaluated by serology (pepsinogen I (PGI), H. pylori and H,K-ATPase) in 64 patients before and 1-4 years after operation. RYGBP, in contrast to gastric restriction, had reduced PGI levels postoperatively. According to serology, the mucosa is atrophic or in a resting state. This study focuses on safety in RYGBP. Hand-assisted laparoscopy was feasible, but not favourable compared to an optimised open procedure. The excluded stomach is no longer inaccessible and characterised by chronic gastritis, low acid production and frequent bile reflux.

The aims of the thesis were to • explore whether radical prostatectomy is beneficial compared with watchful waiting in survival and disease progression • find possible effect modifiers • evaluate a protocol of multiple biopsies and investigate if men with previous benign prostate biopsies are a group at risk for later prostate cancer • inquire into patients’ and clinicians’ experiences of randomization in order to find out what made this study possible to conduct, and thereby contribute to improve randomization in the future The background material was a large randomized clinical trial, the Scandinavian Prostatic Cancer Group Study Number 4, or SPCG-4, which was open for inclusion from February 1989 through December 1999. It comprised 695 men in Sweden, Finland and Iceland who had localized prostate cancer and were randomized to either radical prostatectomy or watchful waiting. After a mean follow-up time of 6.2 years the first analyses, according to intention-to-treat, showed that radical prostatectomy reduced disease specific mortality, risk of metastases and risk of local progression but did not statistically significantly reduce overall mortality. The second analyses confirmed our earlier findings and furthermore, at ten years, radical prostatectomy also statistically significantly reduced overall mortality. Age appeared as an independent effect modifier that will be further investigated. A total of 547 men, with a suspicion of prostate cancer that had undergone multiple biopsies, and whose biopsies had benign histology were later compared with the background population to evaluate whether they were a group at risk of developing prostate cancer. Within six years of follow-up, there was no increased risk of prostate cancer. Patients as well as clinicians used individual strategies to cope with the situation. The randomizing clinician has to understand the patient’s strategy and his expectations in order to individualize the information accordingly.