Køge, Denmark
Køge, Denmark

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Bjornbak C.,Koge Hospital | Bjornbak C.,Copenhagen University | Engel P.J.H.,Roskilde Hospital | Nielsen P.L.,Roskilde Hospital | And 2 more authors.
Alimentary Pharmacology and Therapeutics | Year: 2011

Background Uncertainty remains on topography and persistence of histological subgroups of microscopic colitis (MC). Aim To assess longitudinal clinical, endoscopic, histological, and therapeutic description of MC subgroups including patients with incomplete findings of MC (MCi). Methods Retrospective review of a consecutive cohort with MC and histological reassessment of MCi. Results Clinical characteristics of 168 patients with lymphocytic colitis (LC), 270 with collagenous colitis (CC) and 101 with MCi were similar. At colonoscopy 95% (95% CI: 91-98%) of CC and 98% (93-100%) of LC cases had diagnostic histopathology of MC in both left and right colon. Eight and three patients had characteristics of MC only in the left and right colon, respectively. Histology findings resembling coexistence of the other MC subtype was present in 48% (40-55%) with CC and 24% (18-31%) with LC. A first diagnosis of MC was made in 49 (30%) of 164 patients only at repeat endoscopy. Another 34 of 115 (30%) with MC in the first endoscopy did not fulfil the MC criteria at repeat endoscopy. Only seven cases had a primary endoscopy without histopathological abnormalities. Fifteen percentage of MCi were reclassified as MC. Ileal inflammation was present in 33 of 81 patients. Budesonide was efficacious in all MC subgroups irrespective of bile acid malabsorption. Conclusions Clinical characteristics of microscopic colitis subgroups are indistinguishable. Biopsies from the left colon suffice to exclude microscopic colitis, and the histological diagnosis of microscopic colitis is inconsistent over time. Ileal inflammation is common. The term microscopic colitis should perhaps be considered one clinical entity and include lymphocytic colitis, collagenous colitis, and incomplete findings of microscopic colitis. © 2011 Blackwell Publishing Ltd.


Steenholdt C.,Herlev Hospital | Brynskov J.,Herlev Hospital | Thomsen O.O.,Herlev Hospital | Munck L.K.,Koge Hospital | And 9 more authors.
Gut | Year: 2014

Objective: Although the reasons for secondary loss of response to infliximab (IFX) maintenance therapy in Crohn's disease vary, dose intensification is usually recommended. This study investigated the cost-effectiveness of interventions defined by an algorithm designed to identify specific reasons for therapeutic failure. Design: Randomised, controlled, single-blind, multicentre study. 69 patients with secondary IFX failure were randomised to IFX dose intensification (5 mg/kg every 4 weeks) (n=36) or interventions based on serum IFX and IFX antibody levels using the proposed algorithm (n=33). Predefined co-primary end points at week 12 were proportion of patients responding (Crohn's Disease Activity Index (CDAI) decrease ≥70, or ≥50% reduction in active fistulas) and accumulated costs related to treatment of Crohn's disease, expressed as mean cost per patient, based on the Danish National Patient Registry for all hospitalisation and outpatient costs in the Danish healthcare sector. Results: Costs for intention-to-treat patients were substantially lower (34%) for those treated in accordance with the algorithm than by IFX dose intensification: €6038 vs €9178, p<0.001. However, disease control, as judged by response rates, was similar: 58% and 53%, respectively, p=0.81; difference 5% (-19% to 28%). For per-protocol patients, treatment costs were even lower (56%) in the algorithm-treated group (€4062 vs €9178, p<0.001) and with similar response rates (47% vs 53%, p=0.78; difference -5% (-33% to 22%)). Conclusions: Treatment of secondary IFX failure using an algorithm based on combined IFX and IFX antibody measurements significantly reduces average treatment costs per patient compared with routine IFX dose escalation and without any apparent negative effect on clinical efficacy. Trial Registration No: NCT00851565.


Worm D.,Koge Hospital | Madsbad S.,Hvidovre Hospital | Kristiansen V.B.,Hvidovre Hospital | Naver L.,Koge Hospital | Hansen D.L.,Koge Hospital
Obesity Surgery | Year: 2015

Background: Concerns regarding nutritional deficiencies have recently emerged after Roux-en-Y gastric bypass (RYGB). Methods: A total of 835 subjects underwent RYGB, age 43.3 years, body mass index (BMI) 47.2 kg/m2. Hematological and calcium metabolic variables were measured before, 6, 12, and 24 months after surgery. Daily supplement of 800 mg calcium, 800 U vitamin D, a multivitamin, and a vitamin B12 injection (1 mg) every third month was recommended. In subjects with low ferritin and decreasing hemoglobin levels, oral, or intravenous iron was administered. Results: Hemoglobin concentration decreased from before surgery to month 24 for both men (9.3 ± 0.05 vs. 8.3 ± 0.08 mmol/L, p < 0.001) and women (8.4 ± 0.03 vs. 7.7 ± 0.06 mmol/L, p < 0.001). At 24 months, anemia was present in 25.8 % of women and 22.1 % of men. Predictors of anemia in both sexes were baseline hemoglobin (p < 0.001), excessive weight loss in men, and younger age in women (p < 0.001). Plasma ferritin levels decreased in both sexes (p < 0.01), whereas concentrations of folic acid and vitamin B12 increased from before surgery to 24 months after surgery (p < 0.001). Vitamin D increased from baseline to month 24 in both sexes (p < 0.01). In women, PTH increased from baseline to month 24 (p < 0.05) with no changes in calcium or magnesium. Conclusions: Supplementation of calcium and vitamin D was sufficient. Iron substitution did not prevent anemia, which especially affected premenopausal women. More attention should be given to iron substitution after RYGB. © 2015, Springer Science+Business Media New York.


Begtrup L.M.,University of Southern Denmark | Engsbro A.L.,Koge Hospital | Kjeldsen J.,University of Southern Denmark | Larsen P.V.,University of Southern Denmark | And 3 more authors.
Clinical Gastroenterology and Hepatology | Year: 2013

Guidelines recommend a positive strategy based on symptom criteria to diagnose patients with irritable bowel syndrome (IBS). We conducted a randomized noninferiority trial to determine whether a positive diagnostic strategy is noninferior to a strategy of exclusion, with regard to patients' health-related quality of life (HRQOL).We studied 302 patients (18-50 years old) from primary care who were suspected of having IBS and referred by general practitioners. Patients who fulfilled the Rome III criteria for IBS with no alarm signals were randomly assigned to groups assessed by a strategy of exclusion (analyses of blood, stool samples for intestinal parasites, and sigmoidoscopies with biopsies) or a positive strategy (analyses of blood cell count and C-reactive protein). Patients were followed for 1 year. The primary end point was difference in change of HRQOL from baseline to 1 year between groups (on the basis of the Short Form 36 health survey, physical component summary, and noninferiority margin of 3 points). Secondary outcomes were change in gastrointestinal symptoms, satisfaction with management, and use of resources. Findings of diagnostic misclassification were registered. A positive strategy was noninferior to a strategy of exclusion (difference, 0.64; 95% confidence interval, -2.74 to 1.45). The positive diagnostic strategy had lower direct costs. Each approach had similar effects on symptoms, satisfaction, and subsequent use of health resources. No cases of inflammatory bowel disease, colorectal cancer, or celiac disease were found. In diagnosing IBS in primary care, use of a positive diagnostic strategy is noninferior to using a strategy of exclusion with regard to the patients' HRQOL. Our findings support the current guideline recommendations. ClinicalTrials.gov, Number NCT00659763 and NCT01153295.© 2013 AGA Institute.


Henriksen N.A.,Bispebjerg Hospital | Helgstrand F.,Koge Hospital | Vogt K.C.,Copenhagen University | Jorgensen L.N.,Bispebjerg Hospital | Bisgaard T.,Koge Hospital
Journal of Vascular Surgery | Year: 2013

Objective: Abdominal aortic aneurysm disease has been hypothesized as associated with the development of abdominal wall hernia. We evaluated the risk factors for incisional hernia repair after open elective aortic reconstructive surgery for aortoiliac occlusive disease and abdominal aortic aneurysm. Methods: A retrospective analysis of prospectively recorded data in nationwide databases was carried out, with merged data from the Danish Vascular Registry (January 2006-January 2012), the Danish Ventral Hernia Database (January 2007-January 2012), and the Danish National Patient Register (January 2007-January 2012) to obtain 100% follow-up for incisional hernia repair in patients undergoing open elective aortic reconstructive surgery. The predefined risk factors of age, sex, American Association of Anesthesiologists score, body mass index, smoking status, type of aortic surgery, and type of incision were tested in a multivariate Cox regression model for the risk of incisional hernia repair. Results: We identified 2597 patients, of whom 838 and 1759 underwent open elective surgery for an aortoiliac occlusive disease and abdominal aortic aneurysm, respectively. The median follow-up was 28.9 months (range, 0-71.6 months), and the cumulative risk of hernia repair after aortic reconstructive surgery was 10.4% after 6 years of follow-up. Body mass index >25.0 kg/m2 (adjusted hazard ratio, 1.74; 95% confidence interval, 1.21-2.46) and abdominal aortic aneurysm repair (adjusted hazard ratio, 1.58; 95% confidence interval, 1.06-2.35) were significantly associated with incisional hernia repair. Conclusions: High body mass index and abdominal aortic aneurysm repair were independent risk factors for a subsequent incisional hernia surgery in patients undergoing aortic reconstructive surgery. Copyright © 2013 by the Society for Vascular Surgery.


Rasmussen M.A.,Copenhagen University | Munck L.K.,Copenhagen University | Munck L.K.,Koge Hospital
Alimentary Pharmacology and Therapeutics | Year: 2012

Background Despite similar clinical symptoms, collagenous colitis (CC) and lymphocytic colitis (LC) are considered two distinct disease entities. Aim To compare pathoanatomical findings, clinical presentations, risk factors, course of diseases and response to treatment in CC and LC to establish whether they could be subtypes of the same disease, microscopic colitis (MC). Methods The MEDLINE was searched for CC, LC and MC, and clinical studies of >20 patients were included. Pooled results with 95% confidence intervals were calculated based on the number of patients. Results An abnormal number of intraepithelial lymphocytes are found in 45% (40-50%) with CC, and an abnormal subepithelial collagen band in 16% (13-20%) with LC suggesting a histological overlap. The incidence of CC and LC has increased in parallel. Mean age (CC 63 years; LC 60 years) and clinical presentation are indistinguishable, and females are predominant in CC (77%; 75-79%) as well as LC (68%; 66-70%). Risk factors such as nonsteroid anti-inflammatory drugs consumption CC 39% (36-42%); LC 32% (29-35%) are similar and prevalence of concomitant autoimmune diseases such as coeliac disease (CC 5%; CI: 4-6% and LC 7%; CI: 6-9%) do not differ. Bile acid diarrhoea is highly prevalent in CC (41%; 37-45%) and LC (29%; 24-34%). The effect of budesonide is identical. Conclusions CC and LC could be considered histological subtypes of the same disease, MC. To facilitate recruitment to clinical trials, all MC patients could be included in future trials and stratified for subtypes. © 2012 Blackwell Publishing Ltd.


Tolver M.A.,Koge Hospital
Danish medical journal | Year: 2013

Laparoscopic inguinal hernia repair (TAPP) has gained increasing popularity because of less post-operative pain and a shorter duration of convalescence compared with open hernia repair technique (Lichtenstein). However, investigation of duration of convalescence with non-restrictive recommendations, and a procedure-specific characterization of the early clinical outcomes after TAPP was lacking. Furthermore, optimization of the post-operative period with fibrin sealant versus tacks for fixation of mesh, and the glucocorticoid dexamethasone versus placebo needed to be investigated in randomized clinical trials. The objective of this PhD thesis was to characterize the early clinical outcomes after TAPP and optimize the post-operative period. The four studies included in this thesis have investigated duration of convalescence and procedure-specific post-operative pain and other early clinical outcomes after TAPP. Furthermore, it has been shown that fibrin sealant can improve the early post-operative period compared with tacks, while dexamethasone showed no advantages apart from reduced use of antiemetics compared with placebo. Based on these findings, and the existing knowledge, 3-5 days of convalescence should be expected when 1 day of convalescence is recommended and future studies should focus on reducing intraabdominal pain after TAPP. Fibrin sealant can optimize the early clinical outcomes but the risk of hernia recurrence and chronic pain needs to be evaluated. Dexamethasone should be investigated in higher doses.


Bremholm L.,Koge Hospital
Danish medical journal | Year: 2012

Barrett's Esophagus (BE) is a premalignant condition in the esophagus. Esophageal adenocarcinomas have the fastest increase of incidence of all solid tumors in the western world. BE is defined as areas with macroscopic visible columnar epithelium and intestinal metaplasia oral of the anatomical gastroesophageal junction. The extent of the endoscopic findings is described by the Prague classification. The metaplasia is histologically confirmed by the presence of intestinal metaplasia. The diagnosis of BE can only be made by a combined macroscopic and microscopic examination. The histological description should include evaluation of dysplasia, and if present it should be classified as low or high grade dysplasia. All patients are offered relevant antireflux treatment with PPI or surgery. Ablation or mucosal resection of metaplastic epithelia with or without low grade dysplasia is experimental and it is not recommended outside controlled studies. Treatment of high grade dysplasia and carcinoma in situ is handled in departments treating esophageal cancer. Follow-up with endoscopy and biopsy can be offered. Follow-up endoscopy with biopsy can only be recommended after thorough information to the patients, as evidence for the value is scarce.


Hansen L.B.,Koge Hospital
Danish medical journal | Year: 2013

The 33 amino acid peptide hormone GLP-2 is produced by enteroendocrine L-cells, the density of which is highest in the ileum and the colon, in response to the presence of nutrients in the lumen. The biological effect of GLP-2 is mediated by activation of a G-protein-coupled 7-transmembrane receptor. GLP-2 receptors are expressed in the brainstem, lungs, stomach, small intestine and colon, but not in the heart. It has been shown in several animal studies that GLP-2 infusion increases intestinal blood flow and that this increase is confined to the small intestine. The aim of the three studies, on which the thesis is based, was to investigate basic physiological effects of GLP-2, in healthy volunteers and in SBS patients, with focus on the effects on mesenteric blood flow, blood flow at other vascular sites and effects on cardiac parameters. These parameters have been evaluated after both meal stimulation and GLP-2 administration. The studies showed the following results: Blood flow: In all three studies, blood flow changes in the SMA after GLP-2 administration were similar regarding changes over time and degree of change. Blood flow changes were similar to changes seen after a standard meal. Only RI changes were registered in all three studies, but the TAMV changes in study 2 and 3 had similar characteristics. Cardiovascular parameters: In all three studies no significant changes in blood pressure were registered in relation to GLP-2 administration. In study two and three, where cardiac parameters also were registered by impedance cardiography, increases in CO and SV were seen. Plasma GLP-2: There were, as expected, supraphysiological GLP-2 plasma levels after SC administration. All three studies have shown rapid changes in mesenteric blood flow after administration GLP-2. The changes have been the same both in regards to time to maximum changes (increase) and relatively close in regards to maximum extent of change. The changes in the SBS patients were less than in the healthy test subjects. The findings leave no doubt about that GLP-2 is a potent regulator of upper splanchnic blood flow. The study findings also support the notion that the observed increased mesenteric blood flow, isolated to the SMA, is secondary to the metabolic responses to GLP-2, and that these are likely due to a paracrine action by GLP-2 acting on GLP-2R bearing cells such as enteric neurons, probably expressing NO. In conclusion GLP-2 increases mesenteric blood flow in healthy subjects and in SBS patients, the increase is equivalent to a standard meal and dose dependent. The blood flow is not increased at other arterial vascular sites. GLP-2 does not acutely alter blood pressure, but increases, probably as compensation, pulse rate and cardiac output. GLP-2 induced vascular response in the superior mesenteric artery is related with the length of remaining intestine in SBS patients. The effect is therefore likely to reflect the metabolic activity in the tissue rather than direct effect on the vascular system.


Helgstrand F.,Koge Hospital
Danish medical bulletin | Year: 2011

Early outcome after elective ventral hernia repair is unsatisfactory, but detailed analyses are lacking. The aim of this study was to describe the aetiology of prolonged hospital stay (LOS), readmission and death < 30 days after elective ventral hernia repair. The present study was a nationwide case-control study based on prospective results from elective ventral hernia repairs (incisional, umbilical/epigastric, parastomal and other rare ventral hernia repairs) performed in Denmark during 2008. The exclusion criteria were emergency operation and ventral hernia repair in addition to another surgical procedure. The study group were patients with poor outcome (a LOS ≥ 5 days and/or readmission and/or death ≤ 30 days) and the control group were patients without a poor outcome. Major complications were defined as severe and potentially fatal complications. The cohort included 2,258 patients (a study group counting 258 patients (259 repairs) and a control group comprising 2,000 patients (2,016 repairs)). Patients in the study group underwent repair significantly more often for incisional (76% versus 28%, p < 0.001), parastomal (3% versus 1%, p = 0.001) and recurrent hernia (21% versus 12%, p < 0.001). Furthermore, hernia defects were significantly larger (median 8 cm versus 2 cm, p < 0.001) in the study group than in the control group. Prolonged LOS was mainly due to pain (27%), major complications (19%), and seroma formation (9%). Readmissions were primarily caused by wound infections and pain. Readmissions and prolonged hospital stay after ventral hernia repair were mainly due to pain, major complications, wound infections and seroma formation. The foundation of Engineer Johs. E. Ormstrup and wife Grete Ormstrup and Region Zealand"s foundation for health-care research provided funding for this study. The study was registered with the Danish Data Protection Agency (ref. no. 2008-58-0020) and www.clinicaltrials.gov (ref. no. NCT01388634).

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