Activated systemic inflammatory response at diagnosis reduces lymph node count in colonic carcinoma.

AIM: To investigate a link between lymph node yield and systemic inflammatory response in colon cancer. METHODS: A prospectively maintained database was interrogated. All patients undergoing curative colonic resection were included. Neutrophil lymphocyte ratio (NLR) and albumin were used as markers of SIR. In keeping with previously studies, NLR ≥ 4, albumin < 35 was used as cut off points for SIR. Statistical analysis was performed using 2 sample t-test and χ(2) tests where appropriate. RESULTS: Three hundred and two patients were included for analysis. One hundred and ninety-five patients had NLR < 4 and 107 had NLR ≥ 4. There was no difference in age or sex between groups. Patients with NLR of ≥ 4 had lower mean lymph node yields than patients with NLR < 4 [17.6 ± 7.1 vs 19.2 ± 7.9 (P = 0.036)]. More patients with an elevated NLR had node positive disease and an increased lymph node ratio (≥ 0.25, P = 0.044). CONCLUSION: Prognosis in colon cancer is intimately linked to the patient's immune response. Assuming standardised surgical technique and sub specialty pathology, lymph node count is reduced when systemic inflammatory response is activated.

Multimodal treatment of perianal fistulas in Crohn's disease: seton versus anti-TNF versus advancement plasty (PISA): study protocol for a randomized controlled trial.

BACKGROUND: Currently there is no guideline for the treatment of patients with Crohn's disease and high perianal fistulas. Most patients receive anti-TNF medication, but no long-term results of this expensive medication have been described, nor has its efficiency been compared to surgical strategies. With this study, we hope to provide treatment consensus for daily clinical practice with reduction in costs. METHODS/DESIGN: This is a multicentre, randomized controlled trial. Patients with Crohn's disease who are over 18 years of age, with newly diagnosed or recurrent active high perianal fistulas, with one internal opening and no anti-TNF usage in the past three months will be considered. Patients with proctitis, recto-vaginal fistulas or anal stenosis will be excluded. Prior to randomisation, an MRI and ileocolonoscopy are required. All treatment will start with seton placement and a course of antibiotics. Patients will then be randomised to: (1) chronic seton drainage (with oral 6-mercaptopurine (6MP)) for one year, (2) anti-TNF medication (with 6MP) for one year (seton removal after six weeks) or (3) advancement plasty after eight weeks of seton drainage (under four months anti-TNF and 6MP for one year). The primary outcome parameter is the number of patients needing fistula-related re-intervention(s). Secondary outcomes are the number of patients with closed fistulas (based on an evaluated MRI score) after 18 months, disease activity, quality of life and costs. DISCUSSION: The PISA trial is a multicentre, randomised controlled trial of patients with Crohn's disease and high perianal fistulas. With the comparison of three generally accepted treatment strategies, we will be able to comment on the efficiency of the various treatment strategies, with respect to several long-term outcome parameters. TRIAL REGISTRATION: Nederlands Trial Register identifier: NTR4137 (registered on 23 August 2013).

Smoking and Crohn's disease: active modification of an independent risk factor (education alone is not enough).

INTRODUCTION: Smoking can induce the onset of Crohn's disease in genetically susceptible patients and may accelerate progression and disease severity. There is a paucity of information as to patient knowledge of the impact of smoking on disease progression. The aim of this study was to assess patient awareness, initiate smoking cessation therapy and monitor the effectiveness of an active smoking cessation programme in patients with Crohn's disease. METHODS: All patients with a diagnosis of Crohn's disease over a ten year period were identified from a prospectively managed database. Details of smoking history and patient knowledge of the link between Crohn's disease and smoking were collected through a telephone questionnaire. Current smokers who wished to quit were enrolled in a smoking cessation programme and followed prospectively for 12 months. RESULTS: 340 patients were identified with 281 eligible for inclusion. 181 patients agreed to a telephone survey (64.4% patient uptake). Smokers had an increased incidence of surgical intervention (OR 2.2; CI 1.02, 4.78 P=0.043). Awareness of the link between smoking and Crohn's disease was highest in the current smoking cohort and lowest in the non-smoking cohort (CS:NS; 79.5%:43% p<0.001). 29% of patients with a smoking history had previously been offered smoking cessation therapy. 77% of current smokers opted for smoking cessation therapy. At 6 months 53% of these patients remained smoke free and 37% at 12 months. CONCLUSION: In patients with Crohn's disease, information alone is ineffective at achieving smoking cessation. Good cessation rates are achievable if information is supported by active smoking cessation therapy.

A prospective analysis of patient outcome following treatment of T3 rectal cancer with neo-adjuvant chemoradiotherapy and transanal excision.

BACKGROUND: Local excision is an alternative to anterior or abdomino-perineal resection in patients with early rectal cancer. In more advanced disease, neo-adjuvant therapy (CRXT) can result in significant disease regression such that local excision may be considered. The primary aim was to assess oncological outcome in patients with T3 rectal cancer treated with CRXT and local excision due to unsuitability for or aversion to anterior resection and stoma. The secondary aim was to examine oncological outcomes in patients treated in a similar way in the published literature. METHODS: Between July 2006 and July 2009, patients with rectal cancer staged T3, N0/N1, M0 who were deemed unfit for or who refused anterior resection were offered long-course CRXT. Patients were restaged 8 weeks following completion. If there was a good response (regression grade 2 or 3 clinically and radiologically), full thickness transanal excision was performed. All patients were followed regularly (monthly CT abdomen/pelvis and annual endoscopy) to assess for recurrence of disease. A literature search of PubMed was performed to identify all prospective data available of T3 rectal cancers managed with CRXT and local excision. RESULTS: Ten patients were treated over 3 years. Six patients had complete pathological response, while four patients had a partial response. The resection margins following local excision were clear in all. There was no local recurrence (median follow-up 24 months, range 9-42 months). CONCLUSION: Neo-adjuvant chemoradiotherapy and local excision is an option in patients unfit for or averse to major surgical resection if there is a good response to CRXT.