The Swedish rectal cancer registry.

BACKGROUND: An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR). METHODS: Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually. RESULTS: Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2.4 per cent and the overall postoperative morbidity rate was 35.0 per cent. The 5-year cancer-specific survival rate was 62.3 per cent. The 5-year relative survival rate was 70.1 per cent after anterior resection, 59.8 per cent after abdominoperineal resection and 39.8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9.5 per cent overall, 6.1 per cent after preoperative radiotherapy and 11.4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7.4 per cent overall, 5.9 per cent for those who had radiotherapy and 10.2 per cent for those who did not. The local recurrence rate was 2.9 per cent (28 of 968) for stage I disease, 7.9 per cent (112 of 1418) for stage II, 13.9 per cent (188 of 1357) for stage III and 8.5 per cent (45 of 532) for stage IV. CONCLUSION: These good population-based results are due, in part, to the nationwide prospective quality assurance registration.

Structure of mucosa in continent ileal reservoirs 15 to 19 years after construction.

Mucosa biopsy specimens were obtained from 12 patients with continent ileostomy reservoirs constructed 15 to 19 years previously. Biopsies from normal ileal mucosa, taken from six other patients with no apparent bowel disease, served as controls. The specimens were processed for light and electron microscopy. The reservoir mucosae showed an increased amount of inflammatory cells, but there were no signs of dysplasia. In the goblet cells, sialomucins dominated over sulfomucins; in this respect no difference was found between reservoirs and controls. Morphometric studies showed an increase of mucus-storing goblet cells in the reservoir mucosae, both with regard to relative number and to volume density. The mitotic index was higher than normal in the reservoirs, but the relative number of the Paneth cells and the height of the villus epithelial cells were similar in the reservoirs and the controls. In the reservoirs, the surface amplification factors due to villi and to microvilli (near the villus tips) were reduced by some 29% and 20%, respectively, indicating villus hypotrophy. It is concluded that only minor morphologic changes appear in the ileal reservoir mucosa 15 to 19 years after construction. Morphometry provides a sensitive tool to demonstrate such changes in intestinal morphology.

Ommission of pelvic peritoneal closure after abdominoperineal rectal excision.

Peritonealization of the raw areas and closure of the pelvic floor is sometimes impossible to perform in patients subjected to abdominoperineal rectal excision when combined with extensive lymph node clearance. The postoperative course in 34 patients, treated in that way, necessitating sacrifice of the peritoneum on the dorsal aspect of the abdominal wall and in the pelvis was studied with the possible relevances in mind. Complications requiring laparotomy in the early postoperative period, occurred in three patients, but in only one of the patients was the complication considered to be related to the omission of closing the pelvic floor. Admittedly, small intestinal obstruction complicated the postoperative course later on in another three patients, but it can hardly be excluded that this complication, caused by pelvic recurrence, should not have occurred if pelvic closure had been performed. It is concluded that the importance of peritonealization, covering all raw peritoneal surfaces and pelvic reconstruction, has been overstressed in the past. Moreover, it is also suggested that it is in fact better to leave the pelvic cavity widely open than to perform a reconstruction under tension, even in patients treated by conventional abdominoperineal resection for rectal carcinoma.

Clinical and morphological characteristics of colitis carcinoma and colorectal carcinoma in young people.

Two series of young patients (less than 40 years of age) with colorectal carcinoma (22 idiopathic carcinomas and 25 carcinomas complicating ulcerative proctocolitis), well matched for age and sex, were compared with regard to clinical features, tumour morphology and stage, and ultimate outcome after surgery. The cure rate in both series was low. Although a failure to diagnose colitis carcinoma accurately at an early stage might have contributed to the poor results, such a delay could hardly be responsible for the bad prognosis in patients with idiopathic carcinoma. The vast majority of the patients in both groups studied had highly malignant and/or mucoid adenocarcinoma, and surgery was palliative in about 40% of the patients in both series, owing to widespread dissemination. The general impression gained from this study of factors of histologic grade of malignancy, extent of spread, and survival rate was that colorectal carcinomas in the young, irrespective of being idiopathic or complicating ulcerative colitis, run a rapid course and have a gloomy prognosis. The outloook depends largely on the biologic characteristics of the tumours concerned. The results support previous statements that prophylactic surgery is justified in patients with long-standing ulcerative colitis with total involvement of the colon, particularly in the young. Regrettably, patients with idiopathic carcinoma will not have this chance.

Vitamin B12 in plasma in patients with continent ileostomy and long observation time.

Plasma cobalamins (vitamin B12) were determined by a microbiological method in 235 patients with continent ileostomies and postoperative observation times of 3-13 years (mean, 6 years). The influence of the reservoir on the vitamin B12 values could not be evaluated in 22 patients (9%)--because of prophylactic treatment in 6%, subnormal B12 values before the operation in 1%, and 'treatment' of various neurological symptoms not caused by vitamin B12 deficiency in 2%. Fourteen (7%) of the remaining 213 patients had developed subnormal plasma levels of vitamin B12 and another 14 patients (7%) had 'borderline' values (130-200 pmol/l). The median time interval between reservoir operation and the development of subnormal values was 7.5 years (range, 3-11 years). A small-bowel resection had been added to the proctocolectomy in 11 out of 14 patients with subnormal values and in 8 out of 14 patients with borderline values. Subnormal or borderline values were seen in 27% of patients with Crohn's disease and in 12% of patients with ulcerative colitis. No patient had anaemia or neurological symptoms caused by B12 deficiency. The study shows that most patients with continent ileostomies do not develop B12 deficiency, and there is therefore no need for general prophylaxis. Since at least 7% developed subnormal values, the plasma levels of vitamin B12 should, however, be followed up regularly in all patients with continent ileostomies.

Gastroduodenal and ileal polyps in patients treated surgically for familial polyposis coli with proctocolectomy and continent ileostomy.

Eighteen patients, who previously had been treated surgically for familial polyposis coli with proctocolectomy and a continent ileostomy were re-investigated with endoscopy and X-ray for gastric, duodenal and ileal polyps. Gastric and/or duodenal polyps were found in 6 patients and ileal polyps in 2. Altogether upper GI-polyps were found in 7 patients (39%). Most polyps were true adenomas. In one patient with large gastric adenomas, the severe dysplasia called for a gastric resection. It is obvious that familial polyposis may affect the whole gastro-intestinal tract, therefore necessitating regular surveillance of the upper GI-canal as well as the colon and rectum in patients with this hereditary affliction.

Pregnancy and delivery in patients with a continent ileostomy.

Patients undergoing surgical treatment for inflammatory disease of the intestine are often in their reproductive years. Therefore, it is highly relevant to study the influence of surgical treatment on later pregnancy and delivery. Reported herein are 28 patients with continent ileostomies who have carried 37 pregnancies to term. An increased urge to empty the ileostomy reservoir, especially in the late period of pregnancy, was noted by the majority of patients. About one-third of the patients reported some difficulties with intubation of the reservoir in late pregnancy but in only a few patients did these disturbances result in a revisional operation after delivery. Pregnancy was normal in most instances and only four premature childbirths occurred. All pregnancies resulted in live birth. Vaginal delivery was successful in the majority of the patients, cesarean section being chosen for obstetric reasons in nine instances. From this study, it is concluded that, in patients with a continent ileostomy, normal pregnancy and delivery can be expected. However, in a few instances, the ileostomy function may be disturbed, necessitating later revisional operations.

Quality of life in ileostomy patients before and after conversion to the continent ileostomy.

In a prospective study the quality of life was evaluated in 31 consecutive patients before and after conversion from a conventional to a continent ileostomy. Patient expectations, immediate emotional reactions after the operation and attitudes at the time of the interview were more positive towards the continent ileostomy than the conventional ileostomy. An improved working capacity was affirmed after conversion to the continent ileostomy. Leisure activities and the quality of sexual life were most positively influenced by the continent ileostomy, whereas established family and social relations were not considerably influenced by either type of ileostomy. In conclusion the continent ileostomy improves the quality of life in patients requesting conversion from a conventional ileostomy.

Total body water and total body potassium in ileostomy patients before and after conversion to the continent ileostomy.

Total body water (TBW) and total body potassium (TBK) were studied in 40 ileostomists before (with conventional ileostomy) and one year after conversion to a continent ileostomy. Each patient acted as his own control. Total body water was determined by using an isotope dilution technique and TBK by counting the gamma radiation from the naturally present nuclide 40K in a whole body counter. Measured values of TBW and TBK were compared intraindividually (conventional versus continent ileostomy) and also with 'normal values' obtained from the same laboratory and based on a multiple regression analysis of data from 476 healthy controls. There was no evidence of water or potassium depletion in ileostomy patients, neither before nor after construction of the continent ileostomy.

Omission of gastric decompression after major intestinal surgery.

This study was performed in order to evaluate whether postoperative nasogastric intubation as a routine measure after major intestinal surgery is advisable or not. Factors related to postoperative nasogastric intubation were compared in two consecutive series of patients operated on with construction of a continent ileostomy. 44 patients were provided with a nasogastric tube and 52 patients had no postoperative nasogastric intubation. There were no postoperative complications which could be ascribed to the presence or absence of the nasogastric tube. Patients without nasogastric tube needed less patenteral fluid support and could resume oral feeding earlier than those with nasogastric intubation. It is concluded that postoperative nasogastric intubation can be omitted as a routine procedure after construction of a continent ileostomy.

Continent cecostomy. An account of 30 patients.

In this paper, an account is given of our experience with continent colostomy in man. In five patients, the end-sigmoidostomy was provided with an intussusception valve. Evacuation of the bowel by irrigation through a catheter was laborious and time-consuming and this method was abandoned. In another group of 30 patients, the cecum was isolated from the rest of the colon and its distal end was provided with an intussusception valve. Of the 30 patients, eight were later given continent ileostomies, two were converted to conventional sigmoidostomies, and one patient with fecal incontinence preferred to have intestinal continuity reestablished. Thus, 19 patients still have continent cecostomies and are satisfied with their function. When comparing the function of the continent cecostomy with that of the continent ileostomy, however, it is obvious that the ileostomy function is superior. The experience obtained with this group of patients has resulted in a widening of the indications for constructing a continent ileostomy, including selected patients with various anorectal disorders.

Continent ileostomy. The present technique and long term results.

Continent ileostomies were created in 435 patients in the period 1967-1984. Approximately 50% of the patients were provided with a continent ileostomy in connection with proctocolectomy and in the others a conventional ileostomy was converted to a continent ileostomy. In the majority of patients the indication for proctocolectomy was ulcerative colitis, but 64 patients with Crohn's disease were also included. There was a 1.6% operative mortality overall, but when the material was divided into two groups operated upon during two consecutive time periods, no mortality was recorded in 273 patients operated upon during the latter period. The non-fatal complication rate had also decreased from 23% in the early series to 8% in the group operated upon during the latter period. Revisional surgery because of malfunction of the nipple valve has consecutively decreased from 54% in the original series to less than 10% at the time of writing. Successful outcome of the ileostomy procedure, although revisional surgery was sometimes required, was recorded in 97% of 273 patients operated on during the period 1975-1984.

Long-term follow-up of patients with continent ileostomies.

Thirty-six patients were evaluated after having continent ileostomies for 16 to 20 years. Follow-up included clinical examination, response to a questionnaire, blood tests, and radiologic studies of the gallbladder. In addition, reservoir biopsies from 15 patients were examined. The patients were in excellent general health, all but one having gained weight postoperatively. There was no increased risk for gallstone formation or for urinary tract stone development. Although 11 of the 36 patients had reservoirs that were not provided with a valve, 92 percent of all patients were continent. Working capacity was normal in most patients and no harmful effects of the reservoir were revealed by morphologic or biochemical studies. In conclusion, no deleterious long-term effects were found as a result of the continent ileostomy.

Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection.

BACKGROUND: The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone. METHODS: Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression. RESULTS: Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised. CONCLUSION: Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.

Allopurinol as prophylaxis against pouchitis following ileal pouch-anal anastomosis for ulcerative colitis. A randomized placebo-controlled double-blind study.

BACKGROUND: Pouchitis is the major long-term complication of restorative proctocolectomy for ulcerative colitis (UC). Allopurinol is a scavenger of oxygen-derived free radicals, which it is suggested play a role in the development of UC and pouchitis. The first aim was to test the hypothesis that the incidence of pouchitis can be reduced by prophylactic Allopurinol, and secondly to evaluate if Allopurinol influences the overall pouch function. METHODS: 273 patients with UC who were planned for proctocolectomy and ileal pouch-anal anastomosis at 12 centres in Sweden between October 1994 and June 1997 were offered the opportunity to participate. 184 patients (67%) were randomized to receive postoperative prophylactic Allopurinol 100 mg twice daily or placebo. All 273 patients had clinical and endoscopic follow-up at 1, 3, 6, 12, 18, 24 months after surgery. RESULTS: Of the 184 randomized patients, 94 were randomized to Allopurinol and 90 to placebo; 116 patients (63%) completed follow-up and the crude incidence of pouchitis among those patients fullfilling the protocol was 31% in the Allopurinol group and 28% in the placebo group (ns). The cumulative risk for a first attack of pouchitis was 30% and 26% after 24 months (ns). The overall pouch function improved over time and did not differ significantly between the two groups. CONCLUSIONS: Prophylactic Allopurinol did not reduce the risk of a first attack of pouchitis.