Lymph node yield and tumour subsite are associated with survival in stage I-III colon cancer: results from a national cohort study.

BACKGROUND: It has been suggested that apart from tumour and nodal status, a range of patient-related and histopathological factors including lymph node yield and tumour location seems to have prognostic implications in stage I-III colon cancer. We analysed the prognostic implication of lymph node yield and tumour subsite in stage I-III colon cancer. METHODS: Data on patients with stage I to III adenocarcinoma of the colon and treated by curative resection in the period from 2003 to 2011 were extracted from the Danish Colorectal Cancer Group database, merged with information from the Danish National Patient Register and analysed. RESULTS: A total of 13,766 patients were included in the analysis. The 5-year overall survival ranged from 59.3% (95% CI 55.7-62.9%) (lymph node yield 0-5) to 74.0% (95% CI 71.8-76.2%) (lymph node yield ≥ 18) for patients with stage I-II disease (p < 0.0001) and from 36.4% (95% CI 29.8-43.0%) (lymph node yield 0-5) to 59.4% (95% CI 56.6-62.2%) (lymph node yield ≥ 18) for patients with stage III disease (p < 0.0001). The 5-year overall survival for tumour side left/right was 59.3% (95% CI 57.9-60.7%)/64.8% (CI 63.4-66.2%) (p < 0.0001). In the seven colonic tumour subsites, the 5-year overall survival ranged from 56.6% (95% CI 51.8-61.4%) at splenic flexure to 65.8% (95% CI 64.5-67.2%) in the sigmoid colon (p < 0.0001). In a cox regression analysis, lymph node yield and tumour side right/left were found to be prognostic factors. Tumours at the hepatic and splenic flexures had an adverse prognostic outcome. CONCLUSION: For stage I-III colon cancer, a lymph node yield beyond the recommended 12 lymph nodes was associated with improved survival. Both subsite in the right colon, as well as subsite in the left colon, turned out with adverse prognostic outcome questioning a simple classification into right-sided and left-sided colon cancer.

Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA.

OBJECTIVE: To evaluate short-term outcomes of a new treatment for perforated diverticulitis with purulent peritonitis in a randomized controlled trial. BACKGROUND: Perforated diverticulitis with purulent peritonitis (Hinchey III) has traditionally been treated with surgery including colon resection and stoma (Hartmann procedure) with considerable postoperative morbidity and mortality. Laparoscopic lavage has been suggested as a less invasive surgical treatment. METHODS: Laparoscopic lavage was compared with colon resection and stoma in a randomized controlled multicenter trial, DILALA (ISRCTN82208287). Initial diagnostic laparoscopy showing Hinchey III was followed by randomization. Clinical data was collected up to 12 weeks postoperatively. RESULTS: Eighty-three patients were randomized, out of whom 39 patients in laparoscopic lavage and 36 patients in the Hartmann procedure groups were available for analysis. Morbidity and mortality after laparoscopic lavage did not differ when compared with the Hartmann procedure. Laparoscopic lavage resulted in shorter operating time, shorter time in the recovery unit, and shorter hospital stay. CONCLUSIONS: In this trial, laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III was feasible and safe in the short-term.

A high lymph node yield in colon cancer is associated with age, tumour stage, tumour sub-site and priority of surgery. Results from a prospective national cohort study.

AIM: To determine the relation between patient-related and histopathological factors, as well as the influence of national programs for diagnosing and treatment of colon cancer and a lymph node yield (LNY) ≥ 12. METHOD: An analysis was carried out of the LNY in a nationwide Danish cohort treated by curative resection of stage I-III colon cancer in the period 2003-2011. The association between a LNY ≥ 12 and age, sex, body mass index, open vs. laparoscopic surgery, acute vs. elective surgery, pT stage, tumour sub-site and year of diagnosis was analysed. RESULTS: A total of 13,766 patients were eligible for the analysis. In total, 71.4 % of the patients had a LNY ≥ 12. In multivariate analysis, age, pT stage, tumour sub-site and priority of surgery were independently associated with the probability of a LNY ≥ 12. Odds ratios (ORs) were as follows: age <65 1, 65-75 0.685 (confidence interval (CI) 0.586-0.800), >75 0.517 (CI 0.439-0.609); T1 1, T2 2.750 (CI 2.168-3.487), T3 6.016 (CI 4.879-7.418), T4 6.317 (CI 4.950-8.063); right colon 1, left colon 0.568 (0.511-0.633); elective surgery 1, acute surgery 0.748 (CI 0.625-0.894). Moreover, year of diagnosis was associated with the probability of a LNY ≥ 12: OR 1.480 (CI 1.445-1.516) for each increasing year in the study period. CONCLUSION: A LNY ≥ 12 is significantly associated with age, pT stage, tumour sub-site and priority of surgery. A significant increase in the LNY over the period of the study was observed, probably reflecting the effect of national programmes initiated by the Danish Colorectal Cancer Group.

Increased Lymph Node Yield Is Associated With Improved Survival in Rectal Cancer Irrespective of Neoadjuvant Treatment: Results From a National Cohort Study.

BACKGROUND: It has been proposed that the lymph node yield achieved during rectal cancer resection is associated with survival. It is debated whether a high lymph node yield improves survival, per se, or whether it does so by diminishing the International Union Against Cancer stage drifting effect. OBJECTIVE: The purpose of this study was to evaluate the prognostic implications of the lymph node yield in curative resected rectal cancer. DESIGN: This study was based on data from a prospectively maintained colorectal cancer database. SETTINGS: This was a national cohort study. PATIENTS: All 6793 patients in Denmark who were diagnosed with International Union Against Cancer stage I to III adenocarcinoma of the rectum and so treated in the period from 2003 to 2011 were included in the analysis. MAIN OUTCOME MEASURES: The primary outcome measure was overall survival. RESULTS: The observed percentages of patients with International Union Against Cancer stage III disease with a lymph node yield less than 12 or 12 or more were 28.1 % and 40.7% (p < 0.0001) in the non-neoadjuvant treatment group and 26.9% and 38.3% (p < 0.0001) in the neoadjuvant treatment group. The 5-year overall survival rates for patients with a lymph node yield <12 or 12 or more were 73.1% and 80.6% in International Union Against Cancer stages I to II (p < 0.0001) and 57.4% and 53.3% in stage III (p < 0.142) in the neoadjuvant treatment group and 70.4% and 79.2% in stages I to II (p < 0.0001) and 46.6% and 59.1% in International Union Against Cancer stage III (p < 0.0001) in the non-neoadjuvant treatment group. In multivariate analysis, the lymph node yield turned out to be an independent prognostic factor, irrespective of neoadjuvant treatment. LIMITATIONS: It is not possible in an observational study to tell whether the findings are associations rather than causal relationships. CONCLUSIONS: Increased lymph node yield was associated with better overall survival in rectal cancer, irrespective of neoadjuvant treatment. Stage migration was observed.

A minimum yield of twelve lymph nodes in rectal cancer remains valid in the era of neo-adjuvant treatment : results from a national cohort study.

PURPOSE: The purpose of the study was to examine if a minimum of 12 lymph nodes (LNs) is still valid in rectal cancer after neo-adjuvant treatment. METHODS: An analysis was carried out in a nationwide Danish cohort of 6793 patients, treated by curative resection of stage I-III rectal cancer during the period 2003-2011. The cohort was divided into two groups according to whether neo-adjuvant treatment had been given. The groups were analysed separately and were further analysed according to four lymph node yield (LNY) groups 0-5, 6-11, 12-17 and ≥18. RESULTS: Two thousand one hundred twenty-three patients (31.0 %) received neo-adjuvant treatment. A median LNY of 10 and 15 (p < 0.0001) and rates of node-positive (N-positive) disease of 31.6 and 36.7 % (p < 0.001) were observed with and without (+/-) neo-adjuvant treatment, respectively. The rate of N-positive disease according to tumour stage ranged from 4.8 %/11.4 % (ypT0/pT1) to 42.1 %/64.1 % (ypT4/pT4). The rate of N-positive disease according to LNY ranged from 19.5 %/16.8 % (0-5 LNs) to 42.6 %/37.9 % (≥18 LNs) (-/+neo-adjuvant treatment). In a logistic regression analysis, a significant association was found between N-positive disease and pT/ypT stage as well as between N-positive disease and LNY. CONCLUSIONS: A significantly smaller ratio of N-positive disease was observed in the group of patients who had received neo-adjuvant treatment. The ratio of N-positive disease increased significantly with more advanced tumour stage and increasing LNY irrespective of neo-adjuvant treatment. A minimum of 12 LNs is needed to ensure N-negative disease, irrespective of neo-adjuvant treatment.

Determinants of recurrence after intended curative resection for colorectal cancer.

Despite intended curative resection, colorectal cancer will recur in ∼45% of the patients. Results of meta-analyses conclude that frequent follow-up does not lead to early detection of recurrence, but improves overall survival. The present literature shows that several factors play important roles in development of recurrence. It is well established that emergency surgery is a major determinant of recurrence. Moreover, anastomotic leakages, postoperative bacterial infections, and blood transfusions increase the recurrence rates although the exact mechanisms still remain obscure. From pathology studies it has been shown that tumors behave differently depending on their location and recur more often when micrometastases are present in lymph nodes and around vessels and nerves. K-ras mutations, microsatellite instability, and mismatch repair genes have also been shown to be important in relation with recurrences, and tumors appear to have different mutations depending on their location. Patients with stage II or III disease are often treated with adjuvant chemotherapy despite the fact that the treatments are far from efficient among all patients, who are at risk of recurrence. Studies are now being presented identifying subgroups, in which the therapy is inefficient. Unfortunately, only few of these facts are implemented in the present follow-up programs. Therefore, further research is urgently needed to verify which of the well-known parameters as well as new parameters that must be added to the current follow-up programs to identify patients at risk of recurrence.

Early detection of recurrence after curative resection for colorectal cancer - obstacles when using soluble biomarkers?

OBJECTIVE: Results from monitoring studies using biomarkers in blood samples aiming at early detection of recurrent colorectal cancer (CRC) are presently evaluated. However, some serological biomarker levels are influenced by the surgical trauma, which may complicate translation of the levels in relation to recurrence. The primary purpose of the present study was to evaluate the frequency of postoperative surgical interventions during a follow-up period of patients who have undergone surgery for primary CRC. METHODS: In a prospective multicenter, clinical study, 634 patients resected for primary CRC were followed in the outpatient clinic every third month. Blood samples were drawn at each visit. A subgroup of 165 stage II and III patients, who had been followed for at least 3 years, was selected. Any recent surgical intervention associated with the primary disease and/or other diseases were recorded at each visit to the outpatient clinic. RESULTS: Among the 165 patients, 49 developed recurrence (R+), 107 did not (R-) and 11 developed a new primary cancer, including 2 in the R+ group. Within the 3 years of observation, 78 (47.3%) of the 165 patients underwent 117 (range 1-5) postoperative surgical interventions. Seventy-five operations were related to CRC and 42 to benign diseases, while none were related to a new primary, malignant disease. CONCLUSION: Patients resected for CRC are frequently undergoing surgical procedures in the postoperative follow-up period. Therefore, postoperative monitoring using soluble biomarker levels, which may be influenced by the surgical trauma, must be adjusted in relation to postoperative surgical interventions.

Biologic treatment or immunomodulation is not associated with postoperative anastomotic complications in abdominal surgery for Crohn's disease.

OBJECTIVES: There are concerns that biologic treatments or immunomodulation may negatively influence anastomotic healing. This study investigates the relationship between these treatments and anastomotic complications after surgery for Crohn's disease. PATIENTS AND METHODS: Retrospective study on 417 operations for Crohn's disease performed at four Danish hospitals in 2000-2007. Thirty-two patients were preoperatively treated with biologics and 166 were on immunomodulation. In total, 154 were treated with corticosteroids of which 66 had prednisolone 20 mg or more. RESULTS: Anastomotic complications occurred at 13% of the operations. There were no difference in patients on biologic treatment (9% vs. 12% (p = 0.581)) or in patients on immunomodulation (10% vs. 14% (p = 0.263)). Patients on 20 mg prednisolone or more had more anastomotic complications (20% vs. 11% (p = 0.04)). Anastomotic complications were more frequent after a colo-colic anastomosis than after an entero-enteric or entero-colic (33% vs. 12% (p = 0.013)). Patients with anastomotic complications were older (40 years vs. 35 years (p = 0.014)), had longer disease duration (7.5 years vs. 4 years (p = 0.04)), longer operation time (155 min vs. 115 min (p = 0.018)) and more operative bleeding (200 ml vs. 130 ml (p = 0.029)). Multivariate analysis revealed preoperative treatment with prednisolone 20 mg or more, operation time and a colo-colic anastomosis as negative predictors of anastomotic complications. CONCLUSIONS: Preoperative biologic treatment or immunomodulation had no influence on anastomotic complications. The study confirms previous findings of corticosteroids and a colo-colic anastomosis as negative predictors and also that surgical complexity, as expressed by bleeding and operation time, may contribute to anastomotic complications.

Gene expression profiles in stages II and III colon cancers: application of a 128-gene signature.

PURPOSE: A 128-gene signature has been proposed to predict outcome in patients with stages II and III colorectal cancers. In the present study, we aimed to reproduce and validate the 128-gene signature in external and independent material. METHODS: Gene expression data from the original material were retrieved from the Gene Expression Omnibus (GEO) (n = 111) in addition to a Danish data set (n = 37). All patients had stages II and III colon cancers. A Prediction Analysis of Microarray classifier, based on the 128-gene signature and the original training set of stage I (n = 65) and stage IV (n = 76) colon cancers, was reproduced. The stages II and III colon cancers were subsequently classified as either stage I-like (good prognosis) or stage IV-like (poor prognosis) and assessed by the 36 months cumulative incidence of relapse. RESULTS: In the GEO data set, results were reproducible in stage III, as patients predicted to be stage I-like had a significant lower risk of relapse than patients predicted as stage IV-like (P = 0.04, Gray test). Results were not reproducible in stage II patients (P > 0.05, Gray test). In the Danish data set, two of four stage III patients with relapse were correctly predicted as stage IV-like, and the remaining patients were predicted as stage I-like and unclassifiable, respectively. Stage II patients could not be stratified. CONCLUSIONS: The 128-gene signature showed reproducibility in stage III colon cancer, but could not predict recurrence in stage II. Individual patient predictions in an independent Danish material were unsatisfactory. Additional validation in larger cohorts is warranted.

Seromic profiling of colorectal cancer patients with novel glycopeptide microarray.

Cancer-associated autoantibodies hold promise as sensitive biomarkers for early detection of cancer. Aberrant post-translational variants of proteins are likely to induce autoantibodies, and changes in O-linked glycosylation represent one of the most important cancer-associated post-translational modifications (PTMs). Short aberrant O-glycans on proteins may introduce novel glycopeptide epitopes that can elicit autoantibodies because of lack of tolerance. Technical barriers, however, have hampered detection of such glycopeptide-specific autoantibodies. Here, we have constructed an expanded glycopeptide array displaying a comprehensive library of glycopeptides and glycoproteins derived from a panel of human mucins (MUC1, MUC2, MUC4, MUC5AC, MUC6 and MUC7) known to have altered glycosylation and expression in cancer. Seromic profiling of patients with colorectal cancer identified cancer-associated autoantibodies to a set of aberrant glycopeptides derived from MUC1 and MUC4. The cumulative sensitivity of the array analysis was 79% with a specificity of 92%. The most prevalent of the identified autoantibody targets were validated as authentic cancer immunogens by showing expression of the epitopes in cancer using novel monoclonal antibodies. Our study provides evidence for the value of glycopeptides and other PTM-peptide arrays in diagnostic measures.

Many unexpected abdominal findings on staging computed tomography in patients with colorectal cancer.

INTRODUCTION: Computed tomography (CT) was proven to be superior to preoperative abdominal ultrasound in the preoperative setting for detection of hepatic metastases from colorectal cancer (CRC). The higher sensitivity of CT has resulted in a number of unexpected abdominal findings of varying importance; an issue that was previously studied in relation to CT colonography, but not in relation to staging CT with intravenous contrast in CRC patients. The aim of the present study was to evaluate the number and significance of such unexpected findings on staging CTs in CRC patients. MATERIAL AND METHODS: The study comprises a retrospective analysis of 247 consecutive patients who underwent colorectal cancer surgery at Roskilde Hospital, Denmark, in 2009. A preoperative abdominal staging CT was performed in 245 of these patients. All CT scans and patient records were reviewed by the authors. The unexpected CT findings were classified as being of high, moderate or low clinical importance according to whether they required treatment relatively promptly, later or did not require treatment at all, respectively. RESULTS: Overall, 114 patients (47%) had unexpected findings. Nineteen of the 137 findings (14%) or 8% in all patients were considered to be of high importance. Three per cent of all patients had abdominal aortic aneurysms, 2% had CRC metastases to the adrenal glands, 2% primary kidney tumours and 1% gynaecologic tumours. Twenty per cent of the patients had findings of moderate importance and 29% findings of low importance. CONCLUSION: Staging CT in CRC patients showed nearly 8% of unexpected abdominal findings of high clinical importance requiring relatively prompt treatment. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Laparoscopic reversal of Hartmann's procedure.

INTRODUCTION: A change in procedure from open to laparoscopic reversal of Hartmann's colostomy was implemented at our department between May 2005 and December 2008. The aim of the study was to investigate if this change was beneficial for the patients. MATERIAL AND METHODS: The medical records of all patients who underwent reversal of a colostomy after a primary Hartmann's procedure during the period May 2005 to December 2008 were reviewed retrospectively in a case-control study. RESULTS: A total of 43 patients were included. Twenty-one had a laparoscopic and 22 an open procedure. The two groups matched with regard to age, sex, American Society of Anestheologists (ASA) score, body mass index and indication for Hartmann's operation. A significantly longer operation time was found for laparoscopic than for open surgery (median 285 versus 158 minutes, p < 0.001), but with less blood loss (median 100 versus 600 ml, p < 0.001), faster return of bowel function (median three versus four days, p < 0.01) and shorter postoperative hospitalization (median four versus six days, p < 0.01). No intraoperative complications occurred. One laparoscopic operation was converted (5%). There was no difference in postoperative complications between the two groups (10 versus 14%), and no anastomotic leaks. The total mortality was 2% as one patient died postoperatively after an open operation. CONCLUSION: It is possible for trained laparoscopic colorectal surgeons to perform laparoscopic reversal of Hartmann's procedure as safely as in open surgery and with a faster recovery, shorter hospital stay and less blood loss despite a longer knife time. It therefore seems reasonable to offer patients a laparoscopic procedure at departments which are skilled in laparoscopic surgery and use it for standard colorectal surgery.

The diagnostic value of indeterminate lung lesions on staging chest computed tomographies in patients with colorectal cancer.

INTRODUCTION: Selection of pulmonary staging modality in colorectal cancer surgery is controversial. Computed tomography (CT) clearly outperforms x-ray in terms of sensitivity, but findings of indeterminate lung lesions remain a problem. The aim of the present study was to evaluate the significance of such indeterminate lung findings in staging CT scans. MATERIAL AND METHODS: The study comprises a retrospective analysis of 131 consecutive patients who underwent colorectal cancer surgery in 2004. A preoperative staging CT scan of the chest and abdomen was performed in all patients. Twenty-six patients (20%) had indeterminate lung findings. Four died postoperatively. The remaining 22 were followed for a median period of 26 months. RESULTS: In eight of the 22 patients (36%) lesions progressed. In one patient, the lesion turned out to be a primary lung cancer, in another a lymphoma. In the last six patients (27%), the lesions developed into colorectal cancer lung metastases within a median period of 15 months. These results were significantly different from those obtained in patients who had a normal CT, among whom only 6% developed lung malignancies in the follow-up period (p < 0.0001). The development of lung metastases was significantly related to positive nodal status at operation and elevated carcinoembryonic antigen (CEA) level at follow-up (p < 0.05). CONCLUSION: Approximately one quarter of the indeterminate lung lesions found on staging CT in colorectal cancer patients developed into metastases and one tenth into other lung malignancies, which were most often diagnosed in the second year after surgery. The development of lung metastases was significantly related to positive nodal disease and postoperative CEA elevation.

Identification of Risk Factors Associated With Stage III Disease in Nonmetastatic Colon Cancer: Results From a Prospective National Cohort Study.

PURPOSE: This study aimed to identify possible patient- and tumor-related factors associated with risk of TNM stage III disease in nonmetastatic colon cancer. METHODS: The associations between stage III disease and age, sex, lymph node yield, pathological tumor (pT) stage, tumor subsite, type of surgery, and priority of surgery were assessed in a nationwide cohort of 13,766 patients treated with curative resection of colon cancer. Each level of age, lymph node yield, and pT stage was compared to the preceding level. RESULTS: Age, lymph node yield, pT stage, tumor subsite, and priority of surgery were associated with stage III disease. Odds ratios (95% confidence interval [CI]) were as follows: age < 65/65-75 years: 1.28 (95% CI, 1.15-1.43) and 65-75/ > 75 years: 1.22 (95% CI, 1.13-1.32); lymph node yield 0-5/6-11: 0.60 (95% CI, 0.50-0.72), lymph node yield 6-11/12-17: 0.84 (95% CI, 0.76-0.93), and lymph node yield 12-17/ ≥ 18: 0.97 (95% CI, 0.89-1.05); pT1/pT2: 0.74 (95% CI, 0.57-0.95), pT2/pT3: 0.35 (95% CI, 0.30-0.40), and pT3/pT4: 0.49 (95% CI, 0.47-0.54). Only tumors of the transverse colon were independently associated with lower risk of stage III disease than tumors in the sigmoid colon (sigmoid colon: 1, transverse colon: 0.84 [95% CI, 0.73-0.96]; elective surgery: 1, acute surgery: 1.43 [95% CI, 1.29-1.60]). CONCLUSION: In this study, stage III disease in colon cancer was significantly associated with age, lymph node yield, pT stage, tumor subsite, and priority of surgery but was not associated with right-sided location compared with stage I and II cancers.

The usefulness of a magnetic endoscope locating device in colonoscopy in daily practice: a prospective case-controlled study.

BACKGROUND: This study aimed to investigate the effects of magnetic endoscope imaging (MEI) regarding examination time, caecal intubation rate, and sedation and analgesic requirements during routine colonoscopy compared with earlier used X-ray imaging. METHODS: Consecutive outpatients undergoing colonoscopy were prospectively studied for two periods. In the first period X-ray was used to establish the correct position of the endoscope. In the second period MEI was used. Outcome measures were examination time, caecal intubation rate, median dose of analgesic and sedative administered, and median X-ray dose used. RESULTS: The two groups studied were comparable with regards to age, sex, and number of therapeutic examinations. The examination time was significantly shorter with use of MEI (median 29 min versus 43 min). No significant differences in the use of analgesic and sedative were found (median 50 microg phentanyle and 2 mg midazolam in both groups). Median X-ray dose was 150 cGy in the group using X-ray imaging. CONCLUSION: MEI is the imaging methodology of choice and should always be available in colonoscopy, especially for precise locating of colonic lesions.

Quality of life after cytoreductive surgery plus early intraperitoneal postoperative chemotherapy for pseudomyxoma peritonei: a prospective study.

PURPOSE: The modern treatment of pseudomyxoma peritonei is cytoreductive surgery plus intraperitoneal chemotherapy resulting in a survival of up to 70 percent after 20 years. The goal of this study was to investigate the impact on quality of life of this very aggressive treatment, which has not been done before. METHODS: Twenty-three prospective patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Patients were followed in clinic 3, 6, 12, 18, and 24 months after surgery and had CT scan of the abdomen every 6 months. Quality of life was prospectively assessed with the generic quality of life instrument Short Form-36 Questionnaire, together with the two symptom-specific instruments--European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and Colorectal Cancer Module 38--before surgery and at every postoperative visit. RESULTS: Complete cytoreduction was achieved in 21 patients. No patients died within 30 days. Seventy percent of patients had one or more complications during or after surgery, but all had recovered. Fourteen percent had an asymptomatic recurrence detected within two years. The impact on quality of life of the disease and of its treatment was very modest despite the high morbidity after the treatment. There was a significant decrease in the scores on the Short Form-36 Questionnaire scales of physical dimension and role physical three months after surgery, only returning to normal after another three months. The other scores corresponded to the scores in a normal population. CONCLUSIONS: Cytoreductive surgery plus early postoperative intraperitoneal chemotherapy is an extensive treatment with a high morbidity but with relatively little impact on quality of life in patients with pseudomyxoma peritonei.

Internal herniation after laparoscopic antecolic Roux-en-Y gastric bypass: a nationwide Danish study based on the Danish National Patient Register.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most common surgical treatment for morbid obesity in Denmark. Internal herniation (IH) or intermittent internal herniation (IIH) is a major late complication after LRYGB due to persistent mesenteric defects. However, the incidence of IH/IIH is still not known in Denmark. OBJECTIVES: The primary aim of the study was to assess the incidence of IH/IIH after LRYGB performed in the period between 2006 and 2011 with a follow-up until 2013, where mesenteric defects were not routinely closed during the primary operation. SETTING: Department of Bariatric Surgery, Koege University Hospital, Denmark METHODS: We performed a retrospective nationwide analysis of prospectively collected data from all patients with LRYGB performed in Denmark from 2006 to 2011 based on the Danish National Patient Registry (NPR). From January 2006 to December 2011, 12,221 patients underwent an LRYGB procedure in Denmark. Relevant data from all 12,221 patients were retrieved from the NPR during the follow-up period from January 2006 to May 2013; we registered possible subsequent abdominal operations in these patients. RESULTS: Operations were performed on 398 patients because of suspected IH/IIH; 383 of these patients had IH/IIH (3.1%; 95% CI 2.8-3.5). The estimate for the 5-year cumulative incidence of clinically significant cases with IH/IIH was 4%. The median time interval until the onset of IH/IIH after LRYGB was 15 months (range 0-67 months) in a follow-up period with a median of 38 months (range 16-87 months). CONCLUSION: In the period from 2006 to 2011, mesenteric defects were not routinely closed during LRYGB in Denmark. The cumulative 5-year incidence of IH/IIH after LRYGB was 4% in a median follow-up period of 38 months (range 16-87) in Denmark when data was retrieved from the NPR.

Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications?

BACKGROUND: A well-known complication of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is bowel obstruction due to internal herniation (IH). Evidence suggests that mesenteric defects should be closed during LRYGB to reduce the risk of IH. Therefore, surgeons are now closing mesenteric defects during LRYGB using sutures, clips, or fibrin glue. However, it has been reported that complications may arise due to the closure of mesenteric defects. The aim of this review was to summarize the reported possible complications associated with the closure of mesenteric defects during LRYGB. METHODS: A literature search of PubMed and EMBASE was performed to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS: Thirty studies complied with the inclusion criteria for our analysis, which included 21,789 patients. Reported complications related to closure of the mesenteric defects were: small bowel obstruction because of IH, kinking, and adhesions. IH occurred because of incomplete closure of the mesenteric defects in 1.4% of all patients, 1.2% by the antecolic approach, and 1.9% by the retrocolic approach, respectively. Kinking of the small bowel occurred in .2% of 1630 patients after closure of the mesenteric defects with clips and adhesion formation was found among 4.6% of 152 patients after closure of the mesenteric defects with nonabsorbable sutures. CONCLUSIONS: The reported risk of complications caused by closure of the mesenteric defects during LRYGB seems low.

Watchful waiting versus colorectal resection after polypectomy for malignant colorectal polyps.

INTRODUCTION: Unexpected malignancy in removed colorectal polyps is reported in up to 9% of cases. The introduction of screening for colorectal cancer will inevitably increase the number of removed colorectal polyps and therefore also the incidence of malignant polyps. The treatment strategy is either watchful waiting or subsequent colorectal resection. The aim of this study was to perform a preliminary evaluation of the oncological results of polypectomy for malignant polyps with or without subsequent resection, including the patients' long-term survival. METHODS: This was a retrospective analysis of prospectively collected data on 50 patients with unexpected malignancy after a polypectomy treated between January 2003 and January 2008. A total of 27 patients (54%) were treated with watchful waiting, and 23 (46%) underwent subsequent surgery. The Mann-Whitney U-test and chi-square test were used to compare the results between the two groups. RESULTS: There were more patients in the surgery group with positive resection margins after the polypectomy (p = 0.002). No difference was found regarding tumour differentiation grade, lymphovascular invasion, local recurrence or distant metastasis. Intraoperative complications occurred in three patients (13%, 95% confidence interval: 0-28%). In all, 16 of the 23 operated patients had no residual tumour. Overall long-term survival was higher among the operated patients (p = 0.005), but there was no difference in cancer-free survival (p = 0.071). CONCLUSION: Overtreatment of patients with malignant colorectal polyps seems to occur. Which patients benefit from further surgery has yet to be determined. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.