VAVD vacuum may cause bubble transgression in membrane oxygenators.

BACKGROUND:: Vacuum-assisted venous drainage (VAVD) is widely used to enhance venous blood return from patients undergoing cardiopulmonary bypass (CPB). This vacuum can accidentally reach the oxygenator of the heart-lung machine and draw gas bubbles into the blood. This is known as bubble transgression (BT) and may cause air emboli in the arterial blood line. In order to avoid BT and minimize the risk of patient injury, knowledge of oxygenator tolerance to vacuum load is critical. Thus, the main aim of this thesis was to investigate how much vacuum a membrane oxygenator can withstand before BT appears. METHODS:: We investigated four different adult oxygenators: Quadrox-i, Affinity Fusion, Capiox RX25 and Inspire 6M. They were tested in an in vitro setup where VAVD vacuum was allowed to reach the oxygenator through a non-occlusive roller pump. An ultrasonic clinical bubble counter, Gampt BCC 200, was used to count bubbles on the arterial line when the arterial pump was restarted. RESULTS:: We observed a significant increase in bubble count for two of the oxygenators, caused by -30 mmHg of VAVD vacuum in the blood reservoir (Affinity Fusion and Inspire 6M). Massive air ingress was shown in two of the oxygenators, caused by -30 mmHg of VAVD vacuum in the reservoir (Capiox RX25) and -40 mmHg of VAVD vacuum in the reservoir (Affinity Fusion). CONCLUSION:: VAVD vacuum may cause bubble transgression in an oxygenator. This was shown for all the oxygenators in this test. VAVD vacuum may cause visible massive air ingress in an oxygenator. This was shown for two of the oxygenators in this test (Capiox RX25 and Affinity Fusion). An alarm triggering on negative pressure in the oxygenator or a pressure relief valve might improve safety when using VAVD.

Tumour location is a prognostic factor for survival in colonic cancer patients.

OBJECTIVE: To evaluate survival and prognostic factors in a consecutive series of colon cancer patients from a defined city population in Norway. METHOD: All patients with adenocarcinoma of the colon diagnosed between 1993 and 2000 were registered prospectively. Five-year actuarial survival and 5-year relative survival rates were calculated. Cox regression analyses were used to study the effect of prognostic factors on survival. RESULTS: In the study period 627 patients were admitted. Overall 5-year relative survival was 50% in females and 52% in males. Five-year relative survival in 410 (65%) patients operated with curative intent, was 74% for females and 79% for males. Tumour location in the transverse colon, splenic flexure and descending colon (OR = 1.8), emergency operation (OR = 1.7), TNM stage (OR = 1.8-2.9), blood transfusion of more than two units (OR = 1.8) and age (OR = 4.0-7.1) were independent negative prognostic factors. CONCLUSION: Colon cancer located in the transverse and descending colon is associated with poor prognosis. Comparison of results from different centres is difficult due to selection and classification differences, and different methods used for calculation of survival.

Anastomotic leak following mesorectal excision for rectal cancer: true incidence and diagnostic challenges.

OBJECTIVE: Anastomotic leakage is a potentially serious complication of low anterior resection which may be accompanied by clinical symptoms (clinical leak) or may be silent (subclinical leak). In this study the true incidence of the complication was evaluated, and the diagnostic accuracy of clinical symptoms, conventional rectal radiography (CRR) and computed tomography (CT) was compared. PATIENTS AND METHODS: Fifty-six consecutive patients were included in a prospective trial. Clinical parameters were recorded and CRR and CT performed 6-10 days postoperatively or earlier if a leak was suspected. Endoscopy was performed three months postoperatively. RESULTS: Based on all available information including late endoscopy, 5 (9%) patients had clinical leak and five a leak that was asymptomatic during the hospital stay. Clinical assessment, CRR and CT during the hospital stay had an accuracy of 82%, 93% and 94%, respectively, and a sensitivity of 50%, 60% and 57%, respectively. The specificity of clinical assessment was 89%, whereas both CRR and CT had a specificity of 100%. CONCLUSION: The incidence of anastomotic leakage seemed acceptable when compared with other series. Fifty per cent of the leaks were silent. CRR and CT may be false negative and immediate treatment should be started if clinical signs are highly suggestive of leak, irrespective of radiological findings CT was not more accurate than CRR in detecting anastomotic leak.

Preoperative radiotherapy for esophageal carcinoma.

BACKGROUND: The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. OBJECTIVES: This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery and whether or not any pre-defined patient subgroups benefit more or less from preoperative radiotherapy SEARCH STRATEGY: MEDLINE and CancerLit searches were supplemented by information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists, organisations and industry. The search strategy was run again in MEDLINE, EMBASE and the Cochrane Library on 30th April 2001, two years after original publication. No new trials were found. The search strategy was re-run August 2002 and August 2003 on MEDLINE, EMBASE , CancerLit and The Cochrane Library, and July 2004 and 2005 on MEDLINE, EMBASE and the Cochrane Library. No new relevant trials were identified on any of these occasions. SELECTION CRITERIA: Trials were eligible for inclusion in this meta-analysis provided they randomized patients with potentially resectable carcinoma of the esophagus (of any histological type) to receive radiotherapy or no radiotherapy prior to surgery. Trials must have used a randomization method which precluded prior knowledge of treatment assignment and completed accrual by December 1993, to ensure sufficient follow-up by the time of the first analysis (September 1995). DATA COLLECTION AND ANALYSIS: A quantitative meta-analysis using updated data from individual patients from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. This approach was used to assess whether preoperative radiotherapy improves overall survival and whether it is differentially effective in patients defined by age, sex and tumour location. MAIN RESULTS: With a median follow-up of 9 years, in a group patients with mostly squamous carcinomas, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p=0.062). No clear differences in the size of the effect by sex, age or tumor location were apparent. AUTHORS' CONCLUSIONS: Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients (90% power, 5% significance level) would be needed to reliably detect such an improvement (from 15 to 20%).

Staging of rectal carcinoma with transrectal ultrasonography.

BACKGROUND AND AIMS: Transrectal ultrasonography (TRUS) has proven useful for loco-regional staging of rectal carcinoma in specialised centres, but the investigation is not widely used. The aim of this study was to audit the introduction of TRUS performed by surgeons without previous experience with ultrasonography. MATERIAL AND METHODS: All patients admitted with rectal carcinoma in the period 1996-2002 entered this prospective, comparative study. TRUS with a stiff endorectal probe was performed preoperatively in 118 consecutive patients, 91 of whom subsequently had rectal resection without preoperative radiotherapy (PRT), and seven who had rectal resection after PRT. Twenty patients did not have resection. The main outcome measures was the feasibility of TRUS in staging of rectal cancer, and the accuracy of T- and N-staging, comparing TRUS with the histopathological examination of resected specimens. RESULTS: TRUS was successful in 81/91 patients who underwent rectal resection without PRT. The accuracy of T-staging was 74% overall; 40% in five pT1 tumours, 81% in 26 pT2 tumours, 80% in 45 pT3 tumours and 25% in four pT4-tumours. With regard to perirectal tissue invasion, the sensitivity and specificity of TRUS was 82% and 84%, respectively, and the positive and negative predictive values were 89% and 71%, respectively. The accuracy of TRUS for N-staging was 65%. The sensitivity for detection of lymph node metastases was 41% and the specificity 68%. TRUS was unsuccessful in 21/118 patients, in 12/98 who had rectal resection, and in 9/ 20 who did not have resection, because of stenosis or high location of the tumour precluding correct placing of the probe. CONCLUSIONS: TRUS is often unsuccessful in patients with advanced tumours, especially when the tumour is located in the upper rectum. The predictive values for perirectal tumour invasion were acceptable, but the sensitivity for detection of lymph node metastases was low. These results were obtained by surgeons without previous experience with ultrasonographic examinations.

Comparison of faecal and intestinal concentrations of granulocyte marker protein and localization of gastrointestinal tumours in rats.

BACKGROUND: Increased faecal concentrations of the granulocyte marker protein (GMP) have been found in rats with azoxymethane (AOM) induced carcinoma of the colon, but the origin of this GMP is unknown. The aims were to investigate the concentrations of GMP in different parts of the gastrointestinal (GI) tract in rats with or without AOM-induced carcinoma and to correlate the GMP concentrations to localization of the carcinomas. METHODS: Nineteen rats were given intramuscular injections of AOM, 15 mg/kg, once weekly for 6 weeks and were killed after 22 weeks. Five rats that were not given AOM injections served as controls. RESULTS: All rats given AOM developed tumours; 18 developed a total of 33 adenocarcinomas in the GI tract and one developed an adenoma in the colon. Nine animals had carcinoma in the small bowel, seven of which also had carcinoma of the colon, and nine animals had carcinomas in the large bowel only. No other tumours were found. All except one of the animals that had carcinoma of the colon had elevated faecal GMP concentrations, and from week 11 there was a significant difference in the GMP values between the control group and the group that developed colon carcinoma. In all rats that developed carcinoma in the small bowel, the tumour was localized in the proximal part. In the rats that had been given AOM, the luminal GMP concentrations were significantly higher in the proximal part of the small bowel than in the distal part, but there were no significant differences in the GMP concentrations between animals with and without carcinoma in the small bowel. Sixteen rats developed a total of 24 carcinomas in the colon, and one rat developed an adenoma. Luminal GMP concentration in the distal part of the colon was elevated in all animals with carcinomas in the colon, and the GMP concentrations were significantly higher in the distal part than in the proximal part. Rats with one carcinoma in the colon had significantly lower GMP values in the distal part, compared to rats that had two carcinomas in the colon. CONCLUSIONS: The animal model described is suitable for further studies on many aspects of tumour development in the colon. Furthermore, it is likely that increased faecal GMP concentration in rats with colon carcinoma is a result of an inflammatory process in or around tumours.

Local recurrence after mesorectal excision for rectal cancer.

AIMS: Controversy still exists about the optimal surgical treatment of rectal cancer. The main purpose of the present study was to compare local recurrence (LR) rates after mesorectal excision (ME) and conventional surgery (CS) technique. METHODS: All rectal cancer patients from a defined catchment area were included. Outcome after ME in the period 1993-1999 (n=161) was compared with the outcome after CS (n=217) in the period 1983-1992. Partial ME (PME) was the routine in upper, and total ME the routine in mid- and low rectal cancer. The follow-up programmes were identical, and the median observation times very similar (37 and 38 months) in the two periods. Five-year actuarial LR rate and survival were estimated using the Kaplan-Meier method, and adjustment for prognostic factors was performed with Cox regression analysis. RESULTS: Total LR rate after R0 resection was 7.7% crude and 9% 5 year actuarial in the ME period, as compared with 16.0% crude and 24% actuarial in the CS period (P=0.02). Cox regression analyses confirmed these differences with a hazard ratio of 0.40 for ME vs CS (P=0.02). Isolated LR rate was 2% after ME and 8% after CS. Five-year actuarial total LR rate after rectal resection with curative intent was 11% after ME and 27% after CS (P<0.01). Actuarial total LR rate after PME was 6%, and none of these patients developed isolated LR. CONCLUSION: Standardization of surgical technique and application of ME resulted in a significant reduction of LRs. LR rate was low after PME, indicating that this procedure is adequate in upper rectal cancer.

Mesorectal excision for rectal cancer: functional outcome after low anterior resection and colorectal anastomosis without a reservoir.

OBJECTIVE: The anal sphincters, neorectal capacity and motility may be affected by injury to the autonomic nerves during rectal resection. Anorectal function also depends on the method used for restoration of intestinal continuity, and colonic reservoir reconstruction has been recommended in ultralow anastomosis. This study was undertaken to evaluate the results after nerve preserving mesorectal excision and colorectal anastomosis without a reservoir. PATIENTS AND METHODS: Thirty-five consecutive patients who underwent low anterior resection with primary healing of the anastomosis, were included. Anal manometry with stationary pull through technique, rectal volumetry and symptom scoring (written questionnaires with visual analogue scales) were performed prior to and 12 months after surgery. Anal sphincter function was evaluated in all patients, but five patients with a colonic reservoir were excluded from the other evaluations. Thirty patients entered the main study; 14 patients having a total mesorectal excision (TME) and a low anastomosis (LA) (4-6 cm) and 16 patients a partial mesorectal excision (PME) and a high anastomosis (HA) (7-11 cm from the anal verge). RESULTS: Anal resting and squeeze pressure and rectal sensibility (threshold volume) were unchanged after the operation. The rectal volume eliciting urge to defecate was reduced from median 95 ml to 70 ml (P < 0.01), and the maximum tolerable rectal volume was reduced from 200 to 135 ml (P < 0.01) after the operation. The maximum tolerable volume was significantly lower in patients with LA than in patients with HA (P < 0.01). Overall functional results were good. The patients reported problems with complete bowel emptying (median VAS-score reduction from 90 to 60, P < 0.01), and minor incontinence problems (median VAS-score reduction from 100 to 90, P= 0.03). The reduction of VAS-scores was more pronounced in LA than HA patients (without reaching statistical significance). CONCLUSIONS: Anal sphincter function was preserved after mesorectal excision. Neorectal capacity was reduced, most pronounced in patients with LA. The overall functional results were satisfactory and slightly better in patients with HA than in those with LA.

Screening of first degree relatives of patients operated for colorectal cancer: evaluation of fecal calprotectin vs. hemoccult II.

UNLABELLED: Fecal calprotectin (CPT) is elevated in the majority of patients with known colorectal cancer (CRC), but the specificity is not clarified. AIM: To evaluate if a CPT test (PhiCal ELISA) was more sensitive than Hemoccult II test in detecting colorectal neoplasia, and to obtain reference values in subjects with normal colonoscopy. To evaluate a possible relation between number and extent of dysplasia of adenomas in first degree relatives of patients with CRC and the stage of the carcinoma in the index casus. Further to study the prevalence of CRC and adenomas in the first degree relatives of patients operated for CRC. METHOD: In a multicenter study, 253 first degree relatives of patients with CRC, aged 50-75 years (mean age 60 years) underwent colonoscopy after having delivered stool samples and three Hemoccult II slides. RESULTS: In 237 first degree relatives from 148 patients with CRC, polyps were found in 118 (50%). Seventy three (31%) had adenomas and 17 had adenomas > or =10 mm. Five had asymptomatic cancers. The specificity of fecal CPT for adenomas at cut off levels 15 mg/l. The sensitivity of Hemoccult II for adenomas was 8%, and 4/5 of patients with carcinoma had negative Hemoccult II. The specificity for adenomas was 95%. CONCLUSION: Fecal CPT test was more sensitive than Hemoccult II in detecting colorectal neoplasia but the specificity was lower. In a high risk group like first degree relatives of patients with CRC, there are good reasons to consider fecal CPT as a first test in selecting patients for endoscopy.

[Sphincteroplasty in traumatic anal incontinence]. / Sfinkterplastikk ved traumatisk betinget anal inkontinens.

BACKGROUND: Anal incontinence in young women is often caused by sphincter rupture from obstetric injury or anal fistula surgery. MATERIAL AND METHODS: From 1992 to 1997, 17 women were operated for anal sphincter injury at Aker University Hospital, Oslo, Norway. Data were obtained retrospectively from patient files. RESULTS: In 13 patients, the anal incontinence was caused by obstetric injury and in four by anal fistula surgery. In all patients the external anal sphincter was repaired with overlap technique. In addition, plication of the puborectalis muscle was performed in 15 patients, perineoplasty in eight, vaginoplasty in one and operation for genital prolapse in one. Nine patients had a temporary loop sigmoidostomy. 12 of 16 patients for whom postoperative symptoms had been recorded, reported improved anal continence. Eight of these had complete anal continence, whereas four still experienced some incontinence for gas and loose stools. On clinical examination, 11 patients had normal resting sphincter pressure and voluntary sphincter contraction. Six had weak voluntary contraction; two of these had normal resting sphincter pressure. INTERPRETATION: Traumatic anal sphincter injuries in young patients can seriously impair anal function. Results of surgical treatment are satisfactory in most patients.

[Functional outcome after reservoir surgery in ulcerative colitis]. / Funksjonelt resultat etter reservoarkirurgi ved ulcerøs kolitt.

BACKGROUND: The aim of this study was to examine whether the functional result of restorative proctocolectomy for ulcerative colitis deteriorated by postponing follow-up from three to eight years after pouch surgery. MATERIAL AND METHODS: All patients (n = 58) operated for ulcerative colitis from 1984-97, who still had intact reservoir, responded to a questionnaire on defecating pattern, stool leakage, perianal irritation, urinary function, workload, sexual life, social life, and the patient's opinion on outcome. The results for the first 29 patients were compared to last 29 patients operated. Median follow-up was eight for the first 29 patients and three years for the last 29. RESULTS: There were no significant difference in functional outcome and patient opinion after pouch surgery between the first 29 and last 29 patients (n = 58). Respective figures for median 24-hour stool frequency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defecation 86% and 97%, perianal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) had improved for 11 (19%) and deteriorated for seven patients (12%). Potency was reduced in five (15%) and ejaculation in four patients (12%), one of whom (3%) had retrograde ejaculation. Three (5%) had received a disability pension and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and three (6%) felt worse because of frequent bowel emptying (n = 3), perianal eczema (n = 1) and pouch fistula (n = 1). INTERPRETATION: The results do not demonstrate any significant deterioration of functional outcome after pouch surgery for ulcerative colitis by postoperative increase of follow-up from three to eight years.

Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer.

BACKGROUND: Few studies have evaluated the long-term functional outcome after anastomotic leakage in the treatment of rectal cancer. METHODS: Between 1993 and 1998, 147 patients were admitted with resectable rectal carcinoma, and 92 underwent low anterior resection (LAR). Seventeen patients (18 per cent) developed clinical anastomotic leakage. The functional outcome of 11 of 12 patients, in whom the stoma was subsequently closed and bowel continuity was restored without stricture, was compared with that of 11 matched patients who had undergone LAR without leakage. Anorectal manovolumetry and symptom scoring on visual analogue scales were done 12-48 months after stoma closure. RESULTS: Nine patients made an uneventful recovery after the initial treatment of anastomotic leakage. Eight developed serious septic complications, four of whom had a pelvic abscess, but there was no death. Five patients had chronic complications that precluded closure of the stoma. Patients who had experienced leakage showed reduced neorectal capacity (120 versus 180 ml; P = 0.04), more evacuation problems (P = 0.02), and a trend towards more faecal urgency (P = 0.09) and incontinence (P = 0.06) than control patients. CONCLUSION: Stoma closure was not possible in five of 17 patients who had experienced anastomotic leakage. Patients who had the stoma closed had impaired long-term anorectal function compared with control patients without leakage.

Fecal excretion of calprotectin in colorectal cancer: relationship to tumor characteristics.

BACKGROUND: The aim of this study was to evaluate fecal calprotectin in patients treated for colorectal cancer. Furthermore, the changes in fecal calprotectin concentration from before to after surgery were investigated. METHODS: In 155 patients with newly diagnosed colorectal cancer, two spot samples were taken from the same feces on two consecutive days. RESULTS: Three ways of evaluating calprotectin excretion were compared, (1st spot 1st stool; maximum of 1st spot 1st stool and 2nd spot 1st stool; maximum of 1st spot 1st stool and 1st spot 2nd stool) and gave similar results with median fecal calprotectin values 47 mg/l, 52 mg/l and 54 mg/l, respectively. Median calprotectin concentration did not differ significantly between different tumor stages, although the levels were slightly lower in Dukes stage A tumor than in the rest of the stages. Neither were there any differences in the concentrations related to the localization, size or the histological grading of the carcinoma. As the currently used cut-off level for fecal calprotectin is 10 mg/l, 87% of all patients had elevated fecal calprotectin. Seventy-nine percent of the patients had levels above 15 mg/l and 74% had levels above 20 mg/l (1st spot 1st stool). In patients who delivered fecal samples after the operation the calprotectin value fell significantly from a preoperative median value of 45 mg/l to 14 mg/l after the resection. CONCLUSIONS: The majority of patients with colorectal cancer have increased fecal concentration of calprotectin. One single fecal spot seems to be sufficient for determination of the calprotectin level. Measurement of fecal calprotectin may possibly become of value as a marker for colorectal cancer, although calprotectin, similar to fecal occult blood (FOB) tests, is a non-specific test for colorectal pathology, also being elevated in inflammatory bowel diseases. Further investigation of its specificity is therefore needed.

Morbidity and functional outcome after restorative proctocolectomy for ulcerative colitis.

OBJECTIVE: To find out whether a threefold increase in follow up (median 108 compared with 36 months) influenced major morbidity and functional outcome between the first 32 and the last 32 patients consecutively operated on with J-pouch ileoanal anastomosis for ulcerative colitis from 1984 to 1997. DESIGN: Retrospective and prospective study. SETTING: University hospital, Norway. PATIENTS: 64 patients with ulcerative colitis who had proctocolectomy and ileal pouch-anal anastomoses. INTERVENTIONS: The pouches were mainly hand anastomosed (n = 61) to the dentate line after mucosectomy or anastomosed by double stapling technique without mucosectomy (n = 3). The 58 patients who still had their pouches responded to a questionnaire on functional outcome and satisfaction. MAIN OUTCOME MEASURES: Morbidity, functional outcome, and patients' satisfaction. RESULTS: Major morbidity in these 64 patients comprised pelvic sepsis in 3 (5%), operation for intestinal obstruction in 5 (8%), pouchitis in 12 (19%), fistulas in 7 (11%) and pouch excision in 6 (9%). Thirteen patients (20%) had 35 reoperations and 11 patients (17%) had 22 re-laparotomies. There were more complications among the first 32 patients with the longest follow up than among the last 32 patients, but this difference was significant only concerning the rate of reoperations (31% compared with 9%) because of the higher number of pouch excisions (5 compared with 1) in this group. There were no significant differences in the functional outcome and degree of patient satisfaction between the first 29 and the last 29 patients. Respective values for 24 hour median stool freqency were 7.0 and 6.3, leakage of stool 48% and 38%, ability to defer defaecation 86% and 97%, perineal irritation 59% and 48%, use of antidiarrhoeal medication 55% and 52%, and wearing of pad 28% and 38%. Sexual life (n = 57) was improved in 11 (19%) and reduced in 7 (12%). Potency was reduced in 5 (15%) and ejaculation in 4 (12%), one of whom (3%) had retrograde ejaculation. Three (5%) received disability pensions and five (9%) had reduced workload. After the pouch operation 48 (91%) felt better and 3 (6%) felt worse because of frequent bowel emptying, perineal eczema, or pouch fistula. CONCLUSION: Continence-preserving proctocolectomy carries considerable morbidity, but the long term functional outcome is satisfactory and does not seem to deteriorate substantially.

Preoperative radiotherapy for esophageal carcinoma.

BACKGROUND: The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. OBJECTIVES: This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery and whether or not any pre-defined patient subgroups benefit more or less from preoperative radiotherapy SEARCH STRATEGY: Medline and CancerLit searches were supplemented by information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists, organisations and industry. The search strategy was run again in Medline, Embase and the Cochrane Library on 2nd May 2000, one year after original publication. No new trials were found. SELECTION CRITERIA: Trials were eligible for inclusion in this meta-analysis provided they randomized patients with potentially resectable carcinoma of the esophagus (of any histological type) to receive radiotherapy or no radiotherapy prior to surgery. Trials must have used a randomization method which precluded prior knowledge of treatment assignment and completed accrual by December 1993, to ensure sufficient follow-up by the time of the first analysis (September 1995). DATA COLLECTION AND ANALYSIS: A quantitative meta-analysis using updated data from individual patients from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. This approach was used to assess whether preoperative radiotherapy improves overall survival and whether it is differentially effective in patients defined by age, sex and tumour location. MAIN RESULTS: With a median follow-up of 9 years, in a group patients with mostly squamous carcinomas, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p=0.062). No clear differences in the size of the effect by sex, age or tumor location were apparent. REVIEWER'S CONCLUSIONS: Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients (90% power, 5% significance level) would be needed to reliably detect such an improvement (from 15 to 20%).

Preoperative radiotherapy for esophageal carcinoma. Oeosphageal Cancer Collaborative Group.

BACKGROUND: The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. OBJECTIVES: This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery and whether or not any pre-defined patient subgroups benefit more or less from preoperative radiotherapy SEARCH STRATEGY: Medline and CancerLit searches were supplemented by information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists, organisations and industry. SELECTION CRITERIA: Trials were eligible for inclusion in this meta-analysis provided they randomized patients with potentially resectable carcinoma of the esophagus (of any histological type) to receive radiotherapy or no radiotherapy prior to surgery. Trials must have used a randomization method which precluded prior knowledge of treatment assignment and completed accrual by December 1993, to ensure sufficient follow-up by the time of the first analysis (September 1995). DATA COLLECTION AND ANALYSIS: A quantitative meta-analysis using updated data from individual patients from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. This approach was used to assess whether preoperative radiotherapy improves overall survival and whether it is differentially effective in patients defined by age, sex and tumour location. MAIN RESULTS: With a median follow-up of 9 years, in a group patients with mostly squamous carcinomas, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p=0.062). No clear differences in the size of the effect by sex, age or tumor location were apparent. REVIEWER'S CONCLUSIONS: Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients (90% power, 5% significance level) would be needed to reliably detect such an improvement (from 15 to 20%).

Bladder and sexual dysfunction after mesorectal excision for rectal cancer.

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal excision for cancer. The aim of this study was to examine the frequency of such complications after mesorectal excision, shortly after this method was introduced. METHODS: Spontaneous flowmetry, residual volume of urine measurement and urodynamic examination, including cystometry and simultaneous detrusor pressure and urinary flow recording, was carried out before and 3 months after curative rectal excision. Urinary symptoms and sexual function were evaluated by means of questionnaires before and after operation. Each patient served as his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom had a total mesorectal excision (TME) and ten a partial mesorectal excision, were examined before surgery and 35 again after operation. In two patients, a weak detrusor was detected before operation. Two patients developed signs of bladder denervation after operation. Transitory moderate urinary incontinence appeared in four other women. Six of 24 men reported some reduction in erectile function and one became impotent. Two men reported retrograde ejaculation. All the complications were seen in the TME group. CONCLUSION: Mesorectal excision for rectal cancer resulted in a low frequency of serious bladder and sexual dysfunction.

Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation.

OBJECTIVES: To assess the nutritional status of surgical gastrointestinal and orthopaedic patients, and to audit the practice and documentation of nutritional therapy used on these wards. METHODS: Nutritional status was assessed in 244 patients using body mass index (BMI) and weight loss. Amount and length of nutritional therapy and records of the patients' nutritional state were noted from the patients' records. RESULTS: 94 patients (39%) were mildly/borderline to severely malnourished. Sixty courses of nutritional support were given parenterally or by tube feeding. Twenty seven of these were given for less than a week. Of the remaining 33, the amount of energy given to 17 patients was less than 25 kcal/kg. There was no correlation between patient weight and energy administered. Twenty four patients received less than 1 gram aminoacids per kg bodyweight. Body weight was recorded in 59% of the patients records. CONCLUSION: New routines and staff education are needed.

Granulocyte marker protein is increased in stools from rats with azoxymethane-induced colon cancer.

BACKGROUND: We wanted to investigate the relationship between the fecal levels of granulocyte marker protein (GMP) and the presence of aberrant crypt foci (ACF) and colorectal cancer in rats given injections of azoxymethane (AOM) and fed either of two different diets, a basal diet plus 20% corn oil or 20% beef suet, respectively. METHODS: The rats received intraperitoneal injections of AOM, 15 mg/kg, once weekly for 6 weeks and were killed after 22 weeks. RESULTS: In the group fed beef suet 17 of 19 rats developed colon cancer, whereas in the group fed corn oil 4 of 14 rats developed cancer. None of the 20 control rats fed either the beef suet or corn oil diets developed cancer or aberrant crypts, and GMP remained unchanged. Surprisingly, the numbers of ACF were significantly higher (467 versus 295; P = 0.004) in the group fed corn oil than in the group fed beef suet. On the other hand, the size (crypts/focus) of the ACF was significantly higher (P = 0.03) in the beef suet group. Furthermore, fecal GMP was significantly higher in the beef suet group than in the corn oil group after 18 weeks, and this difference increased further toward the end of the study. GMP was greatly increased in all rats with colorectal cancer. CONCLUSIONS: Fecal GMP may have provided us with a valuable tool for further studies of the induction and progression of neoplasia in rats and, possibly, in mice, since the anti-GMP antibody cross-reacts with feces extracts from mice.

Preoperative radiotherapy in esophageal carcinoma: a meta-analysis using individual patient data (Oesophageal Cancer Collaborative Group).

PURPOSE: The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery. METHODS AND MATERIALS: This quantitative meta-analysis included updated individual patient data from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. RESULTS: With a median follow-up of 9 years, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p = 0.062). No clear differences in the size of the effect by sex, age, or tumor location were apparent. CONCLUSION: Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients would be needed to reliably detect such an improvement (15-->20%).