Clinical management of 52 consecutive retro-rectal tumours treated at a tertiary referral centre.

AIM: The aim of this single-institution study was to analyse the diagnostic methods, preoperative work-up and outcomes of 52 retro-rectal tumours. METHOD: All patients treated for retro-rectal tumours from 2012 to 2017 were included. RESULTS: Out of 52 patients, 40 (77%) were women. The median age of patients at the time of surgery was 43 (19-76) years, and 30 (58%) were asymptomatic at the time of diagnosis. All tumours were visible on magnetic resonance imaging (MRI) prior to surgery. The sensitivity and specificity for predicting malignancy on preoperative imaging for retro-rectal tumours were 25% and 98%, respectively. Forty-four procedures (85%) were performed using the perineal approach. The median hospital stay was 3 (1-18) days. There was no 30-day postoperative mortality. Eleven (21%) patients developed postoperative complications, mostly surgical site infections. Twenty-nine tumours (56%) were benign tailgut cysts. Four (8%) tumours were malignant and were considered to be removed with a tumour-free resection margin. Local recurrent disease was detected on MRI in 14 (27%) patients at a median of 1.05 (range 0.78-1.77) years after primary surgery. Only the multi-lobular shape of the tumour was found to be an independent risk factor for recurrence (P = 0.030). CONCLUSION: A preoperative MRI is mandatory in order to plan the surgical strategy for retro-rectal tumours. Symptomatic, solid, large tumours should be removed because of the risk of malignancy. Minor cystic lesions with thin walls as well as asymptomatic recurrences of benign tumours are suitable to be followed conservatively.

Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit.

AIM: The extralevator abdominoperineal excision (ELAPE) has been expected to reduce the risk of positive circumferential resection margins (CRMs) and local recurrence in locally advanced distal rectal cancer. The aim was to determine whether there is any difference in local recurrence rates between patients who were operated on for distal rectal cancer before and after the introduction of ELAPE in our unit. PATIENTS AND METHODS: In all, 206 patients with distal rectal cancer without distant metastases (T1-4N0-2M0) were treated with curative intent. The patients were divided into two cohorts operated in 2000-2007 (A) and 2008-2014 (B). The ELAPE procedure was introduced in 2008. Since then, it has been used in cases of T4 and T3 tumours with threatened margins. In T1-T3 tumours without threatened margins a conventional abdominal perineal excision has been performed. RESULTS: There was no significant difference in overall survival or cancer-specific survival between the two time periods. The local recurrence rate was 15.5% in group A and 6.7% in group B (P = 0.048), although there was no significant difference in the cumulative local recurrence rate. Intra-operative tumour perforation occurred significantly more often during the earlier period when ELAPE was not in use: group A 15/71 (21.1%) vs group B 11/135 (8.1%), P = 0.01. CRM was positive more often in group A (16.4%) vs group B (7.4%), P = 0.054. CONCLUSION: The local recurrence rate, intra-operative tumour perforation and positive CRM rate were significantly lower during the later period when more extensive surgery (ELAPE) was performed for locally advanced T3-T4 rectal cancer with threatened margins.

The Results of Pancreatic Resections and Long-Term Survival for Pancreatic Ductal Adenocarcinoma: A Single-Institution Experience.

OBJECTIVES: Since the early 1990s, low long-term survival rates following pancreatic surgery for pancreatic ductal adenocarcinoma have challenged us to improve treatment. In this series, we aim to show improved survival from pancreatic ductal adenocarcinoma during the era of centralized pancreatic surgery. METHODS: Analysis of all pancreatic resections performed at Helsinki University Hospital and survival of pancreatic ductal adenocarcinoma patients during 2000-2013 were included. Post-operative complications such as fistulas, reoperations, and mortality rates were recorded. Patient and tumor characteristics were compared with survival data. RESULTS: Of the 853 patients undergoing pancreatic surgery, 581 (68%) were pancreaticoduodenectomies, 195 (21%) distal resections, 28 (3%) total pancreatectomies, and 49 (6%) other procedures. Mortality after pancreaticoduodenectomy was 2.1%. The clinically relevant B/C fistula rate was 7% after pancreaticoduodenectomy and 13% after distal resection, and the re-operation rate was 5%. The 5- and 10-year survival rates for pancreatic ductal adenocarcinoma were 22% and 14%; for T1-2, N0 and R0 tumors, the corresponding survival rates were 49% and 31%. Carbohydrate antigen 19-9 >75 kU/L, carcinoembryonic antigen >5 µg/L, N1, lymph-node ratio >20%, R1, and lack of adjuvant therapy were independent risk factors for decreased survival. CONCLUSION: After centralization of pancreatic surgery in southern Finland, we have managed to enable pancreatic ductal adenocarcinoma patients to survive markedly longer than in the early 1990s. Based on a 1.7-million population in our clinic, mortality rates are equal to those of other high-volume centers and long-term survival rates for pancreatic ductal adenocarcinoma have now risen to some of the highest reported.

Laparoscopic ventral rectopexy in male patients with external rectal prolapse is associated with a high reoperation rate.

BACKGROUND: Laparoscopic ventral rectopexy has been used to treat male patients with external rectal prolapse, but evidence to support this approach is scarce. The aim of this study was to evaluate the results of this new abdominal rectopexy surgical technique in men. METHODS: This was a retrospective multicenter study. Adult male patients who were operated on for external rectal prolapse using ventral rectopexy in five tertiary hospitals in Finland between 2006 and 2014 were included in the study. Patient demographics, detailed operative, postoperative and short-term follow-up data were collected from patient registers in participating hospitals. A questionnaire and informed consent form was sent to all patients. The questionnaire included scores for anal incontinence, obstructed defecation syndrome, urinary symptoms and sexual dysfunction. The main outcome measure was the incidence of recurrent rectal prolapse. Surgical morbidity, the need for surgical repair due to recurrent symptoms and functional outcomes were secondary outcome measures. RESULTS: A total of 52 adult male patients with symptoms caused by external rectal prolapse underwent ventral rectopexy. The questionnaire response rate was 64.4 %. Baseline clinical characteristics and perioperative results were similar in the responder and non-responder groups. A total of 9 (17.3 %) patients faced complications. There were two (3.8 %) serious surgical complications during the 30-day period after surgery that necessitated reoperation. None of the complications were mesh related. Recurrence of the prolapse was noticed in nine patients (17 %), and postoperative mucosal anal prolapse symptoms persisted in 11 patients (21 %). As a result, the reoperation rate was high. Altogether, 17 patients (33 %) underwent reoperation during the follow-up period due to postoperative complications or recurrent rectal or mucosal prolapse. According to the postoperative questionnaire data, patients under 40 had good functional results in terms of anal continence, defecation, urinary functions and sexual activity. CONCLUSIONS: Laparoscopic ventral rectopexy is a safe surgical procedure in male patients with external prolapse. However, a high overall reoperation rate was noticed due to recurrent rectal and residual mucosal prolapse. This suggests that the ventral rectopexy technique should be modified or combined with other abdominal or perineal methods when treating male rectal prolapse patients.

Late mesh migration through the stomach wall after laparoscopic refundoplication using a dual-sided PTFE/ePTFE mesh.

We report a rare complication after laparoscopic fundoplication using a dual-sided PTFE/ePTFE (Bard® Crurasoft™) mesh fixation. A 53-year-old man was re-operated for a recurrent hiatal hernia. The hiatal hernia was reinforced using a mesh. Two years later, the patient presented with serious dysphagia and weight loss. An endoscopy revealed a migrated mesh in the stomach. The mesh was excreted within the stool without notice. The PTFE/ePTFE mesh, which is designed for treating hiatal defects, is considered to have superior tissue incorporation, together with less adhesion formation and fistulation. As mesh migration into the upper gastrointestinal tract is possible, it should be used with great care in the peri-oesophageal region.

Smoking increases the incidence of complicated diverticular disease of the sigmoid colon.

BACKGROUND AND AIMS: The aim of this study was to establish whether smoking is associated with complicated diverticular disease and adverse outcomes of operative treatment of diverticular disease. Smoking has been associated with increased rate of perforations in acute appendicitis as well as failure of colonic anastomosis in patients resected for colonic tumours. It has also been suggested that smoking is a risk factor for complicated diverticular disease of the colon. MATERIAL AND METHODS: Retrospective investigation of records of 261 patients electively operated for diverticular disease in Helsinki University Central Hospital during a period of five years. RESULTS: The smokers underwent sigmoidectomy at a younger age than the non-smokers (p = 0.001) and they had an increased rate of perforations (p = 0.040) and postoperative recurrent diverticulitis episodes (p = 0.019). CONCLUSIONS: We conclude that smoking increases the likelihood of complications in diverticulosis coli. The development of complicated disease also seems to proceed more rapidly in smokers.Key words: Sigmoid resection; laparoscopy; laparoscopic sigmoidectomy; smoking and diverticular disease; complicated diverticular disease; diverticulitis.

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients.

BACKGROUND: We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki. METHODS: Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV. RESULTS: The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good. CONCLUSIONS: Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

Does anyone survive pancreatic ductal adenocarcinoma? A nationwide study re-evaluating the data of the Finnish Cancer Registry.

BACKGROUND: Worldwide survival data for ductal adenocarcinoma of the pancreas are the lowest among the 60 most frequent types of organ cancers. Hence published data on long time survivors of this disease are controversial. We performed a nationwide study comprising all Finnish patients diagnosed with pancreatic cancer in the period 1990-1996 who survived for at least five years after diagnosis. METHODS: Data on patients registered as five year survivors of pancreatic cancer were obtained from the Finnish Cancer Registry and Statistics Finland. Slides or paraffin blocks were collected from patients recorded as having histologically proven pancreatic ductal adenocarcinoma (PDAC) and were re-evaluated in a double blind fashion by three pathologists with special expertise in pancreatic pathology. RESULTS: Between 1990 and 1996, the Finnish Cancer Registry recorded 4922 pancreatic cancer patients, 89 of whom survived for at least five years. Reviewing this series of patients revealed 45 (49%) non-PDACs and 18 cases without histological verification. In 26 patients recorded as having histologically proven PDAC, re-evaluation of histological specimens confirmed PDAC in only 10 patients. CONCLUSIONS: This study indicates that (1) the prognosis of PDAC remains poor and (2) careful histopathological review of all patients with pancreatic cancer is mandatory if survival data are to be meaningful.

CEA, CA 19-9 and CA 72-4 improve the diagnostic accuracy in gastrointestinal cancers.

BACKGROUND: CEA, CA 19-9, CA 242 and CA 72-4 are commonly used tumour markers for gastrointestinal malignancies. The advantage of the concomitant use of these markers is under debate. MATERIALS AND METHODS: Serum concentrations of the markers were measured at the time of diagnosis in 161 patients with benign and 125 with malignant gastrointestinal diseases. Concomitant use of the markers was evaluated in a logistic regression model. RESULTS: CA 19-9, CA 242 or CA 72-4 showed similar sensitivity of 44% for gastric cancer, whereas CEA was elevated in 25% of the cases. In patients with colorectal cancer, CEA was most frequently elevated (54%), followed by CA 242 (46%), CA 19-9 (36%) and CA 72-4 (25%). High CA 19-9 and CA 242 serum levels were frequent in patients with cholangiocarcinoma (86% and 68%, respectively) and pancreatic cancer (80% and 63%, respectively). In the benign disease group, serum CA 19-9 was most frequently elevated, i.e. in 24%, 25% and 38% of patients with pancreatic, biliary and liver disorders, respectively. The overall accuracy of CEA, CA 19-9, CA 242 and CA 72-4 was 66%, 71%, 71% and 66%, respectively (p > 0.18). When combined in a logistic regression model, CA 72-4, CA 19-9 and CEA provided independent diagnostic information, whereas CA 242 contributed with independent diagnostic information only on excluding CA 19-9. The probability of cancer for each patient, calculated with the model, was applied as a diagnostic test and was compared with the single markers by ROC-curve analysis. The AUC value of the probability index was significantly higher than the values of the different tumour markers. CONCLUSION: An algorithm based on the combination of CEA, CA 19-9 and CA 72-4 improved the diagnostic accuracy in gastrointestinal tract malignancies compared with these markers alone.

A comparison of serum and tissue hCG beta as prognostic markers in colorectal cancer.

BACKGROUND: Production of the glycoprotein hormone hCG beta has been associated with aggressive behavior in nontrophoblastic tumors. In this study the prognostic value of serum level and tissue expression of hCG beta were compared in 232 patients with colorectal cancer. MATERIALS AND METHODS: Serum levels were measured with a hCG beta specific immunofluorometric assay. Tissue specimens were stained with the same monoclonal antibody as in the serum assay. RESULTS: The proportion of patients with a positive immunohistochemical expression of hCG beta was higher (22%) than the proportion with elevated serum levels (17%). The correlation between serum and tissue expression was moderate (kappa 0.298). Both serum and tissue expression of hCG beta were independent prognostic factors. hCG beta serum level was a stronger prognostic factor than tissue expression both in uni- and in multivariate analysis. The accuracy when predicting 5-year survival status of the patients was highest (63%) when using the combined results of serum and tissue expression. CONCLUSIONS: There is a moderate correlation between hCG beta expression in serum and in tissue. The predictive accuracy of serum hCG beta was higher than the predictive accuracy of tissue expression, and the prognostic accuracy was further slightly increased when using a combination of tissue and serum expression.

Sialyl Tn is a frequently expressed antigen in colorectal cancer: No correlation with patient prognosis.

Immunohistochemical expression of sialyl Tn antigen (STn), previously claimed to be a prognostic factor in colorectal cancer, was evaluated in 239 patients with colorectal adenocarcinoma. Formalin-fixed, paraffin-embedded specimens were stained with the monoclonal antibody C1282. STn immunoreactivity was seen in 189 of 239 tumors (79%). There was no significant correlation between STn immunoreactivity and Dukes stage, tumor location, histological type or gender. However, STn was significantly more often expressed in younger patients. There was so significant difference in survival between STn-negative patients (median survival 68 months) and STn-positive patients (median survival 79 months). In a Cox multivariate analysis, Dukes stage was the strongest predictor of outcome, followed by the age of the patient, whereas STn did not provide any prognostic information.

Independent prognostic value of preoperative serum markers CA 242, specific tissue polypeptide antigen and human chorionic gonadotrophin beta, but not of carcinoembryonic antigen or tissue polypeptide antigen in colorectal cancer.

The prognostic value of preoperative serum concentrations of carcinoembryonic antigen (CEA), CA 242, tissue polypeptide antigen (TPA), specific tissue polypeptide antigen (TPS) and human chorionic gonadotrophin beta (hCG beta) in 251 patients with colorectal cancer (39 Dukes' A, 98 Dukes' B, 56 Dukes' C and 58 Dukes' D) was investigated. When using the cut-off levels recommended for diagnostic purposes, there was a significantly longer overall survival in patients with low tumour marker levels compared with patients with elevated serum levels for all the investigated markers. In Dukes' stage B, C and D CA 242 emerged as a significant predictor of survival, whereas TPA, TPS and hCG beta showed a value only in Dukes' D. Unfortunately, no marker provided prognostic information in Dukes' A. In multivariate analysis, entering the tumour markers as continuous variables, Dukes' stage was the strongest prognostic factor, followed by CA 242. TPS, hCG beta and localisation of the tumour were also independent prognostic factors, whereas age, gender, CEA and TPA were not.

Differences in serum tumor markers between colon and rectal cancer. Comparison of CA 242 and carcinoembryonic antigen.

PURPOSE: We investigated whether there are differences in serum levels of CA 242 and carcinoembryonic antigen (CEA) between patients with colon and rectal cancer. METHODS: Preoperative serum levels of CA 242 and CEA were determined in 153 patients with colon cancer and in 107 patients with rectal cancer. RESULTS: At the recommended cut-off levels for CA 242 and CEA, the overall sensitivity of CA 242 was 39 percent for both colon and rectal cancer, whereas the sensitivity of CEA was 40 percent for colon and 47 percent for rectal cancer. A combination of CA 242 and CEA increased overall sensitivity to 57 percent in colon cancer and to 62 percent in rectal cancer, whereas specificity decreased by 10 percent, compared with CEA alone. In colon cancer either or both markers were elevated in 38, 46, 56, and 84 percent of patients with Dukes Stages A, B, C, and D, respectively. Corresponding figures for rectal cancer were 52, 46, 71, and 87 percent, respectively. CONCLUSIONS: CA 242 showed equal sensitivity for colon and rectal cancer. In Stages A, C, and D, sensitivity of CEA and of a combination of CEA and CA 242 was higher in rectal than in colon cancer, but the difference was not significant. Concomitant use of markers increased sensitivity sharply compared with use of a single marker both in colon and rectal cancer.

Pre-operative serum levels of CA 242 and CEA predict outcome in colorectal cancer.

The prognostic value of the preoperative serum levels of CA 242 and CEA in patients with colorectal cancer was investigated. The serum concentrations of CA 242 and CEA were determined from preoperative serum samples of 259 patients with colorectal cancer (39 Dukes' A, 100 Dukes' B, 59 Dukes' C and 61 Dukes' D). Survival data of these patients were obtained to the end of 1993. There was a significantly longer survival in patients with a CA 242 level below 20 U/ml compared with patients with an elevated serum level. A difference was seen in overall survival (P < 0.0001), and in Dukes' B (P = 0.016) and Dukes' D (P = 0.009) stages. In Dukes' A and C colorectal cancer, the difference was not significant (P = 0.67 and P = 0.07, respectively). When 5 ng/ml was used as cut-off value for CEA, there was a significant difference in overall survival (P < 0.0001), but not within the different Dukes' stages. The prognosis was considerably worse in patients with concomitant elevation of CA 242 and CEA, compared with the prognosis of patients with normal levels or only one marker elevated (P < 0.0001). When analysing according to stage, a significant difference was seen in Dukes' B (P = 0.0004) and Dukes' C (P = 0.0007) stages. In a multivariate analysis, CA 242 was an independent prognostic factor (P < 0.0001). CEA was also an independent prognostic factor (P = 0.03), but only after exclusion of CA 242. Concomitant rise of CA 242 and CEA was found to be a strong independent prognostic factor (P < 0.0001). This study shows that the pre-operative serum CA 242 level is an independent prognostic factor in patients with colorectal cancer and that the prognosis of patients having a concomitant pre-operative elevation of CA 242 and CEA is poor.

Serum CA 242 and CEA detect different patients with recurrent colorectal cancer.

The aim of this study was to investigate the clinical value of CA 242 and CEA in the follow-up of patients with colorectal cancer. Serial serum samples were available for analysis in 67 patients with subsequent recurrence, of which 36 patients had been treated for colonic and 31 patients for rectal cancer. Liver metastases were found in 32 patients, local recurrences in 18 patients, lung metastases in 11 patients and other distant metastases in 6 patients. The same serum samples were used in quantitating the serum levels of both CA 242 and CEA. At the time of clinical recurrence an elevated CA 242 level was found in 41 patients and an elevated CEA level in 49 patients. Thirty-six patients (54%) showed an elevation of both CA 242 and CEA, five patients (7%) had increased CA 242 alone and 13 patients (19%) increased CEA alone. Altogether, 54 patients (81%) showed an elevation of either or both markers at the time of clinical recurrence. Initially CA 242 alone began to rise in 14 patients (21%) and CEA alone in 16 patients (24%). The lead time was calculated from 28 patients that had four or more serum samples available during follow-up. CA 242 increased in median 5,7 months and CEA in median 3,4 months before clinical recurrence (p=0.34). CA 242 was more sensitive for lung metastases (64%) than CEA (45%), whereas CEA was superior to CA 242 in liver metastases (88% versus 72%, respectively) and in local recurrences (56% versus 39%, respectively). Both CA 242 and CEA seem to be useful in early diagnosis of a recurrence in the follow-up of patients with colorectal cancer.

Preoperative serum levels of CEA and CA 242 in colorectal cancer.

Preoperative serum levels of CEA and CA 242 were determined in 260 patients with colorectal cancer and in 92 patients with benign colorectal diseases. The overall sensitivity of the CEA test was 43% and of the CA 242 test 39%. The corresponding specificities were 90% and 87% respectively, using 5 ng ml-1 as cut-off level for CEA and 20 U ml-1 for CA 242. The sensitivity of CEA was 26%, 32%, 38% and 77% for Dukes A, B, C and D colorectal cancer, and the sensitivity of CA 242 was 26%, 26%, 40% and 67%, respectively. The correlation between CEA and CA 242 was low. Concomitant elevation of both markers was seen in 5%, 12%, 18% and 59% of patients with Dukes A, B, C and D colorectal cancer, respectively. Of all the patients, 23% showed elevation of both the CEA and the CA 242 level, whereas CEA alone was elevated in 20% and CA 242 alone in 15% of the patients with colorectal cancer. Combined use of both markers raised the overall sensitivity from 43% to 58%, but reduced the specificity from 90% to 80%. The increase in sensitivity by combining the two markers was most marked in Dukes A, B and C colorectal cancer. Either or both of the markers were elevated in 46%, 46% and 60% of the patients respectively. The clinical value of combining CEA and CA 242 seems very promising and should be further investigated in prospective studies.