Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study.

BACKGROUND: Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases. METHODS: The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival. RESULTS: Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively. CONCLUSION: Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.

Incidence and management of patients with colorectal cancer and synchronous and metachronous colorectal metastases: a population-based study.

BACKGROUND: This population-based study aimed to examine the incidence, patterns and results of multimodal management of metastatic colorectal cancer. METHODS: A retrospective population-based study was conducted on patients with metastatic colorectal cancer in Central Finland in 2000-2015. Clinical and histopathological data were retrieved and descriptive analysis was conducted to determine the pattern of metastatic disease, defined as synchronous, early metachronous (within 12 months of diagnosis of primary disease) and late metachronous (more than 12 months after diagnosis). Subgroups were compared for resection and overall survival (OS) rates. RESULTS: Of 1671 patients, 296 (17·7 per cent) had synchronous metastases, and 255 (19·6 per cent) of 1302 patients with resected stage I-III tumours developed metachronous metastases (94 early and 161 late metastases). Liver, pulmonary and intraperitoneal metastases were the most common sites. The commonest metastatic patterns were a combination of liver and lung metastases. The overall metastasectomy rate for patients with synchronous metastases was 16·2 per cent; in this subgroup, 3- and 5-year OS rates after any resection were 63 and 44 per cent respectively, compared with 7·1 and 3·3 per cent following no resection (P < 0·001). The resection rate was higher for late than for early metachronous disease (28·0 versus 17 per cent respectively; P = 0·048). Three- and 5-year OS rates after any resection of metachronous metastases were 78 and 62 per cent respectively versus 42·1 and 18·2 per cent with no metastasectomy (P < 0·001). Similarly, 3- and 5-year OS rates after any metastasectomy for early metachronous metastases were 57 and 50 per cent versus 84 and 66 per cent for late metachronous metastases (P = 0·293). CONCLUSION: The proportion of patients with metastatic colorectal cancer was consistent with that in earlier population-based studies, as were resection rates for liver and lung metastases and survival after resection. Differentiation between synchronous, early and late metachronous metastases can improve assessment of resectability and survival.

ANTECEDENTES: El objetivo de este estudio de base poblacional fue analizar la incidencia, la forma de presentación y los resultados del tratamiento multimodal del cáncer colorrectal metastásico (metastatic colorectal cancer, mCRC). MÉTODOS: Se realizó un estudio retrospectivo de base poblacional en pacientes con mCRC en la región central de Finlandia entre 2000 a 2015. Se recuperaron los datos clínicos e histopatológicos y se realizó un análisis descriptivo con el objetivo de analizar la forma de presentación de la enfermedad metastásica. La enfermedad metastásica se definió como sincrónica, metacrónica precoz (< 12 meses) y metacrónica tardía (> 12 meses después del diagnóstico de la enfermedad primaria) y se compararon las tasas de resección y de supervivencia global (overall survival, OS) en estos subgrupos. RESULTADOS: De los 1.671 pacientes revisados, 296 (17,7%) presentaron metástasis sincrónicas, mientras que de los 1.302 pacientes resecados en estadios I-III, 255 (19,6%) tuvieron metástasis metacrónicas: 94 precoces y 161 tardías. La localización metastásica más frecuente fue el hígado, los pulmones y el peritoneo. La combinación más frecuente fue la de metástasis hepáticas y pulmonares. La tasa de resección para pacientes con metástasis sincrónicas fue del 16,2%; en este subgrupo, la OS a 3 y 5 años después de cualquier tipo de resección fue del 62,6% y 44,2% versus 7,1% y 3,3% en los pacientes sin resección, respectivamente (P < 0,001). La tasa de resección fue mayor en la enfermedad metacrónica tardía que en la enfermedad metacrónica precoz (28% versus 17%, P = 0,048). Las tasas de OS a 3 y 5 años después de cualquier resección en los casos de metástasis metacrónicas fueron del 77,8% y 61,9% versus 42,1% y 18,2% en los pacientes sin metastasectomía, P < 0,001. Las tasas de OS a 3 y 5 años después de cualquier metastasectomía en los casos de metástasis metacrónicas precoces fueron del 57,4% y 50,3%, versus 84,3% y 65,6% en las tardías (P = 0,29) CONCLUSIÓN: La proporción de pacientes con mCRC fue similar a la de estudios anteriores de base poblacional, así como las tasas de resección para metástasis hepáticas y pulmonares y la supervivencia después de la resección. Diferenciar entre metástasis sincrónicas, metacrónicas precoces y tardías puede mejorar la posibilidad de resecabilidad y la supervivencia.

Laparoscopic Wide Mesocolic Excision and Central Vascular Ligation for Carcinoma of the Colon.

BACKGROUND AND AIMS: The principle of complete mesocolic excision for colon cancer has been introduced to improve oncologic outcome. However, this approach is scantily discussed for laparoscopic surgery and there is a lack of randomized trials. This study examined oncologic and clinical outcome after laparoscopic wide mesocolic excision and central vascular ligation for colon cancer. MATERIAL AND METHODS: This is a review of prospectively gathered data from a single-institution colorectal cancer database. This study was conducted in the Central Hospital of Central Finland. From January 2003 to December 2011, 222 patients underwent laparoscopic colonic resections with wide mesocolic excision and central vascular ligation in the multimodal setting. The main measures of outcome were cancer recurrence and survival, with early recovery, 30d-mortality and morbidity, reoperation, readmission, and late complications as secondary outcomes. RESULTS: The median follow-up was 5.5 (interquartile range (IQR) = 3.7-8.0) years. The 5-year overall survival for all 222 patients was 80.2% and disease-specific survival was 87.5%, and for those 210 R0-patients with stage I-III disease, 83.9% and 91.3%, respectively. The 5-year disease-free survival was 85.8%: stage I was 94.7%, stage II was 90.8%, and stage III was 75.6% ( p = 0.004). Increasing lymph node ratio significantly decreased the 5-year disease-free survival. Conversion rate to open surgery was 12.2%. Thirty-day mortality was 1.3% and morbidity, 19.7%. Median postoperative hospital stay was 5 (IQR = 3-7) days. CONCLUSION: Laparoscopic wide mesocolic excision and central vascular ligation for colon cancer resulted in good long-term oncologic outcome. Randomized trials are needed to show that laparoscopic complete mesocolic excision technique would become the standard of care for the carcinoma of the colon.

Combination of microsatellite instability and BRAF mutation status for subtyping colorectal cancer.

BACKGROUND: The objective of the study was to examine the role of microsatellite instability (MSI) and BRAF(V600E)mutation in colorectal cancer (CRC) by categorising patients into more detailed subtypes based on tumour characteristics. METHODS: Tumour samples from 762 population-based patients with sporadic CRC were analysed for MSI and BRAF(V600E) by immunohistochemistry. Patient survival was followed-up for a median of 5.2 years. RESULTS: Compared with microsatellite stable (MSS) CRC, MSI was prognostic for better disease-free survival (DFS; 5 years: 85.8% vs 75.3%, 10 years: 85.8% vs 72.9%, P=0.027; HR 0.49, CI 0.30-0.80, P=0.005) and disease-specific survival (DSS; 5 years: 83.2% vs 70.5%; 10 years: 83.2 vs 65.0%, P=0.004). Compared with BRAF wild type, BRAF(V600E) was a risk for poor survival (overall survival; 5 years: 62.3% vs 51.6%, P=0.014; HR 1.43, CI 1.07-1.90, P=0.009), especially in rectal cancer (for DSS, HR: 10.60, CI: 3.04-36.92, P<0.001). The MSS/BRAF(V600E) subtype was a risk for poor DSS (HR: 1.88, CI: 1.06-3.31, P=0.030), but MSI/BRAF(V600E) was a prognostic factor for DFS (HR: 0.42, CI: 0.18-0.96, P=0.039). Among stage I-II patients, the MSS/BRAF(V600E) subtype was independently associated with poor DSS (HR: 5.32, CI: 1.74-16.31, P=0.003). CONCLUSIONS: Microsatellite instable tumours were associated with better prognosis compared with MSS. BRAF(V600E) was associated with poor prognosis unless it occurred together with MSI. The MSI/BRAF(V600E) subtype was a favourable prognostic factor compared with the MSS/BRAF wild-type subtype. BRAF(V600E) rectal tumours showed particularly poor prognosis. The MSS/BRAF(V600E) subtype was associated with increased disease-specific mortality even in stage I-II CRC.

Comparison of laparoscopic and open colonic resection within fast-track and traditional perioperative care pathways: Clinical outcomes and in-hospital costs.

BACKGROUND: This study examined short-term clinical outcomes and in-hospital costs of laparoscopic and open colonic resection within fast-track and traditional care pathways. MATERIAL AND METHODS: A case-control study was performed. From 2007 to 2009, 116 patients underwent laparoscopic or open colonic resection for benign or malignant disease within fast-track care pathway. The control group consisted of 116 age-, sex-, comorbidity-, type of surgery-, and diagnosis-matched patients who received a traditional perioperative care from 2000 to 2007. The main measures of outcome were postoperative hospital stay and in-hospital costs, with 30-day mortality, morbidity, reoperation, and readmission rates as secondary outcomes. RESULTS: The study groups were well balanced for baseline characteristics. Postoperative hospital stay was shorter in the fast-track than in the control group: laparoscopic resection median 3 versus 5 days (p < 0.001) and open resection 4 versus 7 days (p < 0.001). In multivariate analysis fast-track care, laparoscopic surgery and complications were independent determinants affecting the length of hospital stay. Overall, there was a trend toward lower in-hospital costs in the fast-track group compared with the traditional care group, but the difference was not statistically significant. Open surgery within fast-track care was the least costly option compared to laparoscopic or open surgery within traditional care but not significantly so when compared with laparoscopy within fast-track care. Intake of solid food and bowel function recovered 1 day earlier in the fast-track group than in the control group (p < 0.001). Complications were more frequent after open surgery than after laparoscopic surgery (23.3% vs 11.0%, p = 0.012). Reoperation and readmission rates were similar between the study groups. CONCLUSION: Laparoscopy improves the efficiency of fast-track perioperative care without significantly increasing in-hospital costs.

Evaluation of a fast-track protocol for patients undergoing colorectal surgery.

BACKGROUND AND AIMS: Fast-track protocols have been used to optimize the perioperative care and to enhance postoperative recovery. This study examined short-term clinical outcomes and determinants affecting the length of postoperative hospital stay. MATERIAL AND METHODS: From 2007 to 2009, 180 patients underwent laparoscopic or open bowel resection (N = 138) or sacrocolporectopexy (N = 42) in the Central Hospital of Central Finland for various colorectal diseases in the fast-track setting. The main measures of outcome were time to functional recovery, 30-day morbidity, and readmission rates, with hospital stay and patient satisfaction as secondary outcomes. RESULTS: There were no deaths. Time to functional recovery was median 2 (interquartile range 2-3) days. The overall 30-day postoperative morbidity was 14.5% after bowel resection and 0% after sacrocolporectopexy. Relaparotomy rate was 3.6% and 30-day readmission rate 7.2%. Postoperative hospital stay was median 3 days after small bowel and ileo-colic resection, 4 days after segmental colectomy, and 6 days after rectal resection and subtotal colectomy. Patient's body mass index > 30 kg/m2, malignant disease, complexity of surgery, recovery of bowel function later than 2 days after surgery, time to functional recovery > 2 days and postoperative morbidity were patient- and treatment-related determinants increasing postoperative hospital stay. Protocol compliance-related determinants increasing postoperative hospital stay were intake of normal food and mobilization ≥ 6 h/day later than 2 days after surgery and removal of urinary catheter later than 1 day after surgery. CONCLUSION: Postoperative functional recovery was fast, morbidity and readmission rates were low, and postoperative hospital stay short indicating that fast-track care should form the mainstay of elective colorectal surgery.

Remission of membranous glomerulonephritis after pancreatectomy for pancreatic neuroendocrine neoplasm - a rare coincidence.

The concomitant existence of a non-malignant neuroendocrine tumor (NET) and membranous glomerulonephritis (MGN) is rare. We report a subject with kidney biopsy proven MGN and nephrotic syndrome in which a computerized scan tomography (CT) examination was performed revealing a pancreatic tumor. A pancreatectomy was performed and the tumor was shown to be a non-malignant NET with a malignant potential. Although treatment with corticosteroids was initiated remission of MGN was observed within the next month after pancreatectomy. The rapid remission observed shortly after pancreatectomy pointed to that tumor removal contributed to, and that neither spontaneous nor corticosteroid treatment alone did induce the rapid remission of the MGN. The coexistence of the two disorders NET and MGN is very rare, however. This is the first report on remission of MGN after pancreatectomy for a NET.

Epidemiologic aspects of complete rectal prolapse.

BACKGROUND AND AIMS: This study was undertaken to find out the incidence of rectal prolapse. MATERIAL AND METHODS: Ninety-nine patients operated on for rectal prolapse at Jyväskylä Central Hospital were studied. Patients operated between 1988 and 1998 were studied retrospectively from hospital records using chart review and thirty-five patients operated on between 1999 and 2002 were studied prospectively using our proctologic database. RESULTS: The annual incidence of diagnosed complete rectal prolapse in the district of Central Finland was mean 2.5 (range, 0.79-6.08) per 100 000 population. There were ten men (10 percent) and 89 women (90 percent). Median age of the patients was 69 (range, 21-91) years. Forty-eight percent of the patients had concomitant cardiovascular disease and 15 percent psychiatric illness. Anal incontinence affecting quality of life was seen in 64 percent and constipation in 72 percent of patients. Constipation tended to be more attributed to difficult evacuation (72 percent) than to impaired bowel action (18 percent). CONCLUSION: The annual incidence of rectal prolapse is 2.5 per 100 000 population. Rectal prolapse is associated with anal incontinence and constipation in majority of patients.

Tumour regression grading in the evaluation of tumour response after different preoperative radiotherapy treatments for rectal carcinoma.

BACKGROUND AND AIMS: Preoperative radiotherapy (PRT) for rectal carcinoma has been shown to cause tumour regression and increase local control and patient survival. The aim of this study was to examine the usefulness of tumour regression grading (TRG) in quantifying the effect of PRT. METHODS: Depending on the tumour stage (uT), as defined by preoperative endorectal ultrasound (ERUS), fixity and distance from the anal verge, 126 patients with rectal cancer underwent either surgery alone, or received short-course 25-Gy radiotherapy or long-course 50-Gy radiotherapy combined with 5-fluorouracil (5-FU) before surgery. TRG in each group was assessed and compared with the downstaging, defined as a change in preoperative uT stage and pathologic stage (pT). RESULTS: Complete response (no residual tumour, TRG 1) was seen in 7% of the patients (3/44) and total or major regression (TRG 1-3) in 73% of the patients (32/44) treated with 50-Gy chemoradiation. Of those treated with 25-Gy PRT, 21% (9/42) showed major tumour regression. Of the patients who underwent ERUS and PRT, 32% (26/83) were downstaged when comparing uT with pT, but 53% (14/26) of the downstaged tumours showed no response by TRG. In comparison, 50% (28/57) of the tumours with no downstaging showed a marked response by TRG (p=0.05). CONCLUSIONS: Tumour regression grading offers detailed information of the effect of PRT and shows that tumour regression is more marked after long-term chemoradiation than after short-course radiotherapy (p=0.02). In contrast, T-stage downstaging was similar in both groups and did not correlate with the TRG results (p=0.05).

The role of biofeedback therapy in functional proctologic disorders.

BACKGROUND AND AIMS: The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation. MATERIAL AND METHODS: Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database. RESULTS: Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes. CONCLUSIONS: Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

Comparison of a peanut agglutinin test and an immunochemical faecal occult blood test in detecting colorectal neoplasia in symptomatic patients.

BACKGROUND: Currently available methods for detection of early-stage colorectal cancer are reliant on faecal occult blood (FOB) tests. Bleeding, however, is not specific for colorectal neoplasia. Enzymatically detected or peanut agglutinin (PNA)-detectable galactose-beta1-3-N-acetyl-galactosamine residues found in rectal mucus have been used to detect colorectal cancer. METHODS: The sensitivity and specificity of the PNA rectal mucus test were compared with those of an immunological test for faecal occult blood (Hemolex) in 199 symptomatic patients referred for colorectal investigations. All patients also underwent a colonoscopy. SDS-PAGE and PNA-overlay were used to characterize PNA-binding proteins in normal and malignant colorectal tissue. RESULTS: The PNA test had a similar sensitivity to that of Hemolex for colorectal carcinoma (83% vs. 72%), adenomas (55% vs. 50%), inflammatory bowel disease (52% vs. 48%) and hyperplastic polyps (48% vs. 25%). The sensitivity of the PNA test and Hemolex for colorectal neoplasia was 69% vs. 59% and specificity 68% vs. 86% (p=0.002). SDS-PAGE and PNA-overlay showed some commonly expressed PNA-binding proteins in both normal mucosa and colorectal cancer and a higher and even selective expression of 160 kD PNA-binding protein in colorectal cancer. CONCLUSIONS: A single PNA test in its present form is as sensitive an indicator of colorectal neoplasia as Hemolex completed over three days, but lacks specificity. The 160 kD cancer-associated antigen we have identified is under further characterization for development of a more specific PNA test.

Outcome of temporary stomas. A prospective study of temporary intestinal stomas constructed between 1989 and 1996.

PURPOSE: The purpose of this study was to examine the outcome of patients to whom a temporary stoma was constructed in our institution. METHOD: The outcome of patients operated on over an 8-year period was prospectively examined. Special attention was given to the influence of age on complications and closure of stomas. RESULTS: Between 1989 and 1996, a total of 349 intestinal stomas were constructed in 342 patients. In 141 of these patients, the stoma could be considered as temporary. The 30-day mortality rate was 7%. The overall complication rate was 50%. Pure stoma-related complications were observed in 12% of the patients. The final closure rate of temporary stomas was 67%. The closure rate was significantly higher if the temporary stomas were of the double-barrel type. There was no significant difference in the closure rate between patients with benign and malignant diseases, but the rate decreased significantly in age groups over 70 years. CONCLUSIONS: Forty percent of stomas constructed are considered as temporary, but only two-thirds of temporary stomas are closed subsequently. Especially end stomas tend to become permanent in patients over 70 years of age, although the morbidity rates of stoma closure do not differ from those of younger patients.

Germline mutations in BMPR1A/ALK3 cause a subset of cases of juvenile polyposis syndrome and of Cowden and Bannayan-Riley-Ruvalcaba syndromes.

Juvenile polyposis syndrome (JPS) is an inherited hamartomatous-polyposis syndrome with a risk for colon cancer. JPS is a clinical diagnosis by exclusion, and, before susceptibility genes were identified, JPS could easily be confused with other inherited hamartoma syndromes, such as Bannayan-Riley-Ruvalcaba syndrome (BRRS) and Cowden syndrome (CS). Germline mutations of MADH4 (SMAD4) have been described in a variable number of probands with JPS. A series of familial and isolated European probands without MADH4 mutations were analyzed for germline mutations in BMPR1A, a member of the transforming growth-factor beta-receptor superfamily, upstream from the SMAD pathway. Overall, 10 (38%) probands were found to have germline BMPR1A mutations, 8 of which resulted in truncated receptors and 2 of which resulted in missense alterations (C124R and C376Y). Almost all available component tumors from mutation-positive cases showed loss of heterozygosity (LOH) in the BMPR1A region, whereas those from mutation-negative cases did not. One proband with CS/CS-like phenotype was also found to have a germline BMPR1A missense mutation (A338D). Thus, germline BMPR1A mutations cause a significant proportion of cases of JPS and might define a small subset of cases of CS/BRRS with specific colonic phenotype.

Laparoscopic repair of rectal prolapse: surgical technique.

Technical features of laparoscopic rectopexy include complete rectal mobilization without division of the lateral stalks to avoid parasympathetic denervation and postoperative problems with defecation. Suture rectopexy is equally effective as posterior mesh rectopexy in preventing recurrences and eliminates the use of foreign material which is sometimes associated with intense fibrosis, sepsis and increased constipation. According to two randomised studies constipation seems to be less after resection rectopexy than suture or posterior mesh rectopexy alone perhaps by eliminating possible kinking at the rectosigmoid region by falling of the redundant sigmoid colon in the pouch of Douglas. Randomized studies are, however, needed to validate the need for colonic resection and to determine its optimal extent in patients who suffer from rectal prolapse, constipation and slow transit.

Laparoscopic repair of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function.

BACKGROUND: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. METHODS: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. RESULTS: Median operation time was 255 min (range, 180-360) in the resection rectopexy group and 150 min (range, 90-295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3-15) and median time off work was 14 days (range, 12-21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12-60 months). CONCLUSIONS: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated.

Management of duodenal adenomas in 98 patients with familial adenomatous polyposis.

BACKGROUND AND STUDY AIMS: The advantage of endoscopic surveillance and treatment of duodenal polyposis is still unclear in familial adenomatous polyposis (FAP). The aim of this study was to evaluate the progression patterns of duodenal polyposis and the results of treatment. PATIENTS AND METHODS: In our institution, the 98 FAP patients included in the prospective follow-up study underwent at least one upper endoscopic examination, carried out with few exceptions, by a single surgeon endoscopist. The progression patterns of duodenal polyposis, the cumulative risk of severe duodenal polyposis and duodenal cancer as well as the results of surgical treatment were evaluated during a median follow-up of 11 years. RESULTS: Duodenal adenomas were detected in 78 patients corresponding to a cumulative lifetime incidence of 97%. The stage of adenomatosis progressed in 52 (73 %) of the 71 patients who underwent repeated endoscopies. The cumulative risks of stage IV adenomatosis and duodenal carcinoma were 30% and 4 %, respectively. Excisional treatment through open duodenotomy resulted in significant stage regression but was followed by new progression. In all patients the median interval for progression by one stage varied from 4 to 11 years. CONCLUSIONS: Duodenal adenomas almost invariably occur in FAP; endoscopic surveillance is thus warranted to anticipate severe progression and malignant transformation. Excisional surgical treatment can, however, give only transient stage reduction.

SMAD genes in juvenile polyposis.

Juvenile polyposis (JP) is a dominantly inherited condition characterized by the development of multiple hamartomatous tumors, juvenile polyps, in the gastrointestinal tract. The aim of this study was to clarify the role of SMAD4 in JP. DNA from four unrelated JP kindreds and three sporadic JP cases was available for mutation screening. Two truncating defects (one in a familial and one in a sporadic case) and one missense change (in a familial case) that was absent in 55 control samples were detected. To study the possibility that germline mutations in other genes encoding different components of the TGF-beta signaling pathway may be present in these JP patients, mutation analyses of the SMAD2, SMAD3, and SMAD7 genes were also performed. No mutations of these genes were detected in any of the patients. Our results confirm that SMAD4 is a gene predisposing to JP and suggest the existence of further JP loci other than the SMAD2, SMAD3, or SMAD7 genes. Genes Chromosomes Cancer 26:54-61, 1999.

Functional outcome after laparoscopic or open Nissen fundoplication: a follow-up study.

OBJECTIVE: To compare the results of open and laparoscopic fundoplication. DESIGN: Nonrandomized controlled study with a 3-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. INTERVENTIONS: Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. RESULTS: Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. CONCLUSION: From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.

Short and long term outcome after laparoscopic cholecystectomy.

BACKGROUND: As an audit of patients undergoing laparoscopic cholecystectomy this study not only reports the short term results, but attempted to assess the long term effect of the operation on the symptom profiles of the patients. METHODS: Three hundred unselected consecutive patients underwent elective laparoscopic cholecystectomy from January 1991 to July 1994. Short term outcome was analysed by reviewing patient files for operation details, postoperative morbidity, complications, and gallbladder histology. Long term (median 2 years) outcome was evaluated by a detailed postal questionnaire. Symptomatic benefit ratios (BR) accruing from the laparoscopic removal of the gallbladder were calculated. RESULTS: Twelve operations (4.0%) were converted to open surgery and were excluded from long term outcome analyses. Median operation time was 93 (range 40-245) minutes. There were no deaths. Overall morbidity was 13 %. Median postoperative hospital stay was 2 days (range 1-18 days) and median time-off work 15 days (range 2-49 days). The overall response rate to the questionnaire was 87%. Only one of the 261 patients (0.4%) suffered from recurrent common bile duct stones so far. As shown by the benefit ratios the symptoms most effectively relieved by laparoscopic cholecystectomy were biliary pain (0.97), nausea (0.95), vomiting (0.96) and jaundice (0.94). Most patients with diarrhoea (0.70) and heartburn (0.66) felt relief. Constipation (0.39) and food intolerance (0.57) were unaffected. Most patients (90%) felt that the operation-initiating symptom had disappeared and 98 percent of the patients considered that they had obtained overall symptomatic improvement by the operation. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a safe and effective way of treating the most common symptoms related to gallstone disease.