Endoscopic snare resection followed by laser ablation in the treatment of large, sessile rectal adenomas.

BACKGROUND AND AIMS: Large sessile rectal adenomas can be difficult to eradicate, and different treatment modalities are available. The aim of this study was to evaluate outcome after endoscopic snare resection followed by Nd:YAG laser ablation. MATERIAL AND METHODS: Over a 10-year period 92 of 99 (93%) patients were registered prospectively and attended follow-up examinations with endoscopy and biopsies. RESULTS: Fifty-four (59%) men and 38 (41%) women were included; 67 patients (73%) had high grade (severe) intraepithelial dysplasia or intramucosal neoplasia. The adenomas ranged from 2-9 cm (median 4 cm) in diameter, and were located 2-15 cm (median 5 cm) from the anal verge. A median of two (range 1-6) piecemeal snare resection sessions and a median of one (range 1-7) laser treatments were performed for each patient. Complete eradication was achieved in 86 patients (93%). Over a median follow-up period of 26 months, 20/86 (23%) suffered local recurrence, eight of whom were given a second laser treatment without developing further recurrence. In five of eight frail patients considered unsuitable for more radical treatment, repeated laser treatment was effective in keeping the adenoma small and symptoms at a minimum. As a whole the treatment was successful in 74/92 (80%) and partially successful in 5/92 (5%) of the patients. CONCLUSIONS: Snare resection followed by laser ablation is safe and still has a place in the treatment of old, frail patients with large rectal adenomas. However, there is a risk of missing an infiltrating carcinoma, and other treatment options are preferable in fit patients.

Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis.

AIM: The study aimed to evaluate long-term health-related quality of life (HRQOL) and functional outcome in patients who had undergone restorative proctocolectomy with ileo-anal anastomosis (IPAA) for ulcerative colitis and familial adenomatous polyposis. METHOD: A total of 156 patients who underwent IPAA during the period 1984-2003 and who still had an intact pouch were included. The HRQOL score was compared with 4152 individuals from the general Norwegian population using the SF-36 questionnaire, and function was evaluated using the Wexner Continence Grading Scale. RESULTS: One hundred and ten (71%) patients answered the questionnaires, 60 (55%) of whom were men. All except five patients had ulcerative colitis. Median (range) age at interview was 47 (19-66) years, and time after surgery was 12 (2-22) years. The IPAA patients scored slightly, but significantly, lower in four of six SF-36 health domains than the control subjects, adjusted for age and gender. Multiple regression analysis showed frequency of nocturnal defaecation, faecal incontinence and urgency to be independent negative prognostic factors of quality of life. Frequency of defaecation was a median of 7 (3-12) bowel movements during the day and 2 (0-6) at night. The majority had some degree of faecal incontinence, median (range) Wexner score of 8 (0-17), and 40% reported urgency of defaecation necessitating alterations in lifestyle. CONCLUSION: Patients with IPAA reported slightly lower HRQOL rates than the general population and had an inferior functional outcome.

Short term outcome after emergency and elective surgery for colon cancer.

OBJECTIVE: Emergency presentation of colon cancer is common and associated with high mortality and morbidity following surgical treatment. The purpose of this study was to evaluate postoperative mortality and complications in a consecutive and population based series. METHOD: All patients with adenocarcinoma of the colon diagnosed between 1993 and 2007 were registered prospectively. Postoperative mortality and complication rates in elective and emergency patients were compared. Logistic regression analysis was used to identify independent risk factors for postoperative complications. RESULTS: In the study period 1129 patients were admitted, of whom 279 (25%) presented as an emergency. A total of 999 (89%) patients underwent surgical treatment; 924 patients (82%) had a major resection. The mortality rate was 3.5% after elective and 10% after emergency operation with resection (P < 0.01), and the complication rate was 24% and 38% (P < 0.01), respectively. In patients with left-sided obstruction, the mortality rate after Hartmann's procedure was 19% compared to 3% after resection with primary anastomosis (P < 0.01). Multivariate analyses demonstrated that emergency operation, increasing age, advanced tumour stage and ASA class IV were independent risk factors for postoperative mortality. CONCLUSION: Emergency operation for colon cancer was associated with high rates of complications and mortality, indicating that immediate surgery should be avoided if possible. Decompression of left sided obstruction with a stent seems promising, whereas no conclusion can be made with regard to optimal procedure if stent placement fails; in this study Hartmann's procedure was associated with high mortality and morbidity.

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.

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome.

BACKGROUND: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. METHODS: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors ( n=13), unspecified tumors ( n=11), cysts ( n=2), idiopathic thrombocytopenic purpura with ectopic spleen ( n=2), annular pancreas ( n=1), trauma ( n=1), aneurysm of the splenic artery ( n=1), and adenocarcinoma ( n=1). RESULTS: Enucleations ( n=7) and distal pancreatectomy with ( n=12) and without splenectomy ( n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2-22). Postoperatively, opioid medication was given for a median of 2 days (range, 0-13). CONCLUSION: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

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.

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.

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.

[Endoscopic retrograde cholangiopancreatography--a 4-year retrospective study]. / Endoskopisk retrograd kolangiopankreatikografi--et fireårsmateriale.

Endoscopic retrograde cholangiopancreatography (ERCP) may lead to serious complications. Recently, magnetic resonance cholangiopancreatography (MRCP) has been introduced as a diagnostic alternative to ERCP. This study was initiated to document the diagnostic and therapeutic capabilities of ERCP, enabling us to compare the two techniques. Results of 567 ERCP procedures in 371 patients were reviewed. Bile duct stones were the most frequent indication for the procedure (66%). Normal duct systems (37%) and common bile duct stones (35%) were the most frequent findings. Stone extraction was performed in 97 patients. In 18 patients minor stones were left behind and in six patients open choledocholithotomy was performed. Procedure related mortality was 0.3% and 0.8% in the diagnostic and therapeutic group respectively. Five patients developed serious pancreatitis, and duodenal perforation complicated two procedures. 56% of the procedures were diagnostic and could probably have been replaced by MRCP if this technique had been available during the study period.

MR cholangiopancreaticography and endoscopic retrograde cholangiopancreaticography in patients with suspected common bile duct stones.

PURPOSE: To prospectively compare MR cholangiopancreaticography (MRCP) vs. endoscopic retrograde pancreaticography (ERCP) in patients with suspected common bile duct (CBD) stone disease. MATERIAL AND METHODS: Fifty consecutive patients with suspected CBD disease underwent MRCP and then ERCP within 12 h of each other. The result of the MRCP was blinded to the reader of the ERCP. The MRCP was done using a superconducting 1.0 T unit with a heavily T2-weighted breath-hold technique. The ERCP was done in the fluoroscopy suite by one of the clinicians and was evaluated by one of the radiologists who had not read the MRCP examinations. RESULTS: There were 28 true-positives, 17 true-negatives, 1 false-positive, and 4 false-negatives. The sensitivity was 87.5% and the specificity 94.4%, respectively. The positive predictive value was 96.6% and the negative predictive value was 81.1%. CONCLUSION: MRCP was shown to be good enough to replace ERCP as a diagnostic method in patients with suspected CBD disease. MRCP is now our modality of choice after ultrasound in the diagnostic evaluation of these patients.

[Magnetic resonance tomography of biliary and pancreatic ducts]. / Magnetisk resonanstomografi av galle- og pancreasgang.

Magnetic resonance imaging of the biliary and pancreatic ducts, MRCP, is a technique developed over the last few years. Using strongly T2-weighted sequences, images of the biliary and pancreatic ducts similar to ERCP can be obtained within one single inhalation. No contrast media or medication is required. In 23 patients 25 MRCP examinations were retrospectively compared with ERCP or PTC. One patient had normal findings; three had gallbladder stones. Eight out of nine common bile-duct stones were shown. MRCP after papillotomy in one patient showed a common bile-duct stone; ERCP seven days later was normal. MRCP correctly showed obstruction and dilatation of the bileducts in ten patients with tumor and in one patient with chronic pancreatitis. Two of these were erroneously interpreted as caused by stone. 21 of 25 MRCPs were consistent with the final diagnosis. We consider MRCP a promising method which may replace diagnostic ERCP in majority of patients. Stones in the gallbladder and bile-ducts can be diagnosed. The method also shows obstructions and other lesions affecting pancreatobiliary ducts.

[Dissolution of gallstones with methyl-tert-butyl ether. An alternative to surgery in high risk patients]. / Oppløsning av galleblaerestein med metyl-tert-butyl-eter. Et alternativ til operasjon hos risikopasienter.

We treated 27 symptomatic patients by dissolving cholesterol gallstones with methyl tert-butyl ether. Three patients were treated twice. Mean age was 70.2 years. Most patients had elevated risk for surgery. A 5 French polyethylene catheter was introduced percutaneously, transhepatic to the gallbladder. The placement of the catheter was successful in 26 of 30 procedures (87%). Cholecystography showed complete dissolution of stones in 22 of 26 patients treated (85%). Mean treatment time was 11.7 h. In four patients the treatment was stopped before dissolution was complete. Side effects were nausea, pain, fever and vasovagal reaction. 15 patients were followed up for a mean of 22.7 months after dissolution. Ten patients had no biliary symptoms, five patients suffered symptomatic relapse and three had asymptomatic recurrence of stones. We conclude that dissolution of gallstones by methyl tert-butyl ether is an adequate alternative to surgery in selected high risk patients.

Double-contrast barium enema versus colonoscopy in the diagnosis of neoplastic disorders: aspects of decision-making in general practice.

A total of 190 patients, referred by general practitioners for a double-contrast barium enema, were subsequently examined with colonoscopy. With colonoscopy and histology as the reference standard, sensitivity, specificity, positive and negative predictive values, and accuracy for the radiological detection of cancer and polyps were calculated. No cancer was overlooked by the radiological examination, but there were four false positives. The overall sensitivity for polyps was 70%, increasing to 81% for polyps > or = 10 mm. The predictive value was 93-97% for the exclusion of polyps. The caecum was reached in 187 patients by double-contrast barium enema (98%) and in 164 patients (86%) by colonoscopy. Lesions in four of 12 patients who had radiological changes were undetected at the first colonoscopy, but a repeat examination showed polyps > or = 10 mm in size. Although colonoscopy is a more sensitive technique for the detection of small mucosal lesions, the general practitioners may, in the vast majority of patients, rely on a negative result for polyps and cancer obtained by the double-contrast barium enema. The latter is linked with a number of false-positive cases, while colonoscopy is associated with technical difficulties; both techniques may lead to repeated examinations, regardless of which was the first choice.

Dissolution of cholesterol gallbladder stones with methyl tert-butyl ether in patients with increased surgical risk.

The safety and efficacy of methyl tert-butyl ether (MTBE) dissolution of cholesterol gallbladder stones were evaluated in 25 patients with increased risk for surgery. Two patients were treated twice. The MTBE was infused and aspirated manually through a percutaneous transhepatic catheter to the gallbladder. The placement of the catheter failed in three patients (11%). In 19 of 24 patients (79%) there was complete dissolution of stones after a mean treatment time of 12.2 h (range, 4.3-19.5 h). In five patients treatment was discontinued before complete dissolution owing to technical problems or side effects. Side effects were nausea, pain, vasovagal reaction, and fever. Fifteen patients were followed up for a mean of 15.7 months after dissolution. Stone recurrence was found in eight patients, five of whom suffered symptomatic relapse. We conclude that dissolution therapy with MTBE is a safe and adequate alternative to surgery in selected high-risk patients.

Perfusion of the human distal colon and rectum evaluated with endoscopic laser Doppler flowmetry. Methodologic aspects.

The aim of this study was to evaluate methodologic aspects of colonoscopic laser Doppler flowmetry. A Periflux PF1d flowmeter, set to 4 kHz/0.2 sec, with an endoscopic probe (PF 109) was used. In 20 patients, with a median age of 70 years and without colonic disease, flux was recorded at 10, 40, 30, 20, and again at 10 cm from the anal verge. A median of three repeated recordings were made at each level, to calculate average flux and spatial variation. Median flux was 158 (150-167) perfusion units, and the coefficient of variation of repeated recordings 0.14 (0.12-0.17). There was no regional variation, and no increase in flux at 10 cm from the start until the end of the procedure. Pressure of the probe against the bowel wall and severe distention significantly reduced the flux. The interference of light from the endoscopic light source on the flux could not be predicted. It differed with different light sources, and also with the length of probe coming out of the colonoscope--that is, the distance from the light to the measurement point. To avoid the problem, the light source should be turned off while recording.

Serum carcinoembryonic antigen in relation to survival, DNA ploidy pattern, and recurrent disease in 406 colorectal carcinoma patients.

Serum carcinoembryonic antigen (CEA) levels in relation to survival, flow cytometric DNA ploidy pattern, Dukes stage, and recurrent disease was prospectively evaluated in 406 patients with colorectal carcinoma. In 246 patients (61%) the carcinomas were DNA aneuploid. Increased preoperative CEA levels (> 5 micrograms/l) were found in 151 of 363 evaluable patients (42%). Dukes stage-B patients with preoperative CEA elevation showed significantly poorer prognosis than those with normal CEA values (p = 0.001). A weak but significant correlation was found between preoperative CEA level and Dukes stage (Kendall's tau = 0.25, p < 0.01). Of 50 evaluable patients with clinical recurrence and postoperative normal or normalized CEA levels, 28 (56%) had a rise in CEA before or at the time of clinical recurrence. The sensitivity of the CEA test for primary and for recurrent disease was not significantly different in the DNA aneuploid and the DNA near-diploid groups.

[Indications for surgery in ulcerative colitis. Some aspects of a hospital case load]. / Indikasjoner for operasjon ved ulcerøs kolitt. Aspekter ved et sykehusmateriale.

From 1.1.1985 to 1.1.1992, 233 patients with ulcerative colitis were treated in the Medical Department, Aker Hospital. 30 patients (12.9%) were referred for surgery. The main indications for surgery were severe colitis and chronic persisting symptoms. The increased risk of developing colorectal carcinoma in cases of long-standing extensive ulcerative colitis is generally accepted. Many of our unoperated patients belong to this risk group. In the present sample the resection rate was lower than recently reported from Sweden and Denmark. Symptomatic patients in the risk group for developing colorectal carcinoma should be offered surgery more liberally, and asymptomatic patients in this group should be offered colonoscopic surveillance.

Changes in the gastrointestinal mucosa after long-distance running.

Two groups of long-distance runners were investigated for the effect of marathon running on the gastrointestinal mucosa. In one group gastric erosions with bleeding were found in five of nine subjects, mostly localized to the corpus region. The relative gastric blood flow measured by endoscopic laser Doppler flowmetry was slightly decreased in the cardia region (from 7.0 to 5.8; p less than 0.05) but unchanged in the other parts of the stomach, including the erosive lesions. In another group (n = 8) all the subjects showed a substantial increase in the urinary excretion of 51Cr-labeled ethylenediaminetetraacetic acid after oral intake, which indicates an increase in the intestinal permeability. There is reason to suggest that long-distance running affects the integrity of the gastric and the intestinal mucosa.