Patterns and resectability of colorectal cancer recurrences: outcome study within the COLOFOL trial.

BACKGROUND: Improvements in surgery, imaging, adjuvant treatment, and management of metastatic disease have led to modification of previous approaches regarding the risk of recurrence and prognosis in colorectal cancer. The aims of this study were to map patterns, risk factors, and the possibility of curative treatment of recurrent colorectal cancer in a multimodal setting. METHODS: This was a cohort study based on the COLOFOL trial population of patients who underwent radical resection of stage II or III colorectal cancer. The medical files of all patients with recurrence within 5 years after resection of the primary tumour were scrutinized. Follow-up time was 5 years after the first recurrence. Primary endpoints were cumulative incidence, site, timing, and risk factors for recurrence, and rate of potentially curative treatment. A secondary endpoint was survival. RESULTS: Of 2442 patients, 471 developed recurrences. The 5-year cumulative incidence was 21.4 (95 per cent c.i. 19.5 to 23.3) per cent. The median time to detection was 1.1 years after surgery and 87.3 per cent were detected within 3 years. Some 98.2 per cent of patients who had potentially curative treatment were assessed by a multidisciplinary tumour board. A total of 47.8 per cent of the recurrences were potentially curatively treated. The 5-year overall survival rate after detection was 32.0 (95 per cent c.i. 27.9 to 36.3) per cent for all patients with recurrence, 58.6 (51.9 to 64.7) per cent in the potentially curatively treated group and 7.7 (4.8 to 11.5) per cent in the palliatively treated group. CONCLUSION: Time to recurrence was similar to previous results, whereas the 21.4 per cent risk of recurrence was somewhat lower. The high proportion of patients who received potentially curative treatment, linked to a 5-year overall survival rate of 58.6 per cent, indicates that it is possible to achieve good results in recurrent colorectal cancer following multidisciplinary assessment.

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction.

AIM: Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population. METHOD: Medical records of patients identified via the Swedish Colorectal Cancer Register 2007-2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates. RESULTS: A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group. CONCLUSION: This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Influence of primary tumour and patient factors on survival in patients undergoing curative resection and treatment for liver metastases from colorectal cancer.

BACKGROUND: Resection of the primary tumour is a prerequisite for cure in patients with colorectal cancer, but hepatic metastasectomy has been used increasingly with curative intent. This national registry study examined prognostic factors for radically treated primary tumours, including the subgroup of patients undergoing liver metastasectomy. METHODS: Patients who had radical resection of primary colorectal cancer in 2009-2013 were identified in a population-based Swedish colorectal registry and cross-checked in a registry of liver tumours. Data on primary tumour and patient characteristics were extracted and prognostic impact was analysed. RESULTS: Radical resection was registered in 20 853 patients; in 38·7 per cent of those registered with liver metastases, surgery or ablation was performed. The age-standardized relative 5-year survival rate after radical resection of colorectal cancer was 80·9 (95 per cent c.i. 80·2 to 81·6) per cent, and the rate after surgery for colorectal liver metastases was 49·6 (46·0 to 53·2) per cent. Multivariable analysis identified lymph node status, multiple sites of metastasis, high ASA grade and postoperative complications after resection of the primary tumour as strong risk factors after primary resection and following subsequent liver resection or ablation. Age, sex and primary tumour location had no prognostic impact on mortality after liver resection. CONCLUSION: Lymph node status and complications have a negative impact on outcome after both primary resection and liver surgery. Older age and female sex were underrepresented in the liver surgical cohort, but these factors did not influence prognosis significantly.

ANTECEDENTES: Para curar el cáncer colorrectal es necesaria la resección del tumor primario, pero cada día es más frecuente la realización de una metastasectomía hepática con intención curativa. Este estudio basado en un registro nacional analizó los factores pronósticos para los tumores primarios tratados con intención curativa, incluido un subgrupo de pacientes a los que se realizó una metastasectomía hepática. MÉTODOS: En el registro poblacional sueco de cáncer colorrectal se identificaron los pacientes a los que se realizó una resección primaria radical entre 2009-2013 y se cotejaron con un registro de tumores hepáticos. Se obtuvieron los datos sobre el tumor primario y las características del paciente, y se analizó su influencia en el pronóstico. RESULTADOS: Se identificaron 20.853 pacientes con resección radical, de los que en un 38,9% se realizó la resección o ablación de metástasis hepáticas. La supervivencia relativa a 5 años, estandarizada por edad, después de la resección radical del cáncer colorrectal y después de la cirugía de las metástasis hepáticas colorrectales fue del 80,6% (i.c. del 95% 79,8-81,3) y del 49,6% (i.c. del 95%: 46,0-53,2), respectivamente. El análisis multivariable identificó la invasión ganglionar, las metástasis en varias localizaciones, una puntuación ASA alta y las complicaciones postoperatorias después de la resección del tumor primario como factores de riesgo tanto de la resección primaria como de la resección o ablación hepática. No tuvieron influencia sobre la mortalidad tras de la resección hepática ni la edad, el sexo o la ubicación del tumor primario. CONCLUSIÓN: El grado de invasión linfática y las complicaciones después de la resección primaria tuvieron un impacto negativo en los resultados tanto de la cirugía primaria, como de la cirugía hepática. Si bien la edad avanzada y el sexo femenino estaban infrarrepresentados en la cohorte de cirugía hepática, estos factores no influyeron significativamente en el pronóstico.

Postoperative complications following colonic resection for cancer are associated with impaired long-term survival.

AIM: Surgery for colorectal cancer is associated with a high incidence of postoperative complications. The aim of this study was to analyse whether postoperative complications following radical resection for colorectal cancer are associated with increased recurrence rate and impaired survival. METHOD: Patients operated for colon cancer between 2007 and 2009 with curative intent were identified through the Swedish Colorectal Cancer Registry. The cohort was divided into three subgroups: patients who developed severe postoperative complications, patients who developed non-severe complications and patients who did not develop any complication (controls). RESULTS: Of 6779 patients included in the study, 640 (9%) developed severe complications, 994 (15%) non-severe complications and 5145 (76%) had no complications. The 5-year overall survival rate was 60.3% in the severe complication group, 64.2% in the non-severe complication group and 72.8% in the control group (P < 0.01). The 3-year disease-free survival rate was 66.8%, 70.9% and 77.8% respectively (P < 0.01). The recurrence rate did not differ between the three groups. In multivariate analysis, both severe and non-severe complications were found to be risk factors for decreased overall survival at 5 years [hazard ratio (HR) 1.38, 95% CI 1.47-1.92, and HR 1.18, 95% CI 1.27-1.60 respectively; P < 0.05) as well as for decreased 3-year disease-free survival (HR 1.37, 95% CI 1.14-1.65, and HR 1.26, 95% CI 1.08-1.48 respectively; P < 0.05). CONCLUSION: Complications after colonic resection for cancer are associated with impaired 5-year overall survival and 3-year disease-free survival and exhibit more severe postoperative complications, mainly via mechanisms other than cancer recurrence.

High Tie or not in Resection for Cancer in the Sigmoid Colon?

BACKGROUND AND AIMS: The optimal extent of mesenteric resection in colon cancer surgery remains elusive. The aim was to assess the impact on perioperative morbidity and oncological outcome depending on the height of central vessel ligation in sigmoid resection for adenocarcinomas. MATERIAL AND METHODS: All cases of stage I-III sigmoid cancers, operated on with locally radical resections (2007-2009), were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature, that is, ligation of the inferior mesenteric artery, ligation of the superior rectal artery, or ligation of the sigmoid branches. RESULTS: In total, 999 cases were identified and possible to categorize. Although higher ligation level yielded a higher number of lymph nodes, 3- or 5-year overall survival, 5-year disease-free survival, or recurrence rate did not differ between the groups (p = 0.79, p = 0.41, p = 0.67, p = 0.51). No differences in survival were detected after multivariate analysis adjusted for age, sex, T-stage, N-stage, American Society of Anesthesiologists classification, and adjuvant therapy. CONCLUSION: This large population-based study showed increased lymph node yield but no survival benefit or any decreased recurrence rate by high tie in resection of sigmoid cancer.

Quality of life and cost effectiveness in a randomized trial of patients with colorectal cancer and peritoneal metastases.

BACKGROUND: The aim was to compare health-related quality-of-life (HRQOL) and cost-effectiveness between cytoreductive surgery with intraperitoneal chemotherapy (CRS + IPC) and systemic chemotherapy for patients with colorectal peritoneal metastases. METHODS: Patients included in the Swedish Peritoneal Trial comparing CRS + IPC and systemic chemotherapy completed the EORTC QLQ-C30 and SF-36 questionnaires at baseline, 2, 4, 6, 12, 18, and 24 months. HRQOL at 24 months was the primary endpoint. EORTC sum score, SF-36 physical and mental component scores at 24 months were calculated and compared for each arm and then referenced against general population values. Two quality-adjusted life-year (QALY) indices were applied (EORTC-8D and SF-6D) and an incremental cost-effectiveness ratio (ICER) per QALY gained was calculated. A projected life-time ICER per QALY gained was calculated using predicted survival according to Swedish population statistics. RESULTS: No statistical differences in HRQOL between the arms were noted at 24 months. Descriptively, survivors in the surgery arm had higher summary scores than the general population at 24 months, whereas survivors in the chemotherapy arm had lower scores. The projected life-time QALY benefit was 3.8 QALYs in favor of the surgery arm (p=0.06) with an ICER per QALY gained at 310,000 SEK (EORTC-8D) or 362,000 SEK (SF-6D) corresponding to 26,700-31,200 GBP. CONCLUSION: The HRQOL in patients with colorectal peritoneal metastases undergoing CRS + IPC appear similar to those receiving systemic chemotherapy. Two-year survivors in the CRS + IPC arm have comparable HRQOL to a general population reference. The treatment is cost-effective according to NICE guidelines.

No benefit of extended mesenteric resection with central vascular ligation in right-sided colon cancer.

AIM: The optimal extent of mesenteric resection in colon cancer surgery is not known. We have previously shown an increased mortality associated with wider mesenteric resection in right hemicolectomy. This study compares the short- and long-term outcome in three variations of right hemicolectomy based on the position of the vascular ligature in the mesentery. METHOD: In all, 2084 cases of cancer in the caecum or ascending colon were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature: central ligation of ileocolic vessels (ICVs) ± right colic vessels (n = 390), central ligation of ICVs + right branch of middle colic vessels (MCVs) (n = 1360) and central ligation of ICVs + central ligation of MCVs (n = 334). RESULTS: Neither 3-year overall survival, 3-year disease-free survival nor local recurrence rate differed between the groups (P = 0.604; P = 0.247; P = 0.237). There was still no difference after multivariate analysis adjusted for age, sex, American Society of Anesthesiologists classification, TNM stage and adjuvant therapy. An increased peri-operative mortality, however, was observed in extended mesenteric resections, increasing from 0.8% in non-extended to 3.6% in more extended resection, P = 0.025. CONCLUSION: The study showed no survival benefit by more extended mesenteric resection, indicating that there is no need to extend the mesenteric resection to involve the MCVs in cancer of the caecum or ascending colon. On the contrary, increased peri-operative mortality by more extensive mesenteric resection was noted suggesting that a more conservative approach may be favourable.

Cytoreductive surgery and intraperitoneal chemotherapy versus systemic chemotherapy for colorectal peritoneal metastases: A randomised trial.

BACKGROUND: First-line treatment of isolated resectable colorectal peritoneal metastases remains unclear. This study (the Swedish peritoneal study) compares cytoreductive surgery and intraperitoneal chemotherapy (surgery arm) with systemic chemotherapy (chemotherapy arm). METHODS: Patients deemed resectable preoperatively were randomised to surgery and intraperitoneal 5-fluorouracil 550 mg/m(2)/d for 6 d with repeated courses every month or to systemic oxaliplatin and 5-fluorouracil regimen every second week. Both treatments continued for 6 months. Primary end-point was overall survival (OS) and secondary end-points were progression-free survival (PFS), and morbidity. RESULTS: The study terminated prematurely when 48 eligible patients (24/arm) were included due to recruitment difficulties. Two-year OS was 54% in the surgery arm and 38% in the chemotherapy arm (p = 0.04). After 5 years, 8 versus 1 patient were alive, respectively (p = 0.02). Median OS was 25 months versus 18 months, respectively, hazard ratio 0.51 (95% confidence interval: 0.27-0.96, p = 0.04). PFS in the surgery arm was 12 months versus 11 months in the chemotherapy arm (p = 0.16) with 17% versus 0% 5-year PFS. Grade III-IV morbidity was seen in 42% and 50% of the patients, respectively. No mortalities. CONCLUSIONS: Cytoreductive surgery with intraperitoneal chemotherapy may be superior to systemic oxaliplatin-based treatment of colorectal cancer with resectable isolated peritoneal metastases.(ClinicalTrials.gov nr:NCT01524094).

Wide excision in right-sided colon cancer is associated with decreased survival.

BACKGROUND AND AIMS: Nodal involvement is the most important prognostic factor in colon cancer. Although theoretically appealing, it is not known if wider mesenteric excision improves the oncological result. The aim of this retrospective study was to investigate whether wider mesenteric excision yields a superior oncological result. MATERIAL AND METHODS: Depending on the resection length, 333 cases of locally radical right-sided hemicolectomies due to adenocarcinoma were compared for perioperative morbidity and mortality, disease-free survival, and long-term survival. RESULTS: Postoperative mortality was significantly higher in the quartile with the longest resections, p = 0.003. In a multivariate analysis adjusted for age, stage, emergency operation, adjuvant chemotherapy, and year of operation, a negative relationship between resection length and 5-year overall survival was noted, p = 0.01. No differences in the causes of death or in the incidence of local or distant recurrences were noted between groups. CONCLUSIONS: Wider excision in right-sided hemicolectomies was not associated with any oncological benefit but an increased postoperative mortality and a decreased 5-year overall survival. These findings may suggest consideration to perform wide mesenteric resections routinely. Further research is warranted to define which patients benefit from wider resections.

Population-based data from the Swedish Colon Cancer Registry.

BACKGROUND: Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer. METHODS: Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon. RESULTS: This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term. CONCLUSION: These population-based data represent good-quality reference points.

Rho kinase regulates induction of T-cell immune dysfunction in abdominal sepsis.

T-cell dysfunction increases susceptibility to infections in patients with sepsis. In the present study, we hypothesized that Rho kinase signaling might regulate induction of T-cell dysfunction in abdominal sepsis. Male C57BL/6 mice were treated with the specific Rho kinase inhibitor Y-27632 (5 mg/kg of body weight) prior to cecal ligation and puncture (CLP). Spleen CD4 T-cell apoptosis, proliferation, and percentage of regulatory T cells (CD4(+) CD25(+) Foxp3(+)) were determined by flow cytometry. Formation of gamma interferon (IFN-γ) and interleukin 4 (IL-4) in the spleen and plasma levels of HMBG1, IL-17, and IL-6 were quantified by use of enzyme-linked immunosorbent assay (ELISA). It was found that CLP evoked apoptosis and decreased proliferation in splenic CD4 T cells. Inhibition of Rho kinase activity decreased apoptosis and enhanced proliferation of CD4 T cells in septic animals. In addition, CLP-evoked induction of regulatory T cells in the spleen was abolished by Rho kinase inhibition. CLP reduced the levels of IFN-γ and IL-4 in the spleen. Pretreatment with Y-27632 inhibited the sepsis-induced decrease in IFN-γ but not IL-4 formation in the spleen. CLP increased plasma levels of high-mobility group box 1 (HMGB1) by 20-fold and IL-6 by 19-fold. Inhibition of Rho kinase decreased this CLP-evoked increase of HMGB1, IL-6, and IL-17 levels in the plasma by more than 60%, suggesting that Rho kinase regulates systemic inflammation in sepsis. Moreover, we observed that pretreatment with Y-27632 abolished CLP-induced bacteremia. Together, our novel findings indicate that Rho kinase is a powerful regulator of T-cell immune dysfunction in abdominal sepsis. Thus, targeting Rho kinase signaling might be a useful strategy to improve T-cell immunity in patients with abdominal sepsis.

Platelet shedding of CD40L is regulated by matrix metalloproteinase-9 in abdominal sepsis.

BACKGROUND AND OBJECTIVES: Platelet-derived CD40L is known to regulate neutrophil recruitment and lung damage in sepsis. However, the mechanism regulating shedding of CD40L from activated platelets is not known. We hypothesized that matrix metalloproteinase (MMP)-9 might cleave surface-expressed CD40L and regulate pulmonary accumulation of neutrophils in sepsis. METHODS: Abdominal sepsis was induced by cecal ligation and puncture (CLP) in wild-type and MMP-9-deficient mice. Edema formation, CXC chemokine levels, myeloperoxidase levels, neutrophils in the lung and plasma levels of CD40L and MMP-9 were quantified. RESULTS: CLP increased plasma levels of MMP-9 but not MMP-2. The CLP-induced decrease in platelet surface CD40L and increase in soluble CD40L levels were significantly attenuated in MMP-9 gene-deficient mice. Moreover, pulmonary myeloperoxidase (MPO) activity and neutrophil infiltration in the alveolar space, as well as edema formation and lung injury, were markedly decreased in septic mice lacking MMP-9. In vitro studies revealed that inhibition of MMP-9 decreased platelet shedding of CD40L. Moreover, recombinant MMP-9 was capable of cleaving surface-expressed CD40L on activated platelets. In human studies, plasma levels of MMP-9 were significantly increased in patients with septic shock as compared with healthy controls, although MMP-9 levels did not correlate with organ injury score. CONCLUSIONS: Our novel data propose a role of MMP-9 in regulating platelet-dependent infiltration of neutrophils and tissue damage in septic lung injury by controlling CD40L shedding from platelets. We conclude that targeting MMP-9 may be a useful strategy to limit acute lung injury in abdominal sepsis.

Collagen levels are normalized after decompression of experimentally obstructed colon.

AIM: Our aim was to define the dynamics in collagen concentrations in the large bowel wall following decompression of experimental obstruction. METHOD: Colonic obstruction was created in 28 male rats by the placement of a silicone ring around the distal colon. The ring was removed after 4 days to mimic endoscopical decompression by stent deployment. Colon circumference and collagen concentration were measured proximal to the obstructed segment immediately and at 3 and 10 days after decompression. The corresponding colonic sites of 23 sham-operated and eight nonoperated control animals were subjected to identical analyses. RESULTS: Four days of obstruction resulted in a more than twofold increase in colonic circumference (20 vs 8 mm), with a concomitant 43% reduction (P = 0.001) in collagen concentration in the bowel wall proximal to the obstruction compared with sham animals. Three days after decompression, collagen concentrations remained reduced (P < 0.05), while there was no significant difference after 10 days with either sham-operated or nonoperated controls. Colonic circumference of the obstructed colon remained slightly distended (11 mm) on day 10 and tended to correlate (r(S) = 0.51, P = 0.053) with total matrix metalloproteinase activity. CONCLUSION: The marked reduction in collagen concentration in an experimentally obstructed colon is normalized 10 days after decompression. These findings may have clinical implications for the timing of surgical resection.

Standard protocol for assessment of colon cancer improves the quality of pathology.

AIM: Tumour stage is the most important prognostic factor in colon cancer. The aim of this study was to examine the impact on the quality of pathology of the use of a standardized pathological and anatomical (PAD) protocol. METHOD: A standardized PAD protocol for colorectal cancer was developed and all patients subjected to colon resection due to adenocarcinomas between 2004 and 2006 were analysed regarding lymph node status, circumferential resection margin (CRM), and intravascular and perineural growth. Moreover, usage of the PAD protocol and whether a pathologist or biomedicine analytical technician (BMA) performed the lymph node dissection was noted, and also whether the surgical procedure was elective or acute. RESULTS: During the study period 302 colon resections were carried out. The standard protocol was employed in 68% of the cases, varying from 0% to 100% between pathologists. The median number of investigated lymph nodes was 16 ± 11. When the lymph node dissection was performed by a BMA, significantly more lymph nodes were examined; 22 ± 15 and 14 ± 9, respectively (P < 0.01). There was a positive correlation between application of the standard protocol and the number of analysed lymph nodes (< 0.05). Comments on CRM, perineural growth and intravascular growth were also significantly more frequent when the protocol was used. Emergency surgery did not influence the handling of the specimens. CONCLUSION: Minor changes in procedure in terms of a standard protocol for pathology and specimen dissection by BMAs, leading to an increased quality of the PAD-report, may also improve the long-term outcome for patients.

Impact of MDCT with intravenous contrast on the survival in patients with acute superior mesenteric artery occlusion.

Acute thromboembolic occlusion in the superior mesenteric artery (SMA) is a condition with high mortality and morbidity. Multi-detector computerised tomography with intravenous contrast enhancement (MDCTiv) may improve diagnostic accuracy and survival. Patients with acute SMA occlusion were identified between 2004 and 2008 at Malmö University Hospital, Sweden. Medical records were analysed. Each MDCTiv was re-evaluated. A total of 67 patients were identified with SMA occlusion, of which 36 were examined with MDCTiv and ten with plain MDCT without intravenous contrast. In all, 24 (67%) of the 36 patients were correctly diagnosed by MDCTiv at first evaluation. Clinical suspicion of intestinal ischemia followed by a distinct inquiry for intestinal ischemia was associated with trend for a higher rate of correct radiological diagnosis, 18 of 23 (78%), at first evaluation (0.06) but without affecting in-hospital survival (p = 0.27). At re-evaluation, SMA occlusion was found in all cases with MDCTiv, whereas intestinal findings were present in half. In-hospital mortality rate was 42% for patients who underwent MDCTiv, which was significantly lower compared to 90% for the ten patients examined with plain MDCT (p = 0.007) and 71% for patients not examined with MDCTiv or plain MDCT (p = 0.031). Patients that underwent plain MDCT had higher levels of creatinine compared to those examined with MDCTiv (p = 0.005). Patients who underwent intestinal revascularisation, endovascular or open, had higher survival rate (p = 0.001). Examination with MDCTiv in patients with acute SMA occlusion was associated with survival benefit. Hence, MDCTiv seems to be the method of choice in the workup phase. Radiologists should routinely describe the mesenteric vessels in patients with acute abdomen even when the diagnosis is not asked for. Patients with high creatinine levels are at risk to be examined without intravenous contrast, and survival in these patients is poor.

Abdominal plain film findings in acute ischemic bowel disease differ with age.

PURPOSE: To evaluate the use and findings of abdominal plain film in acute ischemic bowel disease (AIBD) in different age subsets, and to correlate the clinical findings. MATERIAL AND METHODS: Eighty-nine radiographically examined patients with AIBD at Malmö University Hospital, Sweden between 1987 and 1996. RESULTS: In 89%, the plain film displayed pathologic signs. Bowel dilatation was more common in the elderly. Of 68 patients aged > or = 71 years, 19 (28%) had colon gas/fluid levels with/without colon dilatation, and of 19 patients > 84 years 16 (84%) had small-bowel dilatation. Of 20 patients aged < 71 years, 1 (5%) had colon gas/fluid levels with/without colon dilatation, and 11 (55%) small-bowel dilatation (P < 0.05; P < 0.05). Gasless abdomen was more common in the younger age group, noted in 5 of 20 (25%) patients aged < 71 years, compared to 2 of 68 (3%) patients aged > or = 71 years (P = 0.001). Of the patients with diarrhea, 13 of 33 (40%) had colon gas/fluid levels with/without colon dilatation compared to 2 of 29 (7%) without (P = 0.003). In the elderly (> or = 71 years), 48 of 53 (91%) patients with bowel dilatation on plain film died, compared to 11 out of 16 (69%) without this finding (P < 0.05). CONCLUSION: Abdominal plain film findings differed with age. Bowel dilatation was more frequent in the elderly with AIBD, whereas gasless abdomen was more common in younger patients. The radiographic findings were associated with clinical symptoms and mortality.