Survival after elective surgery for colonic cancer in Denmark.

AIM: Total mesorectal excision (TME) has been shown to improve the outcome for patients with rectal cancer. In contrast, there are fewer data on complete mesocolic excision (CME) for colonic cancer. METHOD: Data from the National Colorectal Cancer Database were analysed. This includes about 95% of all patients with colorectal cancer in Denmark. Only patients having elective surgery for colonic cancer in the period 2001-2008 were included. Overall and relative survival analyses were carried out. The study period was divided into the periods 2001-2004 and 2005-2008. RESULTS: 9149 patients were included for the final analysis. The overall 5-year survival rates were 0.65 in 2001-2004 and 0.66 in 2005-2008. The relative 5-year survival rates were also within 1% of each other. None of these comparisons was statistically significant. CONCLUSION: Survival following elective colon cancer surgery has been almost unchanged since 2001.

[Perioperative administration of recombinant human erythropoietin in colorectal cancer surgery. A prospective, randomized, double-blind placebo controlled study]. / Perioperativ administration af rekombinant human erytropoietin ved kirurgi for kolorektal cancer. Et prospektivt, randomiseret, dobbeltblindet placebokontrolleret studium.

One hundred patients scheduled for elective colo-rectal cancer surgery, and with a preoperative haemoglobin level < or = 8.5 mmol/l were included. Eighty-one patients could be evaluated. Thirty-eight patients received r-HuEPO in a dose of 300 IU/kg body weight on day four before surgery and 150 IU/kg, daily, for the following seven days, and 43 patients received placebo. In addition, all patients received daily doses of 200 mg iron, orally, for four days before surgery. On the day of surgery and until discharge the haemoglobin concentration was significantly higher in the erythropoietin group compared to the placebo group. The number of blood transfusions given was significantly lower in the erythropoietin group with a mean of 0.3 units per patient (0-6) compared to 1.6 units (0-9) in the control group (p < 0.05). The clinical implications of these findings has yet to be assessed.

Bile reflux into the esophagus. Bilitec 2000 measurements in normal subjects and in patients after Nissen fundoplication.

BACKGROUND: Bilitec 2000 is a new spectrophotometric system that can detect bilirubin within the esophagus. The aim of this study was to test this new system in vitro and in vivo with special attention to patients operated on laparoscopically for gastroesophageal reflux with Nissen fundoplication. METHODS: In vitro studies of gallbladder bile dilution curves at different pHs were performed with a combined pH and Bilitec probe and by investigation of the drift of the Bilitec system. In vivo studies were performed in 34 normal individuals and 12 patients operated on with a laparoscopic Nissen fundoplication. Intra/intervariations were evaluated in normal individuals. RESULTS: The Bilitec system was able to detect changes in absorbance value within the range 0.14-0.6. Absorbance values were about 30% lower in an acid environment. The percentage of the total time with bile reflux was a median (range) of 3.9 (0-49.6) in normal individuals, with an intravariation within the intervariation, and 8.7 (0-36.6) in patients after a Nissen fundoplication. These values did not differ significantly. Eighty-two per cent of the normal subjects had some degree of bile reflux, if an absorbance value > or = 0.14 was accepted as the threshold value for the presence of bile reflux. CONCLUSIONS: Bile reflux in normal individuals is frequent and not different from that in patients after a Nissen fundoplication. Surprisingly, the latter had bile reflux but no or minimal acid reflux. Factors other than bilirubin may interfere with the measurements.

Recombinant human erythropoietin and hemoglobin concentration at operation and during the postoperative period: reduced need for blood transfusions in patients undergoing colorectal surgery--prospective double-blind placebo-controlled study.

In a double-blind placebo-controlled study we investigated the effect of recombinant human erythropoietin (r-HuEPO), on the perioperative hemoglobin concentration and the use of blood transfusions in patients undergoing elective colorectal surgery with a preoperative hemoglobin level

Physicians' abdominal auscultation. A multi-rater agreement study.

BACKGROUND: Abdominal auscultation has an important position in the physical examination of the abdomen. Little is known about rater agreement. The aim of this study was to describe rater agreement and thus, indirectly, the value of the examination. METHODS: In a semi-virtual setup 12 recordings of the intestinal sounds from 8 patients with acute abdominal pain and 4 healthy volunteers were presented to 100 physicians. The physicians were asked to characterize the intestinal sounds as normal or pathologic. Fisher's exact test was used for comparison between groups of physicians. RESULTS: Overall, 72% of the answers with regard to healthy volunteers concluded that the sounds were normal (equalling agreement), whereas 64% of answers with regard to intestinal obstruction concluded that the sounds were pathologic (but agreement was higher due to agreement on wrong diagnosis in one case). Bowel sounds from colonic obstruction were diagnosed as pathologic in 94 of 100 answers. In peritonitis disagreement dominated. Specialists in gastrointestinal medicine diagnosed bowel obstruction significantly more poorly than non-specialists in gastrointestinal surgery (P < 0.05). CONCLUSION: Rater agreement in normal subjects and in patients with intestinal obstruction was acceptable for a clinical examination. Abdominal auscultation is a helpful clinical examination in patients with acute abdominal pain.

[Effect of early postoperative enteral nutrition on postoperative infections]. / Virkningen af tidlig postoperativ enteral ernaering på postoperative infektiøse komplikationer.

We undertook this study to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. In a randomized double blind prospective trial 30 patients received Nutridrink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml nutrition/placebo, 60 ml/h. On the first postoperative day the patients received median 1000 ml nutrition/placebo, second day median 1200 ml nutrition, 1400 ml placebo, third postoperative day median 1000 ml nutrition, 1150 ml placebo and 4th postoperative day median 1000 ml nutrition, 800 ml placebo. All patients were followed for 30 days by the same investigator. The two groups were not different with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, 2/30 compared to 14/30 in the placebo group (p = 0.0009). We conclude that early enteral nutrition given to patients after major abdominal surgery is followed by a major reduction in infectious complications.

Haemostatic aspects of recombinant human erythropoietin in colorectal surgery.

OBJECTIVE: To find out whether recombinant human erythropoietin (r-HuEPO) given perioperatively has any effect on haemostatic activity in patients undergoing elective colorectal resection. DESIGN: A placebo-controlled double-blind study. SETTING: Odense university hospital, Denmark. SUBJECTS: 24 patients undergoing elective colorectal resection, 13 of whom were given r-HuEPO (Eprex) and 11 placebo. MAIN OUTCOME MEASURES: Concentrations of haemoglobin, tissue-type plasminogen activator and plasminogen activator inhibitor-1; activated partial thromboplastin time; prothrombin time; platelet and reticulocyte counts; blood loss; and transfusions. RESULTS: There was no significant change in fibrinolytic activity, prothrombin time, or activated prothrombin time in the treatment group. Platelet counts differed slightly but not significantly, being higher in the r-HuEPO group. There was a significant increase in reticulocyte counts in the r-HuEPO group. CONCLUSION: R-HuEPO given perioperatively significantly increased erythropoiesis in patients undergoing elective colorectal operations but had no influence on haemostatic activity.

Glucagon-like peptide-1 7-36 amide and peptide YY have additive inhibitory effect on gastric acid secretion in man.

BACKGROUND: Glucagon-like peptide-1 7-36 amide (GLP-1) and peptide YY (PYY) are colocalized in the L-cell of the ileal mucosa, and both peptides may function as enterogastrone hormones. However, it is not known whether they interact with regard to the effect on acid secretion. METHODS: The effect of intravenous infusion of GLP-1 and PYY, either alone or in combination, on pentagastrin-induced acid secretion in eight healthy volunteers was examined. The peptides were infused at two different rates: 0.25 pmol/kg/min (low rate) and 0.5 pmol/kg/min (high rate). RESULTS: Given alone, GLP-1 and PYY inhibited acid secretion by 26 +/- 5% and 18 +/- 5% (low rate) and 45 +/- 8% and 38 +/- 7% (high rate), respectively. Combined infusion resulted in an inhibition of 32 +/- 5% (low rate) and 62 +/- 7% (high rate). Both infusion rates resulted in GLP-1 and PYY plasma concentrations below or similar to postprandial levels. CONCLUSION: The present study suggests that the interaction between GLP-1 and PYY in man is of the additive type. The results indicate that GLP-1 and PYY have an important role in the physiologic control of gastric acid secretion.

Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers. Randomized double-blind placebo-controlled multicentre study.

BACKGROUND: Haemostasis is highly pH-dependent and severely impaired at low pH. However, there is no clear evidence that acid-suppressing drugs have beneficial effects in peptic ulcer haemorrhage. Endoscopic haemostatic treatment provides important reduction in morbidity and may be more efficient when a neutral intragastric pH is maintained. METHODS: We conducted a double-blind, placebo-controlled multicentre study of intravenous infusion of omeprazole (80 mg as bolus, followed by 8 mg/h) or placebo for 72 h. All patients received 20 mg omeprazole orally from day 3 until follow-up on day 21. Only patients with ulcer haemorrhage, endoscoped within 12 h after admission, and with a history or signs of circulatory failure and spurting bleeding, oozing bleeding, visible vessel, or clot, were included. Endoscopic intervention was aimed at when spurting bleeding, oozing bleeding, or a visible vessel was observed. The primary efficacy measure was the worst ranking on an overall outcome scale (5 = death, 4 = surgery, 3 = additional endoscopic treatment, 2 = more than 3 units of blood, and 1 = no more than 3 units of blood transfused). Base-line prognostic factors of treatment success by day 3 and of other binary outcomes were considered in a logistic regression model. RESULTS: Two hundred and seventy-four patients were randomly assigned to omeprazole (134 patients) or placebo (140 patients). The number of patients included in the 'intention-to-treat' analysis was 130 in the omeprazole group and 135 in the placebo group. The primary variable, the overall outcome at 72 h, showed a difference (P = 0.004) between the two treatments in favour of omeprazole. Treatment success by 72 h defined as no death, no operation, or no additional endoscopic treatment was 91.0% in the omeprazole group and 79.7% in the placebo group (therapeutic gain, 11.3 percentage units; 95% confidence interval, 2.3 to 20.4 percentage units). Significant differences in favour of omeprazole were also found for secondary variables such as number of blood transfusions, duration and degree of bleeding, and the need for surgery and additional endoscopic treatments on day 3 and day 21. However, the numbers of deaths by day 3, 21, or 35 were very similar. CONCLUSIONS: We found a beneficial effect of intravenous omeprazole in severe ulcer haemorrhage, with a reduction in the number of operations, in endoscopic treatments, and in the duration and severity of bleeding.

Influence of postoperative enteral nutrition on postsurgical infections.

BACKGROUND: This study was undertaken to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. METHODS: In a randomised double blind prospective trial 30 patients received Nutri-drink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml of either nutrition or placebo, 60 ml per hour. On the first postoperative day the patients received either 1000 ml (median) of nutrition or placebo, on day 2 1200 ml (median) nutrition, 1400 ml placebo, on day 3 1000 ml (median) nutrition, 1150 ml placebo, and on day 4 1000 ml (median) nutrition, 800 ml placebo. All patients were followed up for 30 days by the same investigator. RESULTS: The two groups were similar with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, two of 30 compared with 14 of 30 in the placebo group (p = 0.0009). CONCLUSION: Early enteral nutrition given to patients after major abdominal surgery results in an important reduction in infectious complications.

Fibrin and fibrinogen degradation products in plasma of patients with colorectal adenocarcinoma.

PURPOSE: The aim of the present study was to correlate the preoperative plasma levels of TDP in patients with colorectal cancer to tumor stage, metastasis, and postoperative thromboembolic complications. METHODS: Ninety-one patients with colorectal cancer, 20 patients with colorectal adenoma, and 71 patients without neoplastic lesions in the colon or rectum were included in this prospective study. Before surgery, total fibrin and fibrinogen degradation products (TDP) were measured in plasma of all patients with a specific enzyme-linked immunosorbent assay test. Phlebography was performed postoperatively in 82 of 91 patients with colorectal cancer. RESULTS: Median TDP in plasma of patients with colorectal cancer (805 (range, 339-5,024) ng fibrinogen equivalents (ngFE)) was significantly higher than TDP in patients with colorectal adenoma (591 (range, 417-1386) ngFE/ml) and TDP in patients without neoplastic lesions in the colon (632.8 (range, 180-2622) ngFE/ml; P < or = 0.003). In patients with colorectal cancer and liver metastasis, TDP in plasma (1085.5 (range, 468-5024) ngFE/ml) was significantly higher than in patients with localized tumor growth (753 (range, (339-2,780) ngFE/ml; P < or = 0.02). Twenty of 82 patients (24 percent) with cancer developed thromboembolic complications. TDP was preoperatively significantly higher in this group of patients (1,101 (range, 468-2,167) ngFE/ml) compared with patients without thromboembolic complications (753 (range, 339-5024) ngFE/ml; P < or = 0.04). CONCLUSION: Preoperative plasma levels of TDP were elevated in patients with colorectal cancer, especially in patients with liver metastasis and in patients developing postoperative deep venous thrombosis.

Glucocorticoids inhibit the synthesis rate of type III collagen, but do not affect the hepatic clearance of its aminoterminal propeptide (PIIINP).

The aminoterminal propeptide of type III procollagen (PIIINP) is a marker of type III collagen metabolism. The serum concentration of PIIINP is increased during inflammation, probably reflecting stimulated biosynthesis of type III collagen. Serum PIIINP decreases during glucocorticoid treatment. This has been interpreted as an inhibited biosynthesis of type III collagen. However, circulating PIIINP is extracted by the liver, and the decrease in serum PIIINP may also be caused by an increased hepatic elimination. In the present study we investigated the influence of intravenous methylprednisolone on the serum PIIINP level in pigs combined with a simultaneous determination of the hepatic extraction of PIIINP. The serum level of PIIINP decreased by approximately 30% within 2 h following glucocorticoid injection (p < 0.01). The initial hepatic extraction ratio of PIIINP was 0.15 (range 0.05-0.33) and neither changed after administration of methylprednisolone nor differ from that of the controls. Injection of methylprednisolone did not influence the gel filtration profile. The results of this study confirm the previous finding of serum PIIINP being decreased following glucocorticoid administration, but disprove the hypothesis that alterations in the liver extraction of PIIINP explain the decrease.

[Gastroesophageal reflux]. / Gastroøsofageal refluks.

Gastro-oesophageal reflux is a common disorder. About 50% of patients with reflux disease have oesophagitis, a condition which is diagnosed in approximately 20% of all patients referred for gastroscopy. Effective drug regimens combined with life-style modifications can keep the majority of patients free of symptoms. Relapses are frequent and prolonged or life-long maintenance therapy is often required. Complications include stricture formation and development of Barrett's epithelium, a premalignant condition. At present surgery is reserved for patients who do not respond to medical treatment and patients who do not wish to take life-long medical therapy, and should be considered for patients with complications of reflux disease. The operation may be carried out laparoscopically.

Effect of omeprazole and sucralfate on prepyloric gastric ulcer. A double blind comparative trial and one year follow up.

This study compared healing rates, relief of symptoms, frequency of adverse events, and proportion of patients in remission after one year follow up in 104 patients with active prepyloric ulcer during treatment with 40 mg omeprazole once daily or 2 g sucralfate twice daily, using a randomised double blind controlled trial. Healing rates after two, four, and six weeks were (omeprazole/sucralfate) 49%/23%; 83%/59%; 90%/70% respectively. After two weeks, omeprazole was more efficient than sucralfate in relief of daytime and nocturnal epigastric pain, nausea, and heartburn. The proportion of patients in remission after one year follow up was significantly higher in the omeprazole group (p < 0.01). Of the healed patients ulcers recurred in 36% in the omeprazole group and in 46% in the sucralfate group. It is concluded that the ulcer healing rate was higher and symptom relief was more pronounced in the omeprazole group compared with the sucralfate group, and that more patients were still in remission after a one year follow up period.

Hepatic extraction of the aminoterminal propeptide of type III procollagen before and after bile duct ligation in pigs.

The aminoterminal propeptide of type III procollagen is extracted from the circulation by the liver, and PIIINP is found in bile. This study was performed in order to investigate whether biliary excretion contributes substantially to the hepatic extraction of circulating PIIINP. Hepatic extraction before and during a 4-h period after ligation of the common bile duct was assessed from serum PIIINP concentrations in a systemic artery, the portal vein and a hepatic vein of seven healthy anaesthetized pigs. Seven sham-operated anaesthetized pigs served as controls. Ligation of the bile duct did not cause a decrease in the hepatic extraction ratio of circulating PIIINP. The PIIINP serum levels of the cholestatic pigs and of the controls were similar throughout the investigation period. The PIIINP concentrations in bile were only 10% of the corresponding serum values. Gel filtration of sera showed that the lower PIIINP concentration in the hepatic vein, as compared to the artery and the portal vein was due to a selective decrease in the concentration of the intact propeptide. The study shows that biliary excretion does not contribute significantly to the hepatic extraction of circulating PIIINP in the normal liver. Furthermore, the hepatic extraction of circulating PIIINP preferentially affects the intact propeptide, rather than the somewhat larger PIIINP related molecule in serum.

[Extravasation of cytostatics. Example of a severe complication from the use of long-term central venous catheters]. / Ekstravasation af cytostatika. Eksempel på en alvorlig komplikation ved brug af centrale venøse langtidskatetre.

Completely implantable ports have become increasingly popular for venous access in the treatment of cancer. An uncommon but very serious complication is reported here: extravasation of a cytostatic agent secondary to a damaged Port-a-Cath catheter. Guidelines to be observed in implantation are recommended.