The risk for rectal cancer recurrence and overall mortality is not increased in men previously diagnosed with prostate cancer: a report from the Swedish colorectal cancer registry.

INTRODUCTION: Limited data exists on oncological outcomes following rectal cancer surgery in men who have previously been diagnosed with prostate cancer (PC). This study aimed to assess overall mortality and rectal cancer recurrence in men previously diagnosed with PC who underwent bowel resection. METHODS: Data from the Swedish Colorectal Cancer Registry identified men who had rectal cancer surgery between 2000 and 2016, and the National Prostate Cancer Registry was used to identify those with a prior PC diagnosis. Cox regression analysis with propensity score matching was employed for data analysis. The primary outcome was overall mortality. Secondary outcome was recurrence for rectal cancer. RESULTS: Out of 13,299 men undergoing bowel resection for rectal cancer between 2000 and 2016, 1130 had a history of PC. Overall mortality did not significantly differ between men with and without a prior PC diagnosis. Cox regression analyses with propensity score matching revealed that men with previously diagnosed low- or intermediate-risk (HR, 0.79; 95% CI, 0.70-0.90) and high-risk PC (HR, 0.85; 95% CI, 0.74-0.98) had lower overall mortality after rectal cancer surgery compared with men without a PC. There was no significant difference in rectal cancer recurrence between men with a previous low or intermediate-risk PC (HR, 0.92; 95% CI, 0.74-1.14) or high-risk PC (HR, 0.73; 95% CI, 0.52-1.01) compared with those without PC history. CONCLUSION: Men undergoing rectal cancer surgery with a previous diagnosis of prostate cancer do not experience an increased risk of rectal cancer recurrence or overall mortality compared with men without a previous history of prostate cancer.

Management of acute uncomplicated diverticulitis and adherence to current guidelines-a multicentre SNAPSHOT study.

PURPOSE: To explore whether previous participation in clinical studies increases adherence to management guidelines in acute uncomplicated diverticulitis (AUD). METHODS: This retrospective cohort study was designed to give a SNAPSHOT of the management of AUD at six hospitals, three of which had participated in the AVOD trial comparing antibiotic versus non-antibiotic treatment of AUD. Patients with AUD were included from March 2019 through June 2020 and followed for 90 days. The primary outcome was treatment of AUD categorised by antibiotic treatment and inpatient or outpatient management compared between AVOD and non-AVOD hospitals. Descriptive statistics were compiled, and differences between hospitals were assessed with Pearson's chi-squared test. RESULTS: The cohort included 449 patients with AUD of which 63% were women and the median age was 63 (IQR: 52-73) years. Patient characteristics were comparable across the hospitals. Antibiotics were administered to 84 (19%) patients and 113 (25%) patients were managed as inpatients. Management varied significantly between AVOD and non-AVOD hospitals. The mean proportion of patients treated with antibiotics was 7% at AVOD hospitals compared to 38% at non-AVOD hospitals (p < 0.001). The mean proportion of in-hospital management was 18% at AVOD hospitals versus 38% at non-AVOD hospitals (p < 0.001). CONCLUSION: Most patients with AUD were managed according to current guidelines. However, the management varies between hospitals and previous participation in clinical studies may increase knowledge of and adherence to guidelines.

Parastomal Hernia Prevention Using Funnel-Shaped Intra-Abdominal Mesh Compared to No Mesh: The Chimney Randomized Clinical Trial.

Importance: Prophylactic placement of a mesh has been suggested to prevent parastomal hernia. Evidence to support this practice is contradictory. Objective: To determine whether funnel-shaped permanent synthetic parastomal mesh is effective and safe in parastomal hernia prevention. Design, Setting, and Participants: The Chimney Trial was a randomized single-blinded multicenter trial conducted in 4 hospitals in Finland and 1 in Sweden from February 2019 and September 2021. Of 439 patients with rectal adenocarcinoma undergoing either laparoscopic or robotic-assisted abdominoperineal resection or the Hartmann procedure, 143 were enrolled in the trial, 135 received their allocated intervention, and 121 were analyzed at 12-month follow-up. Data were analyzed from December 2023 to May 2024. Intervention: In the intervention group, a permanent colostomy was created with a funnel-shaped intraperitoneal mesh and compared to a control group with a stoma without the mesh. Main Outcome and Measure: The primary end point was the incidence of computed tomography (CT)-confirmed parastomal hernia 12 months after surgery. Results: There were 68 patients (mean [SD] age, 68.7 [11.6] years; 36 [53% male and 32 [47%] female) who received the intended allocation in the mesh group and 67 (mean [SD] age, 66.4 [11.7] years; 48 [72%] male and 19 [28%] female) who received the intended allocation in the control group. CT scans were available for 58 patients in the mesh group and 59 patients in the control group at the 12-month follow-up. CT scans confirmed parastomal hernia in 6 of 58 patients (10%) in the mesh group compared to 22 of 59 patients (37%) in the control group (difference, 27%; 95% CI, 12-41; P < .001). Clinical parastomal hernia as a secondary outcome was recorded in 1 of 60 patients (2%) in the mesh group compared to 27 of 61 (43%) in the control group (difference, 41%; 95% CI, 29-55; P < .001). The number of patients with Clavien-Dindo class II ileus was 23 (35%) in the mesh group compared to 11 (17%) in the control group (difference, 18%; 95% CI, 3-32; P = .006). Only slight differences between the groups were detected in other stoma-related complications, readmissions, operative time, surgical site infections, reoperations, and quality of life. Conclusions and Relevance: In this study, funnel-shaped parastomal mesh prevented a significant number of parastomal hernias without predisposing patients to mesh- or stoma-related complications during 12-month follow-up. The results of this study suggest the funnel-shaped mesh is a feasible option to prevent parastomal hernia. Trial Registration: ClinicalTrials.gov Identifier: NCT03799939.

Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR).

Objective: The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III). Background: There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable. Methods: Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed. Results: Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45). Conclusions: HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.

Lower need for allogeneic blood transfusion after robotic low anterior resection compared with open low anterior resection: a propensity score-matched analysis.

Robotic low anterior resection (R-LAR) for rectal cancer may decrease estimated blood loss compared with open low anterior resection (O-LAR). The aim of this study was to compare estimated blood loss and blood transfusion within 30 days after O-LAR and R-LAR. This was a retrospective matched cohort study based on prospectively registered data from Västmanland Hospital, Sweden. The first 52 patients operated on using R-LAR for rectal cancer at Västmanland Hospital were propensity score-matched 1:2 with patients who underwent O-LAR for age, sex, ASA (American Society of Anesthesiology physical classification system), and tumor distance from the anal verge. In total, 52 patients in the R-LAR group and 104 patients in the O-LAR group were included. Estimated blood loss was significantly higher in the O-LAR group compared with R-LAR: 582.7 ml (SD ± 489.2) vs. 86.1 ml (SD ± 67.7); p < 0.001. Within 30 days after surgery, 43.3% of patients who received O-LAR and 11.5% who received R-LAR were treated with blood transfusion (p < 0.001). As a secondary post hoc finding, multivariable analysis identified O-LAR and lower pre-operative hemoglobin level as risk factors for the need of blood transfusion within 30 days after surgery. Patients who underwent R-LAR had significantly lower estimated blood loss and a need for peri- and post-operative blood transfusion compared with O-LAR. Open surgery was shown to be associated with an increased need for blood transfusion within 30 days after low anterior resection for rectal cancer.

A Deep Neural Network-Based Decision Support Tool for the Detection of Lymph Node Metastases in Colorectal Cancer Specimens.

The identification of lymph node metastases in colorectal cancer (CRC) specimens is crucial for the planning of postoperative treatment and can be a time-consuming task for pathologists. In this study, we developed a deep neural network (DNN) algorithm for the detection of metastatic CRC in digitized histologic sections of lymph nodes and evaluated its performance as a diagnostic support tool. First, the DNN algorithm was trained using pixel-level annotations of cancerous areas on 758 whole slide images (360 with cancerous areas). The algorithm's performance was evaluated on 74 whole slide images (43 with cancerous areas). Second, the algorithm was evaluated as a decision support tool on 288 whole slide images covering 1517 lymph node sections, randomized in 16 batches. Two senior pathologists (C.K. and C.O.) assessed each batch with and without the help of the algorithm in a 2 × 2 crossover design, with a washout period of 1 month in between. The time needed for the evaluation of each node section was recorded. The DNN algorithm achieved a median pixel-level accuracy of 0.952 on slides with cancerous areas and 0.996 on slides with benign samples. N+ disease (metastases, micrometastases, or tumor deposits) was present in 103 of the 1517 sections. The algorithm highlighted cancerous areas in 102 of these sections, with a sensitivity of 0.990. Assisted by the algorithm, the median time needed for evaluation was significantly shortened for both pathologists (median time for pathologist 1, 26 vs 14 seconds; P < .001; 95% CI, 11.0-12.0; median time for pathologist 2, 25 vs 23 seconds; P < .001; 95% CI, 2.0-4.0). Our DNN showed high accuracy for detecting metastatic CRC in digitized histologic sections of lymph nodes. This decision support tool has the potential to improve the diagnostic workflow by shortening the time needed for the evaluation of lymph nodes in CRC specimens without impairing diagnostic accuracy.

Treatment and survival of patients with metachronous colorectal lung metastases.

INTRODUCTION: The lungs are the second most common site for metachronous metastases in colorectal cancer. No treatment algorithm is established, and the role of adjuvant chemotherapy is unclear. This study aimed to map pulmonary recurrences in a modern multimodal treated population, and to evaluate survival depending on management. METHODS: Retrospective study based on the COLOFOL-trial population of 2442 patients, radically resected for colorectal cancer stage II-III. All recurrences within 5 years were identified and medical records were scrutinized. RESULTS: Of 165 (6.8%) patients developing lung metastases as first recurrence, 89 (54%) were confined to the lungs. Potentially curative treatment was possible in 62 (37%) cases, of which 33 with surgery only and 29 with surgery and chemotherapy combined. The 5-year overall survival (5-year OS) for all lung recurrences was 28%. In patients treated with chemotherapy only the 5-year OS was 7.5%, compared with 55% in patients treated with surgery, and 72% when surgery was combined with chemotherapy. Hazard ratio for mortality was 2.9 (95% confidence interval 1.40-6.10) for chemotherapy only compared to surgery. CONCLUSION: A high proportion of metachronous lung metastases after colorectal surgery were possible to resect, yielding good survival. The combination of surgery and chemotherapy might be advantageous for survival.

Impact of COVID-19 on the incidence of CT-diagnosed appendicitis and its complications in the UK and Sweden.

AIM: To compare the number of appendicitis cases and its complications, during the first months of the COVID-19 pandemic in Sweden and the UK and the corresponding time period in 2019. METHOD: Reports of emergency abdominopelvic CT performed at 56 Swedish hospitals and 38 British hospitals between April and July 2020 and a corresponding control cohort from 2019 were reviewed. Two radiologists and two surgeons blinded to the date of cohorts analyzed all reports for diagnosis of appendicitis, perforation, and abscess. A random selection of cases was chosen for the measurement of inter-rater agreement. RESULT: Both in Sweden (6111) and the UK (5591) fewer, abdominopelvic CT scans were done in 2020 compared to 2019 (6433 and 7223, respectively); p < 0.001. In the UK, the number of appendicitis was 36% lower in April-June 2020 compared to 2019 but not in Sweden. Among the appendicitis cases, there was a higher number of perforations and abscesses in 2020, in Sweden. In the UK, the number of perforations and abscesses were initially lower (April-June 2020) but increased in July 2020. There was a substantial inter-rater agreement for the diagnosis of perforations and abscess formations (K = 0.64 and 0.77). CONCLUSION: In Sweden, the number of appendicitis was not different between 2019 and 2020; however, there was an increase of complications. In the UK, there was a significant decrease of cases in 2020. The prevalence of complications was lower initially but increased in July. These findings suggest variability in delay in diagnosis of appendicitis depending on the country and time frame studied.

Increased accuracy in diagnosing diverticulitis using predictive clinical factors.

Background: The aim of this study was to identify clinical factors leading to increased diagnostic accuracy for acute colonic diverticulitis. Methods: Patients with clinical suspicion of acute colonic diverticulitis verified with computed tomography (CT) from two hospitals in Sweden between 9 January 2017 and 31 October 2017 were prospectively included. Symptoms, comorbidities, and laboratory results were documented. Candidate variables were analyzed using logistic regression, and the final variable set that yielded the most accurate predictions was identified using least absolute shrinkage and selection operator regression and evaluated using the area under the receiver operating characteristic (ROC) curve. Results: In total, 146 patients were included (73% women; median age 68 years; age range, 50-94 years). The clinical diagnostic accuracy was 70.5%. In the multiple logistic regression analysis, gender (female vs male odds ratio [OR]: 4.82; confidence interval [CI], 1.56-14.91), age (OR, 0.92; 95% CI, 0.87-0.98), pain on the lower left side of the abdomen (OR, 15.14; 95% CI, 2.65-86.58), and absence of vomiting (OR, 14.02; 95% CI, 2.90-67.88) were statistically significant and associated with the diagnosis of CT-verified diverticulitis. With seven predictors (age, gender, urinary symptoms, nausea, temperature, C-reactive protein, and pain left lower side), the area under the ROC curve was 0.82, and a formula was developed for calculating a risk score. Conclusion: We present a scoring system using common clinical variables that can be applied to patients with clinical suspicion of colonic diverticulitis to increase the diagnostic accuracy. The developed scoring system is available for free of charge at https://phille-wagner.shinyapps.io/Diverticulitis_risk_model/.

Risk factors for developing anorectal dysfunction after anterior resection.

BACKGROUND: Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR. METHODS: This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996-2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I-III rectal cancer patients had AR whereof 412 were included in this study. RESULTS: Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63-0.90; p < 0.001) and clustering (OR 0.78; CI 0.67-0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08-3.31; p = 0.03), incontinence (OR 2.48; 1.29-4.77; p < 0.01), and urgency (OR 4.61; CI 2.02-10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis. CONCLUSION: The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.

Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction.

INTRODUCTION: This study aimed to determine whether day-case closure of loop ileostomy with discharge within 23 h was both feasible and accepted by patients. MATERIALS AND METHODS: We conducted a prospective pilot study where selected rectal cancer patients with diverting loop ileostomy underwent stoma closure in a 23-h stay setting. Patients were followed up on the third, seventh, and 30th postoperative day and phoned daily during the first week. A comparable group of 30 patients who underwent standard in-hospital stoma closure prior to the start of the study were selected retrospectively as historical controls. RESULTS: In total, 30 patients (median age, 67 years; range, 41-79 years) were included. All patients met discharge criteria and were discharged within 23 h of surgery, except one. In total, seven patients (23%) were admitted. Two of these patients underwent laparotomy because of anastomotic leakage and small bowel obstruction, respectively. The mean total length of stay was 1.7 days. Most patients (87%) were satisfied with the treatment without feeling neglected or anxious and preferred the 23-h stay setting. In the control group, the mean length of stay was 5 days. Seven patients (23%) were readmitted. Two of these patients underwent laparotomy because of small bowel obstruction and abscess, respectively. CONCLUSION: Ileostomy closure in a 23-h stay setting in selected patients with meticulous follow up is feasible and safe with high patient satisfaction. CLINICALTRIALS.GOV NUMBER: (NCT02774447).

Risk factors for small bowel obstruction after open rectal cancer resection.

BACKGROUND: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery. METHODS: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed. RESULTS: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO. CONCLUSIONS: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Chimney Trial: study protocol for a randomized controlled trial.

BACKGROUND: Parastomal hernias (PSHs) are common, troubling the lives of people with permanent colostomy. In previous studies, retromuscular keyhole mesh placement has been the most-used technique for PSH prevention but results have been controversial. Additionally, surgical treatment of PSHs is associated with a high rate of complications and recurrences. Therefore, it is crucial to find the most effective way to prevent PSHs in the first place without an increased risk of complications. Due to a lack of adequate research, there is no clear evidence or recommendations on which mesh or technique is best to prevent PSHs. METHODS/DESIGN: The Chimney Trial is a Nordic, prospective, randomized controlled, multicenter trial designed to compare the feasibility and the potential benefits of specifically designed, intra-abdominal onlay mesh (DynaMesh®-Parastomal, FEG Textiltechnik GmbH, Aachen, Germany) against controls with permanent colostomy without mesh. The primary outcome of the Chimney Trial is the incidence of a PSH detected by a computerized tomography (CT) scan at 12-month follow-up. Secondary outcomes are the rate of clinically detected PSHs, surgical-site infection as defined by the Centers for Disease Control and Prevention (CDC), complications as defined by the Clavien-Dindo classification, the reoperation rate, operative time, length of stay, quality of life as measured by the RAND-36 survey and colostomy impact score, and both direct and indirect costs. For each group, 102 patients were enrolled at attending hospitals and randomized at a ratio of 1:1 by browser-based software to receive a preventive mesh or a conventional colostomy without a mesh. Patients will be followed for 1 month and at 1, 3, and 5 years after the operation for long-term results and complications. DISCUSSION: The Chimney Trial aims to provide level-I evidence on PSH prevention. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03799939. Registered on 10 January 2019.

Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case-control study.

PURPOSE: The aim was to identify patient-, tumor- and treatment-related prognostic factors for five-year survival in rectal cancer patients with synchronous stage IV disease. MATERIAL AND METHODS: This nationwide case-control study was based on the Swedish Colorectal Cancer Registry with supplementary information from medical records and the Swedish Inpatient Registry during the period 2000-2008. All resected rectal cancer patients with synchronous metastases that survived more than five years were included as cases. The control group consisted of corresponding patients who lived less than five years, matched in a 1:2 based on gender, age, resection of the rectal tumor, and the study period. RESULTS: A total of 405 patients were identified; 99 long-term survivors (LTS) and 182 short-term survivors (STS). Patient-related factors of symptoms and comorbidity did not differ between LTS and STS. Among the treatment-related factors, multiple site metastases (p = 0.007), bilobar liver metastasis (p = 0.002), and increasing number of liver metastasis (p < 0.001) were associated with STS. Prognostic treatment-related factors were preoperative radiotherapy (p = 0.001), metastasectomy (p < 0.001), and radical resection of the primary tumor (p = 0.014). In the multivariable analysis, the single most important factor for becoming a LTS was a metastasectomy (hazard ratio: 8.474, 95% confidence interval: 4.098-17.543). CONCLUSIONS: The most important prognostic factor for long-term survival in patients with stage IV rectal cancer was metastasectomy, especially liver surgery. With thorough selection of patients for metastasectomy more patients with metastasized rectal cancer may survive beyond five years.

Anastomotic leakage after anterior resection in patients with rectal cancer previously irradiated for prostate cancer.

INTRODUCTION: There are little data on the post-operative outcome of anterior resection (AR) for rectal cancer in men who had received radiotherapy for prostate cancer previously. The aim of this study was to assess the rate of anastomotic leakage (AL) after AR in these patients. METHODS: All men who underwent bowel resection because of rectal cancer between 2000 and 2016 and had been diagnosed previously with prostate cancer were identified by linking the Swedish Colorectal Cancer Registry with the National Prostate Cancer Register. The medical records of men who underwent AR and had previously received radiotherapy for prostate cancer were reviewed. RESULTS: In total, 13299 men had undergone a bowel resection for rectal cancer, 188 of whom had previously received radiotherapy for prostate cancer. Among those who had received radiation therapy, 59 men (31%) had an AR: 50 men (85%) received a diverting ileostomy, 42 men (71%) had an American Society of Anesthesiologists score of 1-2 and 36 men (61%) had tumour stage 1-2. AL was found in 12/59 men (20%), one of whom had a re-laparotomy. There was no 90-day mortality. CONCLUSIONS: In the combined national population-based registries, a minority of patients with rectal cancer had an AR after previous radiotherapy for prostate cancer. These patients were healthy with early cancer stages and, in this selected group of patients, the AL rate was much lower than that reported previously.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings.

PURPOSE: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. METHODS: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model. RESULTS: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469). CONCLUSIONS: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann's procedure: a report from a national registry.

PURPOSE: To describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann's procedure (HP). METHODS: Data were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007-2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed. RESULTS: Of 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3-4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14-2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08-3.67), T4 tumours (OR, 1.68; 95% CI 1.04-2.69) and female gender (OR, 1.73; 95% CI, 1.15-2.61) as risk factors for intra-abdominal infection. ASA score 3-4 (OR, 1.62; 95% CI, 1.12-2.34), elevated BMI (OR, 1.05; 95% CI, 1.02-1.09) and female gender (OR, 2.06; CI, 1.41-3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP. CONCLUSIONS: Despite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann's procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Low risk of complications in patients with first-time acute uncomplicated diverticulitis.

PURPOSE: First-time acute uncomplicated diverticulitis (AUD) has been considered to have an increased risk of complication, but the level of evidence is low. The aim of the present study was to evaluate the risk of complications in patients with first-time AUD and in patients with a history of diverticulitis. METHODS: This paper is a population-based retrospective study at Västmanland's Hospital, Västerås, Sweden, where all patients were identified with a diagnosis of colonic diverticular disease ICD-10 K57.0-9 from January 2010 to December 2014. The records of all patients were surveyed and patients with a computed tomography (CT)-verified AUD were included. Complications defined as CT-verified abscess, perforation, colonic obstruction, fistula, or sepsis within 1 month from the diagnosis of AUD were registered. RESULTS: Of 809 patients with AUD, 642 (79%) had first-time AUD and 167 (21%) had a previous history of AUD with no differences in demographic or clinical characteristics. In total, 16 (2%) patients developed a complication within 1 month irrespective of whether they had a previous history of diverticulitis (P = 0.345). In the binary logistic regression analysis, first-time diverticulitis was not associated with increased risk of complications (OR 1.58; CI 0.52-4.81). The rate of antibiotic therapy was about 7-10% during the time period and outpatient management increased from 7% in 2010 to 61% in 2014. CONCLUSIONS: The risk for development of complications is low in AUD with no difference between patients with first-time or recurrent diverticulitis. This result strengthens existing evidence on the benign disease course of AUD.

Socioeconomic characteristics and comorbidities of diverticular disease in Sweden 1997-2012.

PURPOSE: This study aimed to evaluate the association of socioeconomic status and comorbidities with uncomplicated and complicated diverticular disease (DD) in Sweden. METHODS: We identified all individuals aged ≥30 years in Sweden diagnosed with DD between 1997 and 2012 using the Swedish National Population and Housing Census and the Hospital Discharge Register. Data were analyzed by multivariable logistic regression, with individual-level characteristics as covariates. RESULTS: A total of 79,481 patients (median age 66 [range 30-86] years) were hospitalized for DD, 15,878 (20%) of whom for complicated DD. Admissions for both uncomplicated and complicated DD were more common in women (p < 0.001). A low education level was identified as a risk factor for uncomplicated (unadjusted hazard ratio [HR] 1.79, 95% confidence interval [CI] 1.75-1.82; adjusted HR 1.22, 95% CI 1.19-1.24) and complicated DD (unadjusted HR 1.84, 95% CI 1.77-1.92; adjusted HR 1.26, 95% CI 1.21-1.32). Patients with the lowest income had a lower risk of hospitalization for uncomplicated (adjusted HR 0.94, 95% CI 0.91-0.96) and complicated DD (adjusted HR 0.87, 95% CI 0.83-0.92) than those with the highest income. The correlation coefficient between income and education was 0.25. Diabetes and cardiovascular disease were identified as protective factors against uncomplicated DD (adjusted HR 0.68, 95% CI 0.66-0.69 and HR 0.79, 95% CI 0.74-0.84, respectively). CONCLUSIONS: Patients with the lowest education level had an increased risk of hospitalization for DD. Further studies are needed to explore the association of diabetes and cardiovascular disease with uncomplicated DD.

Detection of Free Cancer Cells in Pelvic Lavage with Double Immunocytochemistry at Rectal Cancer Surgery.

BACKGROUND/AIM: The aim of the present study was to describe a double immunocytochemical staining method for detecting free cancer cells after rectal cancer surgery and to evaluate their extent and prognostic role. MATERIALS AND METHODS: Immunocytochemistry was performed using antibodies against cytokeratin 20/caudal-typehomeobox transcription factor 2 (CDX2) and mucin glycoprotein-2 (MUC2)/p53 protein. The study included 29 patients with infraperitoneal rectal cancer who underwent bowel resection and four controls. The pelvic lavage was retrieved at the start of laparotomy, after total mesorectal excision and after abdominal lavage with sterile water. RESULTS: Free cancer cells were detected with the double immunocytochemical method in the two controls with carcinomatosis and one control with sigmoidal cancer. None of the patients with rectal tumours had presence of free cancer cells. CONCLUSION: Immunocytochemical analysis of peritoneal lavage was feasible and negative in patients with infraperitoneal rectal cancer. Further studies are encouraged to investigate the clinical relevance in cases with free cancer cells after incomplete total mesorectal excision.