Centralizing a national pancreatoduodenectomy service: striking the right balance.

BACKGROUND: Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher-volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume-outcome analysis of a complete national cohort in a health system with long-standing centralization. METHODS: Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high-volume (40 or more procedures/year) or medium-low-volume). RESULTS: Some 394 procedures were performed (201 in high-volume and 193 in medium-low-volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure-to-rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high-volume centre, medium-low-volume units had similar overall complication rates, lower 90-day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure-to-rescue rate. CONCLUSION: Centralization beyond medium volume will probably not improve on 90-day mortality or failure-to-rescue rates after pancreatoduodenectomy.

ANTECEDENTES: Actualmente se aboga por la centralización de la cirugía pancreática debido a los mejores resultados obtenidos en los centros de mayor volumen. Por el contrario, la preocupación de las organizaciones y de los pacientes está en línea con la sobriedad en la centralización. Todavía no se ha alcanzado un consenso en el equilibrio óptimo. Este estudio observacional presenta un análisis de volumen-resultado de una cohorte nacional completa en un sistema de salud con largo tiempo de centralización. MÉTODOS: Se identificaron los datos de todas las duodenopancreatectomías realizadas en Noruega en 2015 y 2016 a través de un registro nacional de calidad y se completaron a través de los datos electrónicos de los pacientes. Los hospitales fueron dicotomizados (volumen alto (≥ 40 procedimientos/año) o volumen medio/bajo)) RESULTADOS: Se realizaron 394 procedimientos (201 versus 193 en unidades de volumen alto versus volumen medio/bajo). Un total de 125 pacientes (31,7%) presentaron complicaciones postoperatorias mayores. Se diagnosticó una fístula pancreática postoperatoria clínicamente relevante en 66 pacientes (16,8%). En total, 17 pacientes (4,3%) fallecieron dentro de los 90 días, y la tasa de fracaso de rescate fue de 17 de 125 (13,6%) pacientes. En el análisis multivariable de comparación con el centro de volumen alto, las unidades de volumen medio/bajo presentaron tasas de complicaciones generales iguales, menor mortalidad a los 90 días (razón de oportunidades, odds ratio, OR 0,2, i.c. del 95% 0,1-0,8) y sin tendencia a una mayor tasa de fracaso de rescate. CONCLUSIÓN: La centralización más allá del volumen medio probablemente no mejore la mortalidad a los 90 días o las tasas de fracaso de rescate después de la duodenopancreatectomía.

Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation.

BACKGROUND: Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed. METHODS: Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's α values, both with 95 per cent confidence intervals. RESULTS: A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46·8, 61·1 and 82·8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's α 0·31, 95 per cent c.i. 0·16 to 0·45). There was a high level of agreement in treatment allocation where resectability assessments were concordant. CONCLUSION: Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.

Health-Related Quality of Life, Cachexia and Overall Survival After Major Upper Abdominal Surgery: A Prospective Cohort Study.

BACKGROUND AND AIMS: Major upper abdominal surgery is often associated with reduced health-related quality of life and reduced survival. Patients with upper abdominal malignancies often suffer from cachexia, represented by preoperative weight loss and sarcopenia (low skeletal muscle mass) and this might affect both health-related quality of life and survival. We aimed to investigate how health-related quality of life is affected by cachexia and how health-related quality of life relates to long-term survival after major upper abdominal surgery. MATERIALS AND METHODS: From 2001 to 2006, 447 patients were included in a Norwegian multicenter randomized controlled trial in major upper abdominal surgery. In this study, six years later, these patients were analyzed as a single prospective cohort and survival data were retrieved from the National Population Registry. Cachexia was derived from patient-reported preoperative weight loss and sarcopenia as assessed from computed tomography images taken within three months preoperatively. In the original trial, self-reported health-related quality of life was assessed preoperatively at trial enrollment and eight weeks postoperatively with the health-related quality of life questionnaire Short Form 36. RESULTS: A majority of the patients experienced improved mental health-related quality of life and, to a lesser extent, deteriorated physical health-related quality of life following surgery. There was a significant association between preoperative weight loss and reduced physical health-related quality of life. No association between sarcopenia and health-related quality of life was observed. Overall survival was significantly associated with physical health-related quality of life both pre- and postoperatively, and with postoperative mental health-related quality of life. The association between health-related quality of life and survival was particularly strong for postoperative physical health-related quality of life. CONCLUSION: Postoperative physical health-related quality of life strongly correlates with overall survival after major upper abdominal surgery.

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications.

BACKGROUND: Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU. MATERIALS AND METHODS: A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI). RESULTS: A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1-168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81-8.65), active cancer (HR 3.49, 95 % CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99-2.73), pulmonary disease (HR 2.06, 95 % CI 1.14-3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure. CONCLUSION: The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

Epidemiology and classification of gastroenteropancreatic neuroendocrine neoplasms using current coding criteria.

BACKGROUND: The lack of uniform criteria for coding of gastroenteropancreatic neuroendocrine neoplasia (GEP-NEN) has hampered previous epidemiological studies. The epidemiology of GEP-NEN was investigated in this study using currently available criteria. METHODS: All patients diagnosed with GEP-NEN between January 2003 and December 2013 in a well defined Norwegian population of approximately 350 000 people were included. Age- and sex-adjusted incidence rates were calculated. The current 2010 World Health Organization criteria, European Neuroendocrine Tumour Society classification and International Union Against Cancer (UICC) classification were used. RESULTS: A total of 204 patients (114 male, 55.9 per cent) were identified. The median age at diagnosis was 61 (range 10-94) years. The annual overall crude incidence was 5.83 per 100,000 inhabitants, with an increasing trend (P = 0.033). The most frequent location was small intestine (60 patients, 29.4 per cent) followed by appendix (48 patients, 23.5 per cent) and pancreas (33 patients, 16.2 per cent). Grade 1 tumours were more common in gastrointestinal (100 patients, 58.5 per cent) than in pancreatic (9 patients, 27 per cent) NEN. According to the UICC classification, 77 patients (37.7 per cent) had stage I, 17 patients (8.3 per cent) stage II, 37 patients (18.1 per cent) stage III and 70 patients (34.3 per cent) had stage IV disease. No patient with stage I disease had grade 3 tumours; advanced tumour grade increased with stage. CONCLUSION: A high crude incidence of GEP-NEN, at 5.83 per 100,000 inhabitants, was noted together with a significant increasing trend over time.

Risk factors, complications and survival after upper abdominal surgery: a prospective cohort study.

BACKGROUND: Preoperative weight loss and abnormal serum-albumin have traditionally been associated with reduced survival. More recently, a correlation between postoperative complications and reduced long-term survival has been reported and the significance of the relative proportion of skeletal muscle, visceral and subcutaneous adipose tissue has been examined with conflicting results. We investigated how preoperative body composition and major non-fatal complications related to overall survival and compared this to established predictors in a large cohort undergoing upper abdominal surgery. METHODS: From 2001 to 2006, 447 patients were included in a Norwegian multicenter randomized controlled trial in major upper abdominal surgery. Patients were now, six years later, analyzed as a single prospective cohort and overall survival was retrieved from the National Population Registry. Body composition indices were calculated from CT images taken within three months preoperatively. RESULTS: Preoperative serum-albumin <35 g/l (HR = 1.52, p = 0 .014) and weight loss >5 % (HR = 1.38, p = 0.023) were independently associated with reduced survival. There was no association between any of the preoperative body composition indices and reduced survival. Major postoperative complications were independently associated with reduced survival but only as long as patients who died within 90 days were included in the analysis. CONCLUSIONS: Our study has confirmed the robust significance of the traditional indicators, preoperative serum-albumin and weight loss. The body composition indices did not prove beneficial as global indicators of poor prognosis in upper abdominal surgery. We found no association between non-fatal postoperative complications and long-term survival.

Long-Term Follow-Up and Survivorship After Completing Systematic Surveillance in Stage I-III Colorectal Cancer: Who Is Still at Risk?

PURPOSE: In patients with a high life expectancy at the time of surgery for colorectal cancer (CRC), the long-term outcome may be influenced by factors other than their cancer. We aimed to investigate the long-term outcome and cause of death beyond a 5-year surveillance programme. METHODS: We evaluated the overall survival (OS) and cancer-specific survival (CSS) of a population-based cohort of stage I-III CRC patients <75 years old who completed a systematic surveillance programme. RESULTS: In total, 161 patients <75 years old, 111 (69 %) of whom were node negative (pN0), were included. The median follow-up time was 12.1 years. The OS was 54 % at 15 years and differed significantly between the pN0 and pN+ patients (65 vs. 30 %; P < 0.001); CSS (72 %) also differed between the pN0 and pN+ patients (85 vs. 44 %; P < 0.001). For the 5-year survivors (n = 119), 14 (12 %) died of CRC during additional long-term follow-up (7 each for pN0 and pN+), and 6 patients (5 %; all pN0) died of other cancers. Patients aged <65 years exhibited better long-term survival (81 %), but most of the deaths were due to CRC (10/12 deaths). Only two of the 14 cancer-related deaths involved microsatellite instable (MSI) CRC. Females exhibited better OS and CSS beyond 5 years of surveillance. CONCLUSIONS: The long-term survival beyond 5-year survivorship for stage I-III CRC is very good. Nonetheless, cancer-related deaths are encountered in one-third of patients and occur most frequently in patients who are <65 years old at disease onset-pointing to a still persistent risk several years after surgery.

Predicting outcomes in patients with perforated gastroduodenal ulcers: artificial neural network modelling indicates a highly complex disease.

PURPOSE: Mortality prediction models for patients with perforated peptic ulcer (PPU) have not yielded consistent or highly accurate results. Given the complex nature of this disease, which has many non-linear associations with outcomes, we explored artificial neural networks (ANNs) to predict the complex interactions between the risk factors of PPU and death among patients with this condition. METHODS: ANN modelling using a standard feed-forward, back-propagation neural network with three layers (i.e., an input layer, a hidden layer and an output layer) was used to predict the 30-day mortality of consecutive patients from a population-based cohort undergoing surgery for PPU. A receiver-operating characteristic (ROC) analysis was used to assess model accuracy. RESULTS: Of the 172 patients, 168 had their data included in the model; the data of 117 (70%) were used for the training set, and the data of 51 (39%) were used for the test set. The accuracy, as evaluated by area under the ROC curve (AUC), was best for an inclusive, multifactorial ANN model (AUC 0.90, 95% CIs 0.85-0.95; p < 0.001). This model outperformed standard predictive scores, including Boey and PULP. The importance of each variable decreased as the number of factors included in the ANN model increased. CONCLUSIONS: The prediction of death was most accurate when using an ANN model with several univariate influences on the outcome. This finding demonstrates that PPU is a highly complex disease for which clinical prognoses are likely difficult. The incorporation of computerised learning systems might enhance clinical judgments to improve decision making and outcome prediction.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer.

BACKGROUND: Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed. METHODS: PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred. RESULTS: Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence. CONCLUSION: Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Treatment of esophageal perforation in octogenarians: a multicenter study.

Esophageal perforation is associated with significant mortality, and this may markedly increase with advanced age. This multicenter study investigates this issue in patients older than 80 years. Data on 33 patients >80 years old who underwent conservative (10 patients), endoclip (one patient), stent grafting (11 patients), or surgical treatment (11 patients) for esophageal perforation were collected from nine centers. Surgical repair consisted of repair on drain in one patient, primary repair in seven patients, and esophagectomy in two patients. Among patients who underwent stent grafting, one required repeat stenting and another stent graft repositioning. One patient was converted to surgical repair after stent grafting. Thirteen patients (39.4%) died during the 30-day and/or in-hospital stay. Their mortality was significantly higher than in a series of patients<80 years old (13.0%, 21/161 patients, P=0.001). Three patients (30.0%) died after conservative treatment, one (100%) after treatment with endoclips, five (45.5%) after stent grafting, and four (36.4%) after surgical repair (P=0.548). Early survival with salvaged esophagus was 42.4% (conservative treatment: 70.0% endoclips 0%, stent grafting: 54.5%, and surgical repair: 54.5%, respectively, P=0.558). Estimated glomerular filtration rate<60 mL/minute/1.73 m2 (70.0% vs. 25.0%, P=0.043) and sepsis (100% vs. 32.1%, P=0.049) at presentation were associated with increased risk of early mortality in univariate analysis. Esophageal perforation in octogenarians is associated with very high early and intermediate high mortality irrespective of the treatment method used.

Risk factors associated with poor lymph node harvest after colon cancer surgery in a national cohort.

AIM: Evaluation of ≥ 12 lymph nodes (LNs) is recommended after surgery for colon cancer. A harvest of ≤ 8 is considered poor, but few reports have evaluated risk factors associated with a poor harvest. This aims of this study were to analyse the clinical, surgical and pathological factors associated with poor LN harvest (LNH), the total number of examined nodes and the effect of LN number on stage. METHOD: All patients reported to the Norwegian Colorectal Cancer Registry during 2007 and 2008 who underwent curative resection for Stage I-III colon cancer were studied. Risk factors for poor LNH and the proportion of Stage III disease were analysed by univariate and multivariate analyses. RESULTS: A total of 2879 patients were included in the study. The median LNH was 14. Overall, 69.9% had ≥ 12 lymph nodes and 14.4% had ≤ 8 LN (poor harvest). Multivariate analysis showed that male sex, age > 75 years, sigmoid tumours, pT category 1-2, failure to use the pathology report template and distance of ≤ 5 cm from the bowel resection margin were all independent factors for poor LNH. Age < 65 years, pT category 3-4, and poor tumour differentiation were independent predictors of Stage III disease. An increased LNH did not increase the proportion of patients identified as being LN positive at the ≤ 8, 9-11 and ≥ 12 LN levels. CONCLUSION: Adequate LNH was achieved in the majority of curative colon cancer resections in this national cohort. Elderly, male patients with sigmoid cancers, and a short distal margin were at increased risk of a poor LNH.

Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography.

BACKGROUND: With an increased use of magnetic resonance imaging, the indications for endoscopic retrograde cholangiopancreatography (ERCP) have changed. Consequently, the patterns and factors predictive of complications after ERCP performed during current routine clinical practice are not well known. METHODS: A prospective multicentre cohort study was undertaken in 11 Norwegian hospitals. Complications and mortality within 30 days after ERCP were analysed by univariable and multivariable regression analysis. RESULTS: There were 2808 ERCP procedures, of which 2573 (91·6 per cent) were therapeutic. More than half of the patients were aged 70 years or more. Common bile duct cannulation was achieved in 2557 procedures (91·1 per cent). Complications occurred in 327 (11·6 per cent) of the procedures, including cholangitis in 100 (3·6 per cent), pancreatitis in 88 (3·1 per cent), bleeding in 66 (2·4 per cent), perforation in 25 (0·9 per cent) and cardiovascular-respiratory events in 32 (1·1 per cent). In the multivariable regression analysis, older age, increasing American Society of Anesthesiologists fitness score, centre ERCP volumes of more than 150 procedures annually and precut sphincterotomy were predictive factors for severe complications. The overall 30-day mortality rate was 2·2 per cent (63 patients), with a procedure-related mortality rate of 1·4 per cent (39 patients). Malignancy was diagnosed in 46 (73 per cent) of the patients who died. CONCLUSION: ERCP is a procedure with considerable risk for complications. Morbidity and mortality are related to patient age and co-morbidity, as well as hospital volume of ERCP procedures and the type of intervention.

Adherence to national guidelines for surveillance after curative resection of nonmetastatic colon and rectum cancer: a survey among Norwegian gastrointestinal surgeons.

AIM: National guidelines recommend enrollment of patients in surveillance programmes following curative resection of colorectal carcinoma (CRC) in order to detect recurrence or distant metastasis at an asymptomatic/early stage when secondary curative treatment can be offered. Little is known about surgeons' adherence to such guidelines. In this national survey we analyse adherence and attitudes to postoperative follow up among Norwegian gastrointestinal surgeons involved in the care of patients with CRC. METHOD: We performed a nationwide survey of all hospitals performing surgery for colon and/or rectum cancer. The presence of a surveillance programme, the type of programme, adherence to national guidelines or report on any deviation thereof, location of follow up at the hospital or with a general practitioner (GPs) and the estimated annual volume of surgery were queried through mail and telephone. RESULTS: All hospitals (n=41) performing colorectal surgery responded, of which 25 (61%) conducted postoperative follow up by surgeons in the hospital outpatient clinics, four (10%) carried out follow up with a combination of hospital outpatient visits and visits to GPs, and 12 (29%) referred surveillance to the GP alone. For total reported patient numbers, almost two-thirds (60%) received surveillance according to national recommendations through outpatient visits with the surgeon or GP, while one-third (37%) were subject to other alternative routines. A small number (2%) received informal 'ad hoc' surveillance only. More liberal use of imaging outside guideline recommendations was reported for rectal cancer patients, while colon cancer patients treated in larger hospitals were more likely to be referred for GP surveillance. CONCLUSION: All hospitals reported having a strategy for surveillance after surgery for colon and rectal cancer, but there was considerable variance in strategy. A scientific audit of the true level of compliance, effectiveness and cost-benefit is warranted at a national level.

Survival effect of implementing national treatment strategies for curatively resected colonic and rectal cancer.

BACKGROUND: The surgical management of rectal cancer has changed substantially over the past decade. There are limited data on the long-term outcome of implementing systematic management strategies. METHODS: Survival of a national cohort of patients treated surgically for colonic and rectal cancer over a 10-year interval was analysed. All 31 158 patients in Norway diagnosed with adenocarcinoma of the colon and rectum between 1994 and 2003 were identified from the Cancer Registry of Norway and the Norwegian Rectal Cancer Registry. Changes in 5-year relative survival were compared by age, stage and tumour location during the early and late years. RESULTS: The study population included 19 053 patients who had a curative resection. The relative 5-year survival rate significantly improved for both colonic cancer (73·8 versus 78·0 per cent; P < 0·001) and rectal cancer (72·1 versus 79·6 per cent; P < 0·001). The 5-year relative survival was significantly better for rectal than colonic cancer during the late period (P = 0·030). Improved 5-year relative survival was related to better outcomes in patients with positive lymph nodes (67·2 and 62·1 per cent for rectal and colonic cancer respectively; each P < 0·001 versus early period), but not for the subgroup aged over 75 years with lymph node-positive colonic cancer. CONCLUSION: In this national cohort, survival after curative surgery for colorectal cancer increased significantly after implementation of national management strategies. Improvements were most evident for rectal cancer and in lymph node-positive disease; they were less substantial for colonic cancer and elderly patients (over 75 years). Strategic treatment changes may be warranted for the latter group.

Rectal cancer with macroscopic peritoneal involvement--clinical challenges and consequences.

OBJECTIVE: In gastrointestinal cancer, serosal involvement indicates advanced disease. We looked at the possible role of clinical peritoneal involvement (CPI) in local recurrences (LRs) and the overall survival of patients with rectal cancer (RC). METHOD: Between 1993 and 2002, 6404 patients were diagnosed with RC. Based on macroscopic findings at surgery and corresponding histological findings, 166 patients (3%) had CPI. Surgery was stratified according to type and extent of operation: as resective or nonresective surgery and as curative (R0) or noncurative (R1 or R2) resection. RESULTS: The presence of CPI was a negative factor for survival with a median of 15 months (95% CI, 12-19) in the presence of CPI compared with 65 months (95% CI, 61-70) without it (P < 0.001). In R0 resections, the median survival was 97 months (95% CI, 90-102) in patients without CPI compared with 48 months (95% CI, 22-74) in patients with CPI (P < 0.001). In R1 or R2 resections, the median survival was 16 months (95% CI, 15-17) in the absence of CPI and 9 months (95% CI, 8-10) in the presence of CPI. The LR rate in patients without CPI was 10.2% compared with 15.7% in patients with CPI (P = 0.022). CONCLUSIONS: Clinical peritoneal involvement is a significant detrimental prognostic factor for the LR of RC and survival in the absence of metastases. Observations from this large national cohort add to what is known about peritoneal involvement. Diagnosed CPI should be taken into consideration when adjuvant treatment strategies are addressed.

Palliative surgery for rectal cancer in a national cohort.

OBJECTIVE: Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer (RC) remains a matter of debate. In this study we analyse prospectively recorded data from a national cohort. METHOD: Among 4831 patients diagnosed with RC between 1997 and 2001, 838 (17%) patients were treated with palliative surgery. Patients were stratified according to disease stage, age and type of surgery. RESULTS: A significantly longer median survival, 12 (range 10-13) months, was observed in patients treated with resection of the primary tumour compared with 5 (range 4-6) months in patients treated with nonresective procedures (P < 0.001). Median survival in months was significantly (P < 0.001) related to age (13; < 60 years of age, 10; 60 to 69 years, 7; 70 to 79 years, 6; >/= 80 years of age). In patients over 80 years, survival was similar regardless of the treatment. Thirty-day mortality varied from 2.5% to 20%, according to age groups. CONCLUSION: The longer survival observed in patients with resection of the primary tumour may partly be explained by patient selection. Elderly patients (>/= 80 years) had a similar survival, irrespective of resection of the primary tumour or not. Careful consideration of the individual patient, extent of disease and treatment-related factors are important in decision-taking for palliative treatment for patients with advanced RC.

Resuscitative emergency thoracotomy in a Scandinavian trauma hospital--is it justified?

OBJECTIVE: Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital. METHODS: Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (Ps) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase. RESULTS: Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>or=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median Ps of 4.4%, range 0-89.5%). Males had significantly lower RTS and Ps (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (Ps) of 51 and 89%), one in a third trimester pregnancy. CONCLUSION: Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention.

Pyloroplasty for benign gastric outlet obstruction--indications and techniques.

The understanding of peptic ulcer disease (PUD) etiology, and improvements in treatment during the last two decades, has dramatically decreased the once so frequently performed procedures for PUD and its complications. Benign gastric outlet obstruction may, however, still require operative intervention when non-operative treatment fails. Today, surgeons in training, and even practicing surgeons, may have limited operative experience with procedures required to alleviate an obstructed pylorus. Our aim of this paper is to review the techniques (the Heineke-Mikulicz and Finney pyloroplasties, and modifications) and indications for pyloroplasty in the modern surgical era.