Unraveling the potential clinical utility of circulating tumor DNA detection in colorectal cancer-evaluation in a nationwide Danish cohort.

BACKGROUND: Increasingly, circulating tumor DNA (ctDNA) is proposed as a tool for minimal residual disease (MRD) assessment. Digital PCR (dPCR) offers low analysis costs and turnaround times of less than a day, making it ripe for clinical implementation. Here, we used tumor-informed dPCR for ctDNA detection in a large colorectal cancer (CRC) cohort to evaluate the potential for post-operative risk assessment and serial monitoring, and how the metastatic site may impact ctDNA detection. Additionally, we assessed how altering the ctDNA-calling algorithm could customize performance for different clinical settings. PATIENTS AND METHODS: Stage II-III CRC patients (N = 851) treated with a curative intent were recruited. Based on whole-exome sequencing on matched tumor and germline DNA, a mutational target was selected for dPCR analysis. Plasma samples (8 ml) were collected within 60 days after operation and-for a patient subset (n = 246)-every 3-4 months for up to 36 months. Single-target dPCR was used for ctDNA detection. RESULTS: Both post-operative and serial ctDNA detection were prognostic of recurrence [hazard ratio (HR) = 11.3, 95% confidence interval (CI) 7.8-16.4, P < 0.001; HR = 30.7, 95% CI 20.2-46.7, P < 0.001], with a cumulative ctDNA detection rate of 87% at the end of sample collection in recurrence patients. The ctDNA growth rate was prognostic of survival (HR = 2.6, 95% CI 1.5-4.4, P = 0.001). In recurrence patients, post-operative ctDNA detection was challenging for lung metastases (4/21 detected) and peritoneal metastases (2/10 detected). By modifying the cut-off for calling a sample ctDNA positive, we were able to adjust the sensitivity and specificity of our test for different clinical contexts. CONCLUSIONS: The presented results from 851 stage II-III CRC patients demonstrate that our personalized dPCR approach effectively detects MRD after operation and shows promise for serial ctDNA detection for recurrence surveillance. The ability to adjust sensitivity and specificity shows exciting potential to customize the ctDNA caller for specific clinical settings.

Long-term outcomes after perioperative treatment with omega-3 fatty acid supplements in colorectal cancer.

BACKGROUND: This study aimed to evaluate the effect of perioperative supplementation with omega-3 fatty acids (n-3 FA) on perioperative outcomes and survival in patients undergoing colorectal cancer surgery. METHODS: Patients scheduled for elective resection of colorectal cancer between 2007 and 2010 were randomized to either an n-3 FA-enriched oral nutrition supplement (ONS) twice daily or a standard ONS (control) for 7 days before and after surgery. Outcome measures, including postoperative complications, 3-year cumulative incidence of local or metastatic colorectal cancer recurrence and 5-year overall survival, were compared between the groups. RESULTS: Of 148 patients enrolled in the study, 125 (65 patients receiving n-3 FA-enriched ONS and 60 receiving standard ONS) were analysed. There were no differences in postoperative complications after surgery (P = 0·544). The risk of disease recurrence at 3 years was similar (relative risk 1·66, 95 per cent c.i. 0·65 to 4·26).The 5-year survival rate of patients treated with n-3 FA was 69·2 (95 per cent c.i. 56·5 to 78·9) per cent, compared with 81·7 (69·3 to 89·4) per cent in the control group (P = 0·193). After adjustment for age, stage of disease and adjuvant chemotherapy, n-3 FA was associated with higher mortality compared with controls (hazard ratio 1·73, 95 per cent c.i. 1·06 to 2·83; P = 0·029). The interaction between n-3 FA and adjuvant chemotherapy was not statistically significant. CONCLUSION: Perioperative supplementation with n-3 FA did not confer a survival benefit in patients undergoing colorectal cancer surgery. n-3 FA did not benefit the subgroup of patients treated with adjuvant chemotherapy or decrease the risk of disease recurrence.

ANTECEDENTES: Este estudio tuvo como objetivo evaluar el efecto de la suplementación perioperatoria con ácidos grasos omega-3 (omega-3 fatty acids, n-3 FA) sobre los resultados perioperatorios y la supervivencia en pacientes sometidos a cirugía de cáncer colorrectal (colorectal cáncer, CRC). MÉTODOS: Los pacientes programados para una resección electiva de CRC entre 2007 y 2010 fueron asignados al azar a recibir dos veces al día un suplemento nutricional oral (oral nutrition supplement, ONS) enriquecido con n-3 FA o un ONS estándar (control) durante siete días antes y después de la cirugía de CRC. Los grupos se compararon mediante análisis estadísticos. Las medidas de resultado incluyeron las complicaciones postoperatorias, la incidencia acumulada de recidivas locales o metastásicas de CCR a los 3 años y la supervivencia global a los 5 años. RESULTADOS: De 148 pacientes reclutados, se analizaron 125 pacientes (65 que recibieron el ONS enriquecido con n-3 FA y 60 que recibieron el ONS estándar). No hubo diferencias en las complicaciones postoperatorias después de la cirugía (P = 0,544). El riesgo de recidiva de la enfermedad a los 3 años no fue diferente entre los grupos (riesgo relativo, RR = 1,66; i.c. del 95% (0,65; 4,26)). La supervivencia a los 5 años para los pacientes tratados con n-3 FA fue del 69,2% (i.c. del 95% (56,5; 78,9)) en comparación con el 81,7% (i.c. del 95% (69,4; 89,4)) en el grupo control (P = 0,193). Después del ajuste por edad, estadio de la enfermedad y quimioterapia adyuvante, n-3 FA se asoció con una mayor mortalidad (cociente de riesgos instantáneos, hazard ratio, HR = 1,73; i.c. del 95% (1,05; 2,83); P = 0,029) en comparación con los controles. Sin embargo, la interacción entre n-3 FA y la quimioterapia adyuvante no fue estadísticamente significativa. CONCLUSIÓN: La suplementación perioperatoria con n-3 FA no confirió un beneficio de supervivencia en pacientes sometidos a cirugía de CRC. El n-3 FA tampoco benefició al subgrupo de pacientes tratados con quimioterapia adyuvante, ni disminuyó el riesgo de recidiva de la enfermedad.

Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis.

AIM: Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure. METHOD: The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis. RESULTS: Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy. CONCLUSION: In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

Final results of a European, multicentre, prospective, observational study of Permacol™ collagen paste injection for the treatment of anal fistula.

AIM: Permacol™ collagen paste (Permacol™ paste) is an acellular cross-linked porcine dermal collagen matrix suspension for use in soft-tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter-preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients. METHOD: Patients (n = 100) with anal fistula were treated, at 10 European surgical sites, with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6 and 12 months post-treatment, with the primary end-point being healing at 6 months. Faecal continence and patient satisfaction were surveyed at each follow-up; adverse events (AEs) were monitored throughout the follow-up. RESULTS: At 6 months postsurgery, 56.7% of patients were healed and the percentage healed was largely maintained, with 53.5% healed at 12 months. Regarding AEs, 29.0% of patients had at least one AE, and 16.0% of patients had one or more procedure-related AE. Most AEs reported were minor and similar to those commonly observed after fistula treatment, and the incidence of serious adverse events was low (4.0% of patients). Regardless of treatment outcome, 73.0% of patients were satisfied or very satisfied with the procedure. CONCLUSION: Permacol™ paste is a promising sphincter-preserving treatment for anal fistulae and has minimal adverse side-effects.

Incidental colorectal FDG uptake on PET/CT scan and lesions observed during subsequent colonoscopy: a systematic review.

BACKGROUND: Incidental colorectal fluorodeoxyglucose (FDG) uptake can be observed during a positron emission tomography/computed tomography (PET/CT) scan. For clinical and/or histological assessment of the cause, a colonoscopy is then performed. A systematic review was conducted to investigate the relationship between incidental colorectal FDG uptake and lesions observed during a subsequent colonoscopy. METHODS: A literature search was conducted using PubMed, Embase, and Web of Science with the keywords concerning PET/CT scan and colonoscopy. The studies were selected using inclusion criteria defined a priori and were described individually to examine the correlation between incidental colorectal FDG uptake and the lesions found at colonoscopy. RESULTS: Twenty-six of 1606 studies found were included. In total, 108,578 patients underwent an FDG-PET/CT scan as part of a diagnostic work-up or cancer staging. In total, 2546 incidental colorectal FDG uptakes were described in 2121 patients (mean age 62.7 years SD ± 5.1), of which 2045 uptakes in 1635 patients were examined by colonoscopy, within a mean of 37 days (SD ± 28). The colonoscopic lesions included neoplasms (n = 1097; 322 cancers), benign lesions (n = 273), and inflammatory lesions (n = 71). Colonoscopies were normal in 604 patients. In total, 82% of lesions were located in the same location as the FDG uptakes. The positive predictive value was 70% (95% CI [68-72]). CONCLUSIONS: Incidental colorectal FDG uptake, as evaluated by subsequent colonoscopy, often reveals neoplastic lesions. Predominantly, lesions were located at the same location as FDG uptake. Further investigation is warranted before recommending that incidental colorectal FDG uptake should always result in referral to diagnostic colonoscopy.

Hypermethylated DNA as a biomarker for colorectal cancer: a systematic review.

AIM: Improved methods for early detection of colorectal cancer (CRC) are essential for increasing survival. Hypermethylated DNA in blood or stool has been proposed as a biomarker for CRC. Biochemical methods have improved in recent years, and several hypermethylated genes that are sensitive and specific for CRC have been proposed. Articles describing the use of hypermethylated promoter regions in blood or stool as biomarkers for CRC were systematically reviewed. METHOD: A systematic literature search was performed using the Medline, Web of Science and Embase databases. Studies were included if they analysed hypermethylated genes from stool or blood samples in correlation with CRC. Studies in languages other than English and those based on animal models or cell lines were excluded. RESULTS: The literature search yielded 74 articles, including 43 addressing blood samples and 31 addressing stool samples. In blood samples, hypermethylated ALX4, FBN2, HLTF, P16, TMEFF1 and VIM were associated with poor prognosis, hypermethylated APC, NEUROG1, RASSF1A, RASSF2A, SDC2, SEPT9, TAC1 and THBD were detected in early stage CRC and hypermethylated P16 and TFPI2 were associated with CRC recurrence. In stool samples, hypermethylated BMP3, PHACTR3, SFRP2, SPG20, TFPI2 and TMEFF2 were associated with early stage CRC. CONCLUSION: Hypermethylation of the promoters of specific genes measured in blood or stool samples could be used as a CRC biomarker and provide prognostic information. The majority of studies, however, include only a few patients with poorly defined control groups. Further studies are therefore needed before hypermethylated DNA can be widely applied as a clinical biomarker for CRC detection and prognosis.

A prospective multicentre observational study of Permacol collagen paste for anorectal fistula: preliminary results.

AIM: Permacol collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. METHOD: Patients (N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. RESULTS: Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. CONCLUSION: Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects.

Long-term anorectal, urinary and sexual dysfunction causing distress after radiotherapy for anal cancer: a Danish multicentre cross-sectional questionnaire study.

AIM: The objective of primary radiotherapy for anal cancer is to remove cancer while maintaining anorectal function. However, little is known about anorectal function among long-term survivors without colostomy. Using a cross-sectional questionnaire study, we examined symptoms and distress related to the dysfunction of pelvic organs after radiotherapy for anal cancer. METHOD: A questionnaire regarding anorectal, urinary and sexual symptoms was sent to anal cancer patients without recurrence or colostomy, diagnosed during 1996-2003, and treated with curative intent (chemo)radiotherapy at three Danish centres. For each symptom we assessed frequency and severity and the level of symptom-induced distress (no, little, moderate or great distress). RESULTS: Of 94 eligible patients, 84 (89%) returned the completed questionnaire at a median of 33 months after radiotherapy. Incontinence for solid stools, liquid stools and gas occurred at least monthly in 31%, 54% and 79% of patients, respectively. Overall 40% of patients reported great distress from incontinence for solid or liquid stools at least monthly. Faecal urgency occurring at least monthly was experienced by 87% of patients and caused great distress in 43%. Stress, urge or another type of urinary incontinence occurred at least monthly in 45% and caused great distress in 21%. Urinary urgency occurred at least monthly in 48% but only caused great distress in 14%. Sexual desire was severely decreased in 58% and only 24% were satisfied with their sexual function. CONCLUSION: Distressing long-term anorectal and sexual dysfunction was common after radiotherapy for anal cancer, and morbidity due to urinary dysfunction was moderate.

Venous thrombosis in pancreaticobiliary tract cancer: outcome and prognostic factors.

BACKGROUND: The differences in outcome among cancer patients with incidental vs. symptomatic venous thromboembolism (VTE) are unknown. In this study, patients with extrahepatic pancreaticobiliary tract cancer (PBC) were selected for a prospective cohort study between February 2008 and February 2011. METHODS: At the time of cancer diagnosis, all patients were examined for deep vein thrombosis with bilateral compression ultrasonography (biCUS). Computed tomography pulmonary angiography was also performed to diagnose pulmonary embolisms. After inclusion, the patients were followed up with clinical examinations, blood collections, and biCUS. RESULTS: A total of 121 PBC patients were enrolled. At the time of cancer diagnosis, 15 patients had experienced a VTE (12.4%, 95% confidence interval [CI] 7.1-19.6), including six symptomatic and nine incidental cases. A total of 25 first-time VTE events were identified (20.7%; 95% CI 13.8-29.0). Patients with a VTE had reduced survival, with a median overall survival (OS) of 4.4 months (95% CI 2.2-11.5). The median OS of the patients with incidental VTE was 3.0 months (95% CI 0.1-15.0), which was not different from the median OS of the patients with symptomatic VTE (5.0 months; 95% CI 2.1-14.5). The median OS was 11.9 months (95% CI 8.1-14.7) in the PBC patients with no VTEs. CONCLUSION: The occurrence of a VTE event in a PBC patient within the first months of the disease is associated with significantly increased mortality.

Pre-admission use of glucocorticoids and 30-day mortality following colorectal cancer surgery: a population-based Danish cohort study.

BACKGROUND: Previous studies indicate that pre-admission glucocorticoids increase the risk of perioperative complications. AIM: To examine whether pre-admission use of glucocorticoids affects 30-day mortality after colorectal cancer (CRC) surgery. METHODS: We conducted a nationwide population-based cohort study by linking Danish medical registries. All residents in Denmark who underwent CRC surgery from 2001 to 2011 were included. We characterised subjects who filled their most recent glucocorticoid prescription ≤90, 91-365 and >365 days before their surgery date as prevalent, recent and former users, respectively. Prevalent users were subgrouped into new (first-ever prescription ≤90 days before surgery date) and continuing users. We estimated 30-day cumulative mortality by the Kaplan-Meier method and corresponding mortality rate ratios (MRRs) using Cox proportional hazard regression, adjusting for potential confounders. RESULTS: Of the 34 641 CRC patients included, 3966 (11.5%) had filled one or more prescriptions of glucocorticoids within the year before the surgery date. Thirty-day mortality among prevalent users of oral glucocorticoids was 15.0% vs. 7.3% among non-users [MRR = 1.28; 95% confidence interval (CI): 1.03, 1.58]. Among new users, the 30-day mortality was 17.8% (MRR = 1.92; 95% CI: 1.30, 2.83) while it was 14.2% among continuing users (MRR = 1.13; 95% CI: 0.88, 1.44). No associations were found for recent or former use of oral glucocorticoids nor for use of inhaled, intestinal-acting, and mixed glucocorticoids. CONCLUSIONS: Prevalent use, particulary new use, of oral glucocorticoids was associated with markedly increased 30-day mortality after colorectal cancer surgery compared to patients not exposed to any glucocorticoids.

Prevalence of venous thromboembolism at diagnosis of upper gastrointestinal cancer.

BACKGROUND: Venous thromboembolism (VTE) in patients with upper gastrointestinal (GI) cancer increases morbidity and mortality. This study aimed to determine the prevalence of VTE at diagnosis of upper GI cancer. METHODS: Patients admitted between February 2008 and February 2011 with upper GI cancer (pancreatic, extrahepatic biliary, lower oesophageal, gastro-oesophageal junction or gastric cancer) were investigated in a cross-sectional cohort study. At cancer diagnosis, all patients were examined for deep vein thrombosis (DVT) by means of bilateral compression ultrasonography. From February 2009 and onwards, computed tomographic pulmonary angiography (CTPA) was also performed for the diagnosis of pulmonary embolism (PE). RESULTS: Some 250 patients had ultrasonography; CTPA was performed in 143 patients on admission. DVT was detected in 13 (5·2 per cent) of the 250 patients, eight (3·2 per cent) of whom were asymptomatic. DVT was correlated with tumour location in the pancreaticobiliary tract (odds ratio (OR) 6·27, 95 per cent confidence interval 1·18 to 33·38; P = 0·031) and tumour stage IV (OR 19·34, 2·33 to 160·70; P = 0·006). PE was detected in 11 (7·7 per cent) of 143 patients, eight (5·6 per cent) of whom were asymptomatic. PE embolism was also significantly more common in patients with pancreaticobiliary tract cancer (OR 7·81, 1·28 to 47·62; P = 0·026) and in those with stage IV disease (OR 17·19, 1·83 to 161·50; P = 0·013). CONCLUSION: The prevalence of VTE at cancer diagnosis was significantly higher in patients with pancreaticobiliary tract cancer than in those with other forms of upper GI cancer, and in patients with advanced cancer stage.

Randomized clinical trial of perioperative omega-3 fatty acid supplements in elective colorectal cancer surgery.

BACKGROUND: Omega-3 fatty acids (n-3 FAs) may have beneficial clinical effects, and n-3 FA supplements may improve outcome after surgery. METHODS: In a randomized double-blind placebo-controlled trial in single centre, patients referred for elective colorectal cancer surgery received either an n-3 FA-enriched oral nutritional supplement (ONS) (Supportan, 200 ml twice daily) providing 2.0 g eicosapentaenoic acid (EPA) and 1.0 g docosahexaenoic acid (DHA) per day, or a standard isocaloric and isonitrogenous ONS, for 7 days before and 7 days after surgery. The primary endpoint was infectious and non-infectious complications within 30 days of surgery. Secondary endpoints were length of hospital stay, intensive care unit admission, readmissions, and concentrations of marine n-3 FAs and arachidonic acid in granulocyte membranes. RESULTS: Some 148 consecutive patients (68 women, 80 men; mean age 71 (range 41-89) years) were randomized. There was no significant difference between groups in infectious or non-infectious postoperative complications (P = 1.000). Granulocyte levels of EPA, DHA and docosapentaenoic acid (DPA) were significantly higher in the n-3 FA-enriched supplement group compared with the control group (P < 0.001). The arachidonic acid level in granulocytes was significantly lower in the enriched group than in the control group (P < 0.001). CONCLUSION: EPA, DHA and DPA were incorporated into granulocytes in patients receiving n-3 FAs, but this was not associated with improved postoperative outcomes. REGISTRATION NUMBER: NCT00488904 (http://www.clinicaltrials.gov).

Use of systemic glucocorticoids and the risk of colorectal cancer.

BACKGROUND: Systemic glucocorticoids are potent immunosuppressants, potentially facilitating carcinogenesis. Studies examining glucocorticoids and colorectal cancer risk are few. AIM: To investigate the association between use of systemic glucocorticoids and colorectal cancer risk, both overall and by cancer stage (localised versus metastatic). METHODS: We conducted a nested population-based case-control study in Northern Denmark (1.8 million people) using medical registries. The study included 14,158 patients with a first-time diagnosis of colorectal cancer from 1991 through 2010. Using risk set sampling, we identified 141,580 population controls, matched on age and gender. Logistic regression models were used to compute odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for covariates. RESULTS: Frequent use of systemic glucocorticoids (defined as >2 prescriptions) was not associated with overall colorectal cancer risk [adjusted OR (aOR) = 0.93 (95% CI: 0.85-1.00)], compared with never/rare use (≤2 prescriptions). Associations according to duration of use and doses (quartiles of cumulative prednisolone equivalents) were also near the null. Examining colorectal cancer by stage, no substantial associations were found between long-term use (>5 years) of high-dose (>5500 mg) systemic glucocorticoids and localised [aOR = 1.12 (95% CI: 0.81-1.55)] or metastatic [aOR = 0.82 (95% CI: 0.59-1.14)] cancer. CONCLUSION: Despite immunological and metabolic effects of frequent use of systemic glucocorticoids, which would be expected to increase colorectal cancer risk, we found no substantial association between the two.

Preoperative plasma D-dimer predicts 1-year survival in colorectal cancer patients with absence of venous thromboembolism (VTE): a prospective clinical cohort study.

BACKGROUND: Fibrin formation is required for tumor angiogenesis, metastasis and invasion. Cancer discovered at the same time as or shortly after venous thromboembolism (VTE) tends to be advanced, and the prognosis poor. Previous studies have demonstrated that plasma D-dimer - a degradation product of cross-linked fibrin - correlates with tumor stage and prognosis in patients with colorectal cancer. However, it remains unclear whether D-dimer is of prognostic significance in colorectal cancer patients with absence of VTE. OBJECTIVE: To examine whether the preoperative plasma D-dimer level predicts 1-year survival in pre- and postoperative VTE-negative colorectal cancer patients admitted for surgery. METHODS: We measured preoperative D-dimer levels in 157 patients, and computed Kaplan-Meier survival curves according to the levels of D-dimer. Cox proportional-hazard regression analysis was used to compute hazard ratio as a measure of 1-year mortality rate ratio, controlling for potential confounding factors. The Aalborg Hospital's standard cut-off level of 0.3 mg L(-1) was used to distinguish negative and positive D-dimer results. RESULTS: The overall 1-year survival rate was 87.3% (95% confidence interval (CI), 81.0-91.6%), with 78.1% survival (95% CI, 65.9-86.4%) in the positive D-dimer group compared with 93.6% survival (95% CI, 86.2-97.1%) in the negative D-dimer group. The adjusted hazard ratio of death in the positive D-dimer group compared with the negative D-dimer group was 3.6 (95% CI, 1.3-9.9). CONCLUSION: A positive preoperative D-dimer is associated with a poor prognosis in colorectal cancer patients with absence of VTE.

Cardiac tamponade as a rare complication in laparoscopic incisional hernia repair.

Laparoscopic repair of incisional hernias has become an increasingly used procedure over the last few years. Recent studies have shown several advantages using this technique. Fixation of the mesh is usually achieved by spiral tackers. In this case, we describe the development of cardiac tamponade due to protruding spiral tackers occurring 9 days postoperatively.

High preoperative prevalence of deep venous thrombosis in patients with colorectal cancer.

BACKGROUND: Deep venous thrombosis (DVT) is a major complication of cancer and a predictor of reduced survival. The postoperative prevalence of DVT in colorectal cancer surgery is high, but the preoperative prevalence is unknown. The aim of this observational study was to estimate the preoperative prevalence of DVT in patients with colorectal cancer. METHODS: Some 193 consecutive patients with newly diagnosed colorectal cancer admitted for intended curative surgery were examined with compression ultrasonography for DVT before surgery. RESULTS: DVT was detected in 15 (7.8 per cent) of the 193 patients, with a prevalence of 16 per cent in women (12 of 76) versus 2.6 per cent in men (three of 117 (adjusted odds ratio (OR) 5.8 (95 per cent confidence interval (c.i.) 1.4 to 23.2)). The risk of DVT was strongly correlated with increasing American Society of Anesthesiologists (ASA) risk score: adjusted OR 6.8 (95 per cent c.i. 1.6 to 28.7 for ASA group III or IV versus ASA group I or II). Pulmonary embolism was detected in two patients (1.0 per cent). CONCLUSION: A high preoperative prevalence of DVT was observed in patients with colorectal cancer, especially among women and patients in ASA groups III and IV.

Complement activation in plasma before and after infliximab treatment in Crohn disease.

BACKGROUND: Crohn disease is characterized by up-regulated intestinal inflammation mainly caused by increased tumour necrosis factor alpha (TNF-alpha) levels. However, the complement system (C) may also have a role in maintaining inflammation. METHODS: Plasma from 26 patients with Crohn disease complicated by fistulizing ano-rectal disease was collected before and after three Infliximab infusions (5 mg kg(-1)). RESULTS: Before treatment, the C3-activation capacities (C3-AC) in plasma from patients with Crohn disease were comparable with values obtained from healthy controls. The classical C pathway-mediated C3-AC, mannan-binding lectin C4-AC, leucocyte count, C-reactive protein concentration and Crohn Disease Activity Index decreased significantly 8 weeks after the first infusion of Infliximab (P < 0.04, Wilcoxon test). CONCLUSIONS: Before treatment, all three C pathways were within the normal range in plasma from patients with Crohn disease; the decrease observed in the classical pathway-mediated C3-AC after treatment with Infliximab reflects a general down-regulation in immune activation.

Inverted Meckel's diverticulum masquerading Crohn disease in the small intestine.

We describe a case of Meckel's diverticulum containing ectopic gastric epithelium being the leading point in an ileoileal intussusception. This is usually an acute or subacute condition, but in this case the course was protracted and the case was misdiagnosed and treated as Crohn disease.

Relationship of coagulation test abnormalities to tumour burden and postoperative DVT in resected colorectal cancer.

In a prospective study, coagulation test results were compared in 137 patients with colorectal cancer (CRC) and 39 subjects with benign colorectal diseases. Prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT), and soluble fibrin (SF) were measured in plasma before and after surgery. CRC patients presented with significantly higher values of F1+2 and TAT than controls. Patients with localised CRC had elevated values of F1+2 and TAT, whereas patients with advanced CRC also had elevated SF values. TAT and SF levels correlated with tumour spread, and normal values virtually excluded advanced cancer. Postoperative deep venous thrombosis (DVT) was diagnosed by phlebography in 20% of the CRC patients. Preoperative values of the markers did not predict postoperative DVT, but postoperative values did.