One decade of rectal prolapse surgery: a national study.

PURPOSE: We aimed to investigate the development of common procedures used as treatment for rectal prolapse over a decade and to determine if the choice of primary operation affects the reoperation rate. METHODS: This is a retrospective analysis of operative data from a National Data Registry, Landspatientregisteret (LPR), from the period of January 1, 2004 to December 31, 2014. All hospitalized surgical treatments are registered in LPR. RESULTS: Sixteen hundred and twenty-five patients with rectal prolapse underwent 1834 operations. There were 94% women and mean age at surgery was 71.6 ± 18.1 years, with no difference over the 11 years. The types of operations performed differed (p < 0.0001), with an increase in overall number of operations and increasing use of laparoscopic procedures. There were 209 reoperations, of which 129 patients were primarily operated with a perineal procedure. The mean age at reoperation was 72.8 ± 17.3 years. The most frequently used reoperation was laparoscopic rectopexy. The overall reoperation rate was 16%: 10% for both open and laparoscopic rectopexy, and for perineal procedures 26% (p < 0.001). The overall 30-day mortality was 2.1% and there was no difference in mortality between the procedures (p = 0.23). CONCLUSIONS: The overall number of rectal prolapse operations was increasing. There was a clear trend towards extended use of laparoscopic rectopexy both as primary procedure and as reoperation. The highest reoperation rates were for the perineal procedures.

Prevention of parastomal hernia in the emergency setting.

AIM: This study assessed safety and efficacy associated with hernia prophylaxis using a retromuscular slowly resorbable synthetic mesh for stoma reinforcement. METHOD: This was a cohort study with a historic reference group. The study took place in a high-volume surgical department. During a 2-year period (July 2012-July 2014), we included 109 patients undergoing emergency surgery with formation of ileostomy or colostomy. All patients received a retromuscular slowly resorbable synthetic mesh (TIGR®, Novus Scientific) at the stoma site. The reference group included 117 patients who underwent emergency stoma formation without a prophylactic mesh in the 2-year period prior to July 2012. The primary endpoint was effect on prevention of parastomal hernia within 1 year. Secondary endpoints were 30-day and 1-year complications including mortality. RESULTS: The operative field was contaminated or dirty in 48% of the procedures. Operative time was significantly longer in the mesh group. The cumulative incidences of parastomal hernia at 1 year for the control and the mesh group were 8 and 7% (p = 0.424), respectively. The postoperative 30-day and 1-year rate of complications, reoperations and mortality were not different between the two groups. No patients underwent removal of the mesh and no clinical mesh infections were seen. CONCLUSION: Use of a resorbable synthetic mesh during emergency ostomy formation showed no significant preventive effect on formation of parastomal hernia after 1 year. Although surgery was often conducted in a severely contaminated field, the procedure was without significantly increased complication rate.

Incisional hernias after open versus laparoscopic surgery for colonic cancer: a nationwide cohort study.

BACKGROUND: Laparoscopic surgery for colonic cancer decreases the incidence of postoperative complications and length of hospital stay as compared with open surgery, while the oncologic outcome remains equivalent. It is unknown whether the surgical approach impacts on the long-term rate of incisional hernia. Furthermore, risk factors for incisional hernia formation are not fully elucidated. The aim of this study was to evaluate the long-term effect of elective open versus laparoscopic surgery for colonic cancer on development of incisional hernia. METHODS: This nationwide cohort study included patients operated on electively for colonic cancer with primary anastomosis in Denmark from 2001 to 2008. Patient data were obtained from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry. Multivariable Cox regression and competing risks analysis were performed. RESULTS: A total of 8489 patients were included, with a median follow-up of 8.8 (interquartile range 7.0-10.7) years. The incidence of incisional hernia was increased among patients operated on with open techniques compared with patients undergoing laparoscopic surgery (7.3 vs. 5.2 %, p < 0.001). After adjustment for confounders, laparoscopic approach was associated with a decreased risk of incisional hernia formation (hazard ratio [HR] 0.62, 95 % confidence interval [CI] 0.44-0.89; p = 0.009). Other factors associated with increased risk of incisional hernia were wound infection, fascial dehiscence, anastomotic leak, and body mass index >25 kg/m(2). CONCLUSIONS: This nationwide analysis demonstrated that laparoscopic as compared with open access for curative resection of colonic cancer was associated with a decreased risk of incisional hernia formation.

Compression anastomotic ring-locking procedure (CARP) is a safe and effective method for intestinal anastomoses following left-sided colonic resection.

BACKGROUND: Compression anastomotic ring-locking procedure (CARP) is a novel procedure for creating colonic anastomoses. The surgical procedure allows perioperative quantification of the compression pressure between the intestinal ends within the anastomosis and postoperative monitoring of the anastomotic integrity. We have recently shown that CARP is a safe and effective method for colonic anastomoses in pigs, and the purpose of the present study was to evaluate CARP for colonic anastomoses in humans. MATERIALS AND METHODS: This is a prospective study on 25 patients undergoing elective left-sided colonic resection. Time for evacuation of the anastomotic rings, perioperative compression pressure, and adverse effects were recorded. Postoperative blood samples were collected daily, and flexible sigmoidoscopy was performed 8-12 weeks after surgery to examine the anastomoses. RESULTS: Fourteen out of 25 patients underwent CARP. CARP was not used in 11 patients due to advanced tumor disease (two cases) and size restrictions (nine cases). No case of anastomotic leakage, bowel obstruction, or stenosis formation was observed. No device-related perioperative adverse events were noted. The surgical device evacuated spontaneously in all patients by the natural route after a median of 10 days. Perioperative compression pressure ranged between 85 and 280 mBar (median 130 mBar). Flexible sigmoidoscopy revealed smooth anastomoses without signs of pathological inflammation or stenosis in all cases. CONCLUSION: Our results indicate that the novel suture-less CARP is a safe and effective method for creating colonic anastomoses. Further studies are warranted in larger patient populations to compare CARP head-on-head with stapled and/or hand-sewn colonic anastomoses.

Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results.

AIM: We report the clinical and anal manometric results of elderly patients treated with laparoscopic ventral rectopexy (LVR) for full-thickness rectal prolapse. METHOD: From March 2009 to June 2012, patients were consecutively included. A modified laparoscopic Orr-Loygue procedure with posterior mobilisation was used. The patients were evaluated preoperatively, 2 months postoperatively and after 1 year. We registered Wexner incontinence scores and laxative uses by a questionnaire and performed simple anal manometry. RESULTS: A total of 46 patients underwent operation, all women. The median age was 83 years (range 34-99), median prolapse size was 8 cm (range 2-15), and 30 % had previous prolapse surgery. The median operative time was 135 min (range 90-215), and the median length of stay was 2 days (range 1-14). The 30-day morbidity rate was 15 %, and there were two (4 %) deaths within 30 days. There was a significant reduction in incontinence scores after 2 months and 1 year. The anal resting pressures improved from 10 cm H(2)O slightly to 16 cm H(2)O after 2 months, significantly, and still significant after 1 year at 13 cm H(2)O. There were no changes in the use of laxatives. The median follow-up time was 1.5 years (range 0.5-3), and there were two prolapse recurrences (4 %) in this period. CONCLUSIONS: Laparoscopic ventral rectopexy with posterior mobilisation seems to be effective and relatively well tolerated, although not without mortality in elderly debilitated patients. It improves incontinence. With increased life-year expectance, these patients may benefit from a lower risk of recurrence compared with perineal procedures.

Chromogranin A is a sensitive marker of progression or regression in ileo-cecal neuroendocrine tumors.

OBJECTIVE: The correlation between plasma Chromogranin A concentrations and changes in tumor size evaluated by computed tomography (CT) - as a gold standard - was evaluated. MATERIAL AND METHODS: One hundred and sixteen patients with CgA-producing ileo-cecal neuroendocrine tumors were evaluated by events, which were recorded when a CT was followed by another CT 1 - 12 months later. Change in tumor size was defined as regression, progression, or stable disease using RECIST criteria 1.1. Of 426 events, there were 97 with progression, 279 with stable disease, and 50 with regression. Based on the ROC curves a cutoff value of 25% change was selected to discriminate between increased, decreased, or unchanged CgA concentrations in plasma, using a sensitive radioimmunoassay with well-defined epitope specificity. RESULTS: In the 97 events showing tumor progression diagnostic sensitivity and specificity of an increased CgA concentration were 86% and 86%, respectively. The positive and negative predictive values were 64% and 85%, respectively. In the 279 events with unchanged tumor size the diagnostic sensitivity and specificity of an unchanged CgA concentration were 73% and 86%, and the positive and negative predictive values were 91% and 63%, respectively. In the 50 events showing tumor regression, diagnostic sensitivity and specificity of a decrease in CgA concentration were 78% and 91%, the positive and negative predictive values being 55% and 97%. CONCLUSIONS: CgA concentrations in plasma have a high diagnostic accuracy in monitoring patients with ileo-cecal neuroendocrine tumors. In particular, an increase in plasma CgA concentration was useful to indicate tumor progression.

Mortality after abdominal emergency surgery in nonagenarians.

PURPOSE: To search the pattern of diagnoses in nonagenarians undergoing emergency abdominal surgery between January 2009 and December 2013 in two hospitals. To test the hypothesis that pre-hospital functional status is an effective criterion for predicting postoperative mortality in nonagenarians after emergency abdominal surgery. METHODS: The study is an observational study on 157 patients. Patients were identified from the operation database and perioperative data were extracted as prospectively information supplied by retrospective data from patient electronic files. The primary endpoints were short, middle and long-term mortality and the secondary endpoint was to identify preoperative factors associated with postoperative mortality. RESULTS: The most frequent reason for operation was intestinal obstruction. Overall mortality in the cohort was 34% (n = 54) after 30 days and 54% (n = 84) after 1 year. Amongst patients developing a serious complication (classified as Clavien Dindo class III or greater) after surgery (n = 45) the mortality was 80% (n = 36) after 30 days and 89% (n = 40) after 1 year. In multivariate analysis, a high American Association of Anesthesiologists class (ASA) and a high Performance Status (PS) class (low performance) were significant predictors of post-operative mortality. CONCLUSION: Our data support pre-admission functional status for predicting postoperative mortality after emergency abdominal surgery in nonagenarians.

Stoma-site hernia after stoma reversal following rectal cancer resection.

INTRODUCTION: Stoma-site incisional hernia is a common complication. Besides decreasing affected patients' quality of life, it may lead to emergency surgery due to incarceration. If stoma sites lead to an incisional hernia analogous to other abdominal incisions, considerable underreporting may be present in the literature. METHODS: This was a single-centre, retrospective cohort study comprising consecutive patients undergoing laparoscopic rectal resection for rectal carcinoma with temporary diverting stoma and subsequent stoma reversal. CTs were reviewed to identify stoma-site incisional hernia, and potential confounders for development of a hernia were assessed. RESULTS: A total of 91 patients underwent stoma reversal and subsequent CT. In all, 72 of the 91 included patients had a transverse colostomy, among whom 19 (26%) developed a hernia. Among the remaining 19 patients treated with an ileostomy, four (21%) developed stoma-site incisional hernia. The mean time from stoma reversal to follow-up CT was 47.6 months (range: 28.5-66.7 months). No significant associations between stoma-site hernia and the included potential risk factors were observed. CONCLUSIONS: 25% developed reversal-site incisional hernia. We were unable to find any predictors for development of stoma reversal-site hernia. If hernias occur as frequently as this study shows, investigation of potential ways to decrease their occurrence is warranted. FUNDING: none. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (R. no. 2012-58-0004).

Prevention of parastomal hernia using mesh in patients undergoing rectum extirpation.

INTRODUCTION: Developing a parastomal hernia can lead to emergency surgery and cause discomfort. Placing a pro-phylactic mesh around the ostomy may potentially prevent hernias from developing. Randomised clinical trials and reviews have reported contradictory results from this prophylactic procedure with different rates of hernias and success. This descriptive cohort study aimed to investigate the rate of parastomal hernia after applying prophylactic mesh in patients undergoing surgery for rectal cancer. METHODS: In the period from 2010 to 2016, we included 133 patients who had a permanent colostomy with prophylactic mesh placement due to rectal cancer. The patients were seen in the ostomy ambulatory at least three times annually, and bulges and hernias were registered by a trained nurse. Computed tomography was used for verification of parastomal hernia. Data were registered retrospectively from patient files. RESULTS: After a median follow-up of 22 months, 24% of patients developed a parastomal hernia. Development of parastomal bulge without a subsequent hernia diagnosis was seen in 21%. The one-year rate of parastomal hernia was 9.7%. CONCLUSIONS: This cohort study supports the thesis of a low short-time rate of parastomal hernia in patients who had a prophylactic mesh placed during the ostomy formation and indicates that the rate of hernia increases over time after the first post-operative year. FUNDING: none. TRIAL REGISTRATION: not relevant.

Bacterial antigen-induced release of white cell- and platelet-derived bioactive substances in vitro.

OBJECTIVES: Poor prognosis after resection of primary colorectal cancer may be related to the combination of perioperative blood transfusion and subsequent development of infectious complications. Various white cell- and platelet-derived cancer-growth substances may be involved in this process. Therefore, we studied the in vitro release of substances from white cells and platelets stimulated by bacterial antigens and supernatants from stored red-cell components. METHODS: Eight units of whole blood (WB) and 8 U of buffy-coat-depleted red-cell (SAGM) blood were donated by healthy blood donors. Subsequently, one-half of each unit was leucocyte-depleted by filtration, and all 32 half-units were stored under standard conditions for 35 d. Just after storage, and on d 7, 21, and 35 during storage, aliquots of the supernatants were removed from the units and frozen at -80 degrees C. WB from other healthy donors was stimulated for 2 h with sodium chloride (controls), with Escherichia coli (E. coli) lipopolysaccharide (LPS) alone, or with LPS plus supernatants from the WB units (diluted 1:10), or from the SAGM units (diluted 1:20) stored for 0, 7, 21, or 35 d, respectively. Similar assays were performed using Staphylococcus aureus-derived protein A as a stimulatory antigen. The concentration of eosinophil cationic protein (ECP), myeloperoxidase (MPO), histamine (HIS), and plasminogen-activator inhibitor-1 (PAI-1) were determined in supernatants from the stored blood and in assay supernatants by using enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay (RIA) methods. RESULTS: The extracellular concentration of ECP, MPO, and HIS increased significantly in a storage-time-dependent manner in nonfiltered WB and SAGM blood, and the increase was abrogated by prestorage leukofiltration. Similarly, PA-1 increased significantly in nonfiltered WB, and the increase was abrogated by prestorage leukofiltration. The supernatant concentrations of the four substances were significantly increased in LPS-stimulated (0.5-4 fold) and in protein A-stimulated (0.5-13.5-fold) assays compared with controls. The addition of supernatants from stored nonfiltered WB or SAGM blood significantly increased the assay supernatant of ECP, MPO, HIS, and PAU-1 concentrations storage-time-dependently in LPS-stimulated assays. Prestorage leukofiltration abrogated the additional effect of supernatants from stored blood. Similar results were observed for ECP and HIS through the addition of supernatants from stored blood to protein A-stimulated assays. Protein A stimulation did not lead to increased PA-1 release in assays diluted by supernatants from stored blood. However, the MPO concentrations were significantly (p = 0.004), and independent of storage time and leukofiltration, increased in protein A-stimulated assays diluted by supernatants from stored blood compared with sodium chloride dilution. CONCLUSION: Extracellular ECP, MPO, HIS, and PA-1 accumulate during storage of nonfiltered red-cell components, but the accumulation can be prevented by prestorage leukofiltration. In addition, bacterial antigens appear to induce significant release of the substances from white cells and platelets. Addition of supernatants from stored, nonfiltered WB and SAGM blood may increase the substance levels in a storage-time-dependent manner, and prestorage leukofiltration may prevent further increase by supernatants, except for MPO.

Case-mix study of single incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery in colonic cancer resections.

UNLABELLED: Single incision laparoscopic surgery (SILS) may be even less invasive to a patient than conventional laparoscopic surgery (CLS). AIM OF THE STUDY: of the applicability of the procedure, the first 1½ year of experiences and comparison with CLS for colonic cancer resections. MATERIAL AND METHODS: Since November 2010 SILS procedures was trained by two surgeons. Data was prospectively registered. Each of all colonic cancer resections was blindly matched with two patients operated with CLS within the period from 2009-2011 with respect of procedure, gender, T stadium, age, ASA score and BMI. In the routine accelerated "fast track" program the use of additional opioids was registered. RESULTS: SILS was performed in 18 patients with cancer resections. Comparisons between the SILS procedures and the matched 36 CLS operations showed no significant difference in operation time, blood loss, lymph node harvest and hospital stay, but length of vascular pedicle was significantly larger in SILS procedures. Although only 50% of SILS patients received opioids postoperatively, this was not significantly different from the 71% receiving opioids in the CLS group, and similarly no significant difference in number of administrations or amount of opioids were seen. CONCLUSION: With reservation of a small study group we find SILS is like worthy to CLS in colorectal cancer surgery and a benefit in postoperative recovery and pain is possible, but has to be investigated in larger randomised studies.

Prolapse of submucous lipoma of the sigmoid colon.

Lipomas of the colon are rare and usually presenting in the later ages of life. This case describes and discusses the symptoms and signs of lipomas, recommendations and rationale for treatment.

Preliminary results after single-port laparoscopic colonic surgery.

INTRODUCTION: Single incision laparoscopic surgery (SILS) may be even less invasive to patients than conventional laparoscopic surgery (CLS). The present study investigates the applicability of the procedure and we report the first year of experiences and operative quality. MATERIAL AND METHODS: Patients were selected clinically and after computed tomography. Easy resections (or stoma creations) with small tumours, a body mass index < 30 kg/square meter and American Society of Anesthesiologists group I-II were included. The data were prospectively registered until 1 January 2012. In the standard accelerated "fast track" programme, the use of additional opioids was registered. RESULTS: SILS was performed in 24 patients including 15 patients with cancer resections. In eight stoma creations, no scars were left other than the stoma hole. The overall conversion rate was 17% and the complication rate was 13% with no wound infections. In the 15 SILS colon resections, median operation time (171 min.), blood loss (0 ml), lymph node harvest (median n = 14), dissection quality (73% mesocolic), specimen length (23 cm), height of vascular pedicle (8 cm) and hospital stay (three days) were comparable to international reports. One serious complication of small bowel injury was seen, but this was the only complication (7%) in this group. CONCLUSION: With the proviso that our study population was limited in size, SILS seems equal to CLS in colorectal cancer surgery - although with a high conversion rate in the learning period, and it is a suitable procedure for minimal invasion in creation of a stoma.

[Laparoscopic surgery for colorectal cancer in Denmark]. / Laparoskopisk operation for kolorektal cancer i Danmark.

INTRODUCTION: Laparoscopic resection of colorectal cancer may be oncologically equal to open surgery. Since 2001 the departments performing colorectal cancer surgery in Denmark, have reported variables for patient diagnostics, treatment and course to the DCCG database. MATERIAL AND METHODS: This article is based on data for patients classified with laparoscopic procedure until 31.12.2007. RESULTS: From an annual number of 50 operations, the number increased to 761 completed laparoscopic operations in 2007. The median number of investigated lymph nodes in radical colon operation increased from 11 in 2001-2005 to 15 in 2007. The median blood loss was 50 ml. The postoperative complications were 27% after rectum surgery and 20% after colon surgery, whereas the rate of anastomotic leakage was 7% in both groups. Total 30-day-mortality was 5.5% in the rectum group and 3% in the colon group, and the median length of stay was eight and four days, respectively. Departments performing more than 100 laparoscopic procedures removed significantly more lymph nodes during colon surgery and had lower rate of anastomosis leakage compared with departments with less experience. CONCLUSION: The oncologic quality of laparoscopic surgery was satisfying in the short term. The postoperative complication rate was equal to international results. Yet, a rate of 7% anastomotic leakage after colon surgery warrants further investigation.

[Rapid growing liposarcoma in retroperitoneum]. / Hurtigt voksende liposarkom i retroperitoneum.

A 36-year-old male was admitted with a giant abdominal tumour and dyspnoea from thoracic displacement. Symptoms were one year of haemorrhoids, but complaints of growing abdomen presented only for 10 weeks. Ultrasound could not differentiate tumour from the liver, but MR scan could. A 24.2 kg inhomogeneous tumour adhesive to the right kidney capsule was removed in toto from retroperitoneum. Histological diagnosis: Sclerosing, low differentiated liposarcoma. Besides radical surgery only radiation therapy may have effect in treatment of retroperitoneal soft tissue sarcomas.