Diverticulosis and risk of diverticulitis in 10 years; a Swedish retrospective observational study.

BACKGROUND: Diverticulosis is a common condition and is thought to be increasing in the Western population. Several studies have attempted to estimate the prevalence of diverticulosis and it's inflamed state, diverticulitis, with results varying depending on study population and methodology, The aim of this study was to investigate the prevalence of diverticulosis in patients undergoing colonoscopy at a Swedish academic referral centre and to study the incidence of diverticulitis in a 10-year follow-up. METHODS: All patients who had undergone colonoscopy at the Endoscopy unit, Skåne University Hospital, Sweden, during 01 January 2010 through 31 December 2011 were identified. The colonoscopy referrals, colonoscopy reports, and medical records until 14 June 2022 were reviewed. RESULTS: In all, 2648 patients were included in the study, whereof 910 patients had reported diverticulosis (34.4%). During the 10-year follow-up, the overall incidence of computed tomography verified diverticulitis was 4.4%, and 0.6% for patients with and without diverticulosis at index colonoscopy, respectively. Of the 50 patients that developed diverticulitis, 21 were complicated and 29 uncomplicated. CONCLUSION: Diverticulosis is a common condition in the population, although most patients will not develop diverticulitis.

Muscle mass and quality as predictors for complications, recurrence and length of hospital stay in acute uncomplicated diverticulitis: a retrospective cohort study.

OBJECTIVES: The aim of this study was to investigate the potential correlation between muscle mass/muscle quality and risk of complications or recurrence in patients presenting with acute uncomplicated diverticulitis. It was also to study if low muscle mass/quality correlated to prolonged hospital stay. MATERIALS AND METHODS: The study population comprised 501 patients admitted to Helsingborg Hospital or Skåne University Hospital between 1 January 2015 and 31 December 2017, who had been diagnosed with acute uncomplicated diverticulitis and undergone computed tomography upon admission. The scans were used to estimate skeletal muscle mass and muscle radiation attenuation (an indicator for muscle quality). Skeletal muscle index was obtained by adjusting skeletal muscle mass to the patients' height. Values of below the fifth percentile of a normal population were considered low. RESULTS: There were no differences between the patients with normal versus those with low skeletal muscle mass, skeletal muscle index or muscle radiation attenuation regarding risk of complications or recurrence of diverticular disease. However, as only 11 patients had complications, no conclusion as to a potential correlation can be made. Low muscle quality correlated to longer hospital stay, also when adjusting for other potential confounders. CONCLUSIONS: Muscle mass/quality do not seem to serve as predictor of risk for recurrent disease in patients with acute uncomplicated diverticulitis. However, low muscle radiation attenuation was associated with prolonged hospital stay. This indicates that muscle quality, assessed by computed tomography scan, might be used in clinical practise to identify patients at risk of longer hospitalisation.

Impact of previous diverticulitis on 5-year survival and recurrence rates in patients with colorectal cancer.

BACKGROUND: Diverticulitis and colorectal cancer (CRC) share epidemiological characteristics, but their relationship remains unknown. It is unclear if prognosis following CRC differ for patients with previous diverticulitis compared to those with sporadic cases and patients with inflammatory bowel disease or hereditary syndromes. AIM: The aim was to determine 5-year survival and recurrence after colorectal cancer in patients with previous diverticulitis, inflammatory bowel disease and hereditary colorectal cancer compared to sporadic cases. METHODS: Patients <75 years of age diagnosed with colorectal cancer at Skåne University Hospital Malmö, Sweden, between January 1st 2012 and December 31st 2017 were identified through the Swedish colorectal cancer registry. Data was retrieved from the Swedish colorectal cancer registry and chart review. Five-year survival and recurrence in colorectal cancer patients with previous diverticulitis were compared to sporadic cases, inflammatory bowel disease associated and hereditary colorectal cancer. RESULTS: The study cohort comprised 1052 patients, 28 (2.7%) with previous diverticulitis, 26 (2.5%) IBD, 4 (1.3%) hereditary syndromes and 984 (93.5%) sporadic cases. Patients with a history of acute complicated diverticulitis had a significantly lower 5-year survival rate (61.1%) and higher recurrence rate (38.9%) compared to sporadic cases (87.5% and 18.8% respectively). CONCLUSION: Patients with acute complicated diverticulitis had worse 5-year prognosis compared to sporadic cases. The results emphasize the importance of early detection of colorectal cancer in patients with acute complicated diverticulitis.

Accuracy of magnetic resonance imaging staging of tumour and nodal stage in rectal cancer treated by primary surgery: a population-based study.

AIM: The preoperative stage of rectal cancer is an important prognostic factor affecting treatment recommendations. Currently, magnetic resonance imaging (MRI) is used for clinical staging to identify patients who should be recommended for neoadjuvant oncological treatment. The aim of this work was to investigate the accuracy of the preoperative T- and N-stage and also involvement of the mesorectal fascia (MRF) as determined by MRI in a Swedish national cohort. METHOD: Patients who had undergone resectional surgery for rectal cancer without neoadjuvant treatment in Sweden in the period 2013-2017 were identified through the Swedish Colorectal Cancer Registry (n = 2062). The T- and N-stage determined by preoperative MRI were compared with the histopathological results. The MRI-assessed MRF status was compared with the circumferential resection margin. RESULTS: Sensitivity for differentiating T1-2 from T3-4 was 69% and specificity 77%. Sensitivity to detect N1-2 was 42% and specificity 81%. Sensitivity for MRF positivity was 50% and specificity 92%. Agreement analysed by weighted kappa analysis was 0.47 for T-stage [confidence interval (CI) 0.44-0.51], 0.24 for N-stage (CI 0.19-0.24) and 0.20 for MRF status (CI 0.12-0.29). CONCLUSION: In this study, accuracy of the preoperative MRI was lower than expected for rectal cancers. Overstaging might lead to potentially harmful neoadjuvant treatment and understaging can lead to a higher risk of tumour recurrence. The results of this study show that efforts should be made to increase the accuracy of the preoperative evaluation in order to optimize treatment recommendations.

Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™.

BACKGROUND: Oncoplastic breast-conserving surgery allows larger resections in unfavorable locations, with an improved chance of preserving esthetics. Indications and timing for potential contralateral surgery to obtain symmetry are not clear. The aim of this study was to evaluate patient satisfaction after unilateral oncoplastic volume displacement surgery, to investigate potential risk factors for lower patient satisfaction and to assess patient wish for contralateral surgery. METHOD: A cohort of 144 women, consecutively treated for breast cancer with unilateral breast-conserving oncoplastic volume displacement surgery, followed by radiotherapy and with an unoperated contralateral breast, was sent the BREAST-Q™ breast-conserving therapy (BCT) and a study-specific questionnaire. In all, 120 women (83%) responded. For these women, the median value for resected specimen weight was 92 g (range 14-345) and for the estimated percentage of the breast volume excised 15% (range 3-35%). RESULTS: The median patient-reported score for "Satisfaction with breast" (BREAST-Q™ BCT) was 74/100. Factors associated with a score below median value in a simple logistic regression model adjusted for age and BMI were axillary clearance (OR 2.46, 95% CI 1.09-5.56), neoadjuvant chemotherapy (OR 3.26, 95% CI 1.15-9.24), and low breast density (OR 2.32 95% CI 1.02-5.29). Thirteen women (11%) were interested in contralateral surgery. CONCLUSION: Most patients in this study cohort, who had undergone breast-conserving therapy with oncoplastic volume displacement techniques, were satisfied with their breasts without surgery to the contralateral breast. This indicates that contralateral surgery to achieve symmetry only should be performed after individual evaluation and as a delayed procedure.

Aesthetic result after breast-conserving therapy is associated with quality of life several years after treatment. Swedish women evaluated with BCCT.core and BREAST-Q™.

PURPOSE: A gold standard for evaluation of aesthetic outcome after breast-conserving therapy (BCT) is still lacking. The BCCT.core software has been developed to assess aesthetic result in a standardised way. We aimed to study how the result of BCCT.core after BCT is associated with quality of life, measured with the BREAST-Q™, a validated questionnaire. METHODS: Women eligible for BCT were consecutively recruited between February 1st 2008 and January 31st 2012 (n = 653). Photographs of 310 women, taken one year after BCT, were evaluated using the BCCT.core software. The postoperative BCT module of the BREAST-Q™ questionnaire was administered by mail and 348 questionnaires were returned (median 5.5 years after BCT). In all, 216 women had both BCCT.core results and completed BREAST-Q™ questionnaires available. RESULTS: The results from the BCCT.core evaluation were: excellent n = 49 (15.8%); good n = 178 (57.4%); fair n = 73 (23.5%); poor n = 10 (3.2%). The median BREAST-Q™ score for satisfaction with breasts was 66 [interquartile range (IQR) 57-80] and for psychosocial well-being 82 (IQR 61-100). Poor/fair results on BCCT.core were associated with Q-scores below median for both satisfaction with breasts [odds ratio (OR) 3.4 (confidence interval (CI) 1.7-6.8)] as well as for psychosocial well-being [OR 2.2 (CI 1.1-4.2)]. CONCLUSIONS: A statistically significant association between BCCT.core results one year after BCT and quality of life ratings using BREAST-Q™ several years later is shown in this study. This implies that the BCCT.core may be valuable in BCT follow-up and used as a standardised instrument in the evaluation of aesthetic results.

Patients Undergoing Breast-Conserving Surgery Can Benefit from the Opportunity to Participate in Choosing Their Surgical Technique.

BACKGROUND: Shared decision-making is increasingly advocated in many countries. The aims of this study were to investigate whether patients receiving breast-conserving surgery at Skåne University Hospital Malmö, Sweden, perceived an offered possibility to join in the decision-making process regarding the surgical method; to identify potential determinants for not having perceived such an offer; and to study how this perception of being offered an opportunity to take part in the decision-making process affected satisfaction with the aesthetic outcome. METHODS: Women offered breast-conserving surgery were consecutively recruited over a period of 4 years. In all, 324 women completed a study-specific questionnaire. RESULTS: A majority of the women (53 %) perceived that they had not, or had only partly, been offered a possibility to take part in the decision-making process. Patients who reported that they had received enough preoperative information regarding the expected aesthetic result were more likely to have perceived such an offer (odds ratio (OR) 5.44; confidence interval (CI) 2.83-10.43). Women who had perceived an opportunity to be involved were more satisfied with the aesthetic result (OR 2.71; CI 1.18-6.25) and more likely to have had their expectations met regarding the aesthetic result (OR 5.91; CI 2.01-17.38). CONCLUSION: When deciding on a suitable surgical approach for women with early breast cancer, physicians could try to more clearly communicate to the women that they can choose whether or not to participate in the decision-making regarding surgical technique. This might improve satisfaction. An important part of patient involvement is sufficient preoperative information.

Determinants for patient satisfaction regarding aesthetic outcome and skin sensitivity after breast-conserving surgery.

BACKGROUND: With the development of new surgical techniques in breast cancer, such as oncoplastic breast surgery, increased knowledge of risk factors for poor satisfaction with conventional breast-conserving surgery (BCS) is needed in order to determine which patients to offer these techniques to. The aim of this study was to investigate patient satisfaction regarding aesthetic result and skin sensitivity in relation to patient, tumour, and treatment factors, in a consecutive sample of patients undergoing conventional BCS. METHODS: Women eligible for BCS were recruited between February 1, 2008 and January 31, 2012 in a prospective setup. In all, 297 women completed a study-specific questionnaire 1 year after conventional BCS and radiotherapy. Potential risk factors for poor satisfaction were investigated using logistic regression analysis. RESULTS: The great majority of the women, 84%, were satisfied or very satisfied with the overall aesthetic result. The rate of satisfaction regarding symmetry between the breasts was 68% and for skin sensitivity in the operated breast it was 67%. Excision of more than 20% of the preoperative breast volume was associated with poor satisfaction regarding overall aesthetic outcome, as was axillary clearance. A high BMI (≥30 kg/m2) seemed to affect satisfaction with symmetry negatively. Factors associated with less satisfied patients regarding skin sensitivity in the operated breast were an excision of ≥20% of preoperative breast volume, a BMI of 25-30 kg/m2, axillary clearance, and radiotherapy. Re-excision and postoperative infection were associated with lower rates of satisfaction regarding both overall aesthetic outcome and symmetry, as well as with skin sensitivity. CONCLUSIONS: Several factors affect patient satisfaction after BCS. A major determinant of poor satisfaction in this study was a large excision of breast volume. If the percentage of breast volume excised is estimated to exceed 20%, other techniques, such as oncoplastic breast surgery, with or without contralateral surgery, or mastectomy with reconstruction, may be considered.

Total mesorectal excision quality in rectal cancer surgery affects local recurrence rate but not distant recurrence and survival: population-based cohort study.

BACKGROUND: The quality of the total mesorectal excision specimen in rectal cancer surgery is assessed with a three-tier grade (mesorectal, intramesorectal and muscularis propria). This study aimed to analyse the prognostic impact of the total mesorectal excision grade on survival, and to identify risk factors for intramesorectal and muscularis propria resection in a population-based setting. METHODS: All patients in the Swedish Colorectal Cancer Registry with rectal cancer stage I-III ≤ 10 cm from the anal verge, diagnosed 2015-2019, undergoing total mesorectal excision were analysed. Clinical, surgical and pathological data were retrieved and analysed for the following primary outcomes: local and distant recurrence and overall and relative survival; secondary outcomes were risk factors for total mesorectal excision grading (intramesorectal or muscularis propria resection). Of note, postoperative death < 30 days or recurrence within 90 days were exclusion criteria for survival and recurrence analysis. Recurrence-free patients with less than 3 years follow-up, and patients lacking data regarding recurrence, were also excluded from recurrence analyses. RESULTS: Overall, of 7979 patients treated during the study interval, 1499 patients were eligible for recurrence, 2441 patients for survival and 2476 patients for risk-factor analyses, of which 75% were graded mesorectal, 17% intramesorectal and 8% muscularis propria. Median follow-up for survival was 42 (1-77) months. The worst total mesorectal excision grading (muscularis propria resection) was an independent risk factor for local recurrence in multivariable analysis (HR 2.73, 95% c.i. 1.07 to 7.0, P = 0.036). Total mesorectal excision grade had no impact on distant recurrence or survival. Female sex, tumour level <5 cm, abdominoperineal resection, minimally invasive surgery (laparoscopic and robotic), high blood loss, long duration of surgery and intraoperative perforation were independent risk factors for worse total mesorectal excision grading (intramesorectal and/or muscularis propria resection) in multivariable analyses. CONCLUSION: Muscularis propria resection increases the risk of local recurrence but does not seem to affect distant recurrence or survival.

Long-term Outcomes of Endoscopic Vacuum Therapy and Transanal Drainage for Anastomotic Leakage After Anterior Resection.

BACKGROUND/AIM: Anastomotic leakage (AL) after anterior resection for rectal cancer occurs in up to 26% of patients. In the last decade, endoscopic vacuum therapy (EVT) has gained interest as a treatment option for AL. This study aimed to compare the clinical success rate of EVT versus transanal drainage (TD) in AL treatment and investigate whether the frequency of bowel continuity differed. PATIENTS AND METHODS: Patients treated for rectal cancer at the Skåne University Hospital, Sweden between 2009-2018 were identified through the Swedish Colorectal Cancer Registry (SCRCR). Patient characteristics, operative and AL data were retrieved by SCRCR and chart review. RESULTS: Out of 1,095 patients subjected to rectal cancer surgery, 361 patients had undergone anterior resection. AL occurred in 39 patients, of these 14 patients were treated with EVT and 17 with TD. Bowel continuity was achieved in 50% of patients treated with EVT and 65% of patients treated with TD (p=0.28). The patients were under treatment for a median period of 24.5 days (IQR=11-36 days) when treated with EVT and 37 days (IQR=17-51 days) with TD. CONCLUSION: No superiority of EVT treatment could be shown in restoring bowel continuity. This questions the role of EVT in AL treatment after anterior resection.

Long-term outcome of lymph vessel transplantation after chronic lymphorrhea.

A 52-year-old male patient developed a chronic fistula with excessive lymph leakage in the left axilla following removal of an enlarged lymph node with chronic local adipose tissue inflammation due to infection. After multiple surgeries, treatment with lymphatic vessel transplantation was successful. No recurrence occurred over 20 years of follow-up.

Tumor and nodal staging of colon cancer: accuracy of preoperative computed tomography at a Swedish high-volume center.

BACKGROUND: When deciding treatment options for patients with colon cancer, accurate staging is required. In Sweden, the main preoperative evaluation modality to determine tumor and nodal stage is computed tomography (CT). PURPOSE: The aim of this study was to investigate how well the preoperative (CT-determined) clinical tumor and nodal stage (cTN) correlated with the postoperative histopathological stage (pTN). Another aim was to validate the tumor and nodal stage data in the Swedish Colorectal Cancer Registry (SCRCR). MATERIAL AND METHODS: The SCRCR was used to identify patients with colon cancer, treated at a Swedish high-volume center during 2013-2016 (n = 974). Data were gathered from medical records regarding cTN and pTN stage, and predefined patient and tumor variables. The agreement between cTN and pTN was analyzed using kappa statistics. RESULTS: After excluding patients with either pre- or postoperative TN stage missing, 383 patients remained for further analyses. The analyses showed an agreement between cT and pT of κ: 0.27 and between cN and pN of κ: 0.21 (fair agreement). When comparing tumors with low (T1-3; N0) versus high risk (T4; N1-2), the kappa value was 0.19 (slight agreement). When comparing the SCRCR to medical records, 78% of completely staged tumors had been correctly reported. CONCLUSION: The agreement between cTN and pTN was low in this study population, indicating a need for enhanced precision of the preoperative staging process. A high frequency of erroneous preoperative staging data in the SCRCR shows the need for further efforts of ensuring correct data transfers into the registry.