Patterns and resectability of colorectal cancer recurrences: outcome study within the COLOFOL trial

BACKGROUND

Improvements in surgery, imaging, adjuvant treatment, and management of metastatic disease have led to modification of previous approaches regarding the risk of recurrence and prognosis in colorectal cancer. The aims of this study were to map patterns, risk factors, and the possibility of curative treatment of recurrent colorectal cancer in a multimodal setting.

METHODS

This was a cohort study based on the COLOFOL trial population of patients who underwent radical resection of stage II or III colorectal cancer. The medical files of all patients with recurrence within 5 years after resection of the primary tumour were scrutinized. Follow-up time was 5 years after the first recurrence. Primary endpoints were cumulative incidence, site, timing, and risk factors for recurrence, and rate of potentially curative treatment. A secondary endpoint was survival.

RESULTS

Of 2442 patients, 471 developed recurrences. The 5-year cumulative incidence was 21.4 (95 per cent c.i. 19.5 to 23.3) per cent. The median time to detection was 1.1 years after surgery and 87.3 per cent were detected within 3 years. Some 98.2 per cent of patients who had potentially curative treatment were assessed by a multidisciplinary tumour board. A total of 47.8 per cent of the recurrences were potentially curatively treated. The 5-year overall survival rate after detection was 32.0 (95 per cent c.i. 27.9 to 36.3) per cent for all patients with recurrence, 58.6 (51.9 to 64.7) per cent in the potentially curatively treated group and 7.7 (4.8 to 11.5) per cent in the palliatively treated group.

CONCLUSION

Time to recurrence was similar to previous results, whereas the 21.4 per cent risk of recurrence was somewhat lower. The high proportion of patients who received potentially curative treatment, linked to a 5-year overall survival rate of 58.6 per cent, indicates that it is possible to achieve good results in recurrent colorectal cancer following multidisciplinary assessment.

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction

Aim

Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population.

Method

Medical records of patients identified via the Swedish Colorectal Cancer Register 2007–2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates.

Results

A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group.

Conclusion

This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Influence of primary tumour and patient factors on survival in patients undergoing curative resection and treatment for liver metastases from colorectal cancer

Background

Resection of the primary tumour is a prerequisite for cure in patients with colorectal cancer, but hepatic metastasectomy has been used increasingly with curative intent. This national registry study examined prognostic factors for radically treated primary tumours, including the subgroup of patients undergoing liver metastasectomy.

Methods

Patients who had radical resection of primary colorectal cancer in 2009–2013 were identified in a population‐based Swedish colorectal registry and cross‐checked in a registry of liver tumours. Data on primary tumour and patient characteristics were extracted and prognostic impact was analysed.

Results

Radical resection was registered in 20 853 patients; in 38·7 per cent of those registered with liver metastases, surgery or ablation was performed. The age‐standardized relative 5‐year survival rate after radical resection of colorectal cancer was 80·9 (95 per cent c.i. 80·2 to 81·6) per cent, and the rate after surgery for colorectal liver metastases was 49·6 (46·0 to 53·2) per cent. Multivariable analysis identified lymph node status, multiple sites of metastasis, high ASA grade and postoperative complications after resection of the primary tumour as strong risk factors after primary resection and following subsequent liver resection or ablation. Age, sex and primary tumour location had no prognostic impact on mortality after liver resection.

Conclusion

Lymph node status and complications have a negative impact on outcome after both primary resection and liver surgery. Older age and female sex were underrepresented in the liver surgical cohort, but these factors did not influence prognosis significantly.

Postoperative complications following colonic resection for cancer are associated with impaired long-term survival

AIM

Surgery for colorectal cancer is associated with a high incidence of postoperative complications. The aim of this study was to analyse whether postoperative complications following radical resection for colorectal cancer are associated with increased recurrence rate and impaired survival.

METHOD

Patients operated for colon cancer between 2007 and 2009 with curative intent were identified through the Swedish Colorectal Cancer Registry. The cohort was divided into three subgroups: patients who developed severe postoperative complications, patients who developed non-severe complications and patients who did not develop any complication (controls).

RESULTS

Of 6779 patients included in the study, 640 (9%) developed severe complications, 994 (15%) non-severe complications and 5145 (76%) had no complications. The 5-year overall survival rate was 60.3% in the severe complication group, 64.2% in the non-severe complication group and 72.8% in the control group (P < 0.01). The 3-year disease-free survival rate was 66.8%, 70.9% and 77.8% respectively (P < 0.01). The recurrence rate did not differ between the three groups. In multivariate analysis, both severe and non-severe complications were found to be risk factors for decreased overall survival at 5 years [hazard ratio (HR) 1.38, 95% CI 1.47-1.92, and HR 1.18, 95% CI 1.27-1.60 respectively; P < 0.05) as well as for decreased 3-year disease-free survival (HR 1.37, 95% CI 1.14-1.65, and HR 1.26, 95% CI 1.08-1.48 respectively; P < 0.05).

CONCLUSION

Complications after colonic resection for cancer are associated with impaired 5-year overall survival and 3-year disease-free survival and exhibit more severe postoperative complications, mainly via mechanisms other than cancer recurrence.

High Tie or not in Resection for Cancer in the Sigmoid Colon?

BACKGROUND AND AIMS

The optimal extent of mesenteric resection in colon cancer surgery remains elusive. The aim was to assess the impact on perioperative morbidity and oncological outcome depending on the height of central vessel ligation in sigmoid resection for adenocarcinomas.

MATERIAL AND METHODS

All cases of stage I-III sigmoid cancers, operated on with locally radical resections (2007-2009), were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature, that is, ligation of the inferior mesenteric artery, ligation of the superior rectal artery, or ligation of the sigmoid branches.

RESULTS

In total, 999 cases were identified and possible to categorize. Although higher ligation level yielded a higher number of lymph nodes, 3- or 5-year overall survival, 5-year disease-free survival, or recurrence rate did not differ between the groups (p = 0.79, p = 0.41, p = 0.67, p = 0.51). No differences in survival were detected after multivariate analysis adjusted for age, sex, T-stage, N-stage, American Society of Anesthesiologists classification, and adjuvant therapy.

CONCLUSION

This large population-based study showed increased lymph node yield but no survival benefit or any decreased recurrence rate by high tie in resection of sigmoid cancer.

Quality of life and cost effectiveness in a randomized trial of patients with colorectal cancer and peritoneal metastases

BACKGROUND

The aim was to compare health-related quality-of-life (HRQOL) and cost-effectiveness between cytoreductive surgery with intraperitoneal chemotherapy (CRS + IPC) and systemic chemotherapy for patients with colorectal peritoneal metastases.

METHODS

Patients included in the Swedish Peritoneal Trial comparing CRS + IPC and systemic chemotherapy completed the EORTC QLQ-C30 and SF-36 questionnaires at baseline, 2, 4, 6, 12, 18, and 24 months. HRQOL at 24 months was the primary endpoint. EORTC sum score, SF-36 physical and mental component scores at 24 months were calculated and compared for each arm and then referenced against general population values. Two quality-adjusted life-year (QALY) indices were applied (EORTC-8D and SF-6D) and an incremental cost-effectiveness ratio (ICER) per QALY gained was calculated. A projected life-time ICER per QALY gained was calculated using predicted survival according to Swedish population statistics.

RESULTS

No statistical differences in HRQOL between the arms were noted at 24 months. Descriptively, survivors in the surgery arm had higher summary scores than the general population at 24 months, whereas survivors in the chemotherapy arm had lower scores. The projected life-time QALY benefit was 3.8 QALYs in favor of the surgery arm (p=0.06) with an ICER per QALY gained at 310,000 SEK (EORTC-8D) or 362,000 SEK (SF-6D) corresponding to 26,700-31,200 GBP.

CONCLUSION

The HRQOL in patients with colorectal peritoneal metastases undergoing CRS + IPC appear similar to those receiving systemic chemotherapy. Two-year survivors in the CRS + IPC arm have comparable HRQOL to a general population reference. The treatment is cost-effective according to NICE guidelines.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis

Background

Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial.

Methods

Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results.

Results

Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P &lt; 0·001); however, the Cleveland Global Quality of Life score did not differ between groups.

Conclusion

The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 (http://www.clinicaltrials.gov).

No benefit of extended mesenteric resection with central vascular ligation in right-sided colon cancer

AIM

The optimal extent of mesenteric resection in colon cancer surgery is not known. We have previously shown an increased mortality associated with wider mesenteric resection in right hemicolectomy. This study compares the short- and long-term outcome in three variations of right hemicolectomy based on the position of the vascular ligature in the mesentery.

METHOD

In all, 2084 cases of cancer in the caecum or ascending colon were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature: central ligation of ileocolic vessels (ICVs) ± right colic vessels (n = 390), central ligation of ICVs + right branch of middle colic vessels (MCVs) (n = 1360) and central ligation of ICVs + central ligation of MCVs (n = 334).

RESULTS

Neither 3-year overall survival, 3-year disease-free survival nor local recurrence rate differed between the groups (P = 0.604; P = 0.247; P = 0.237). There was still no difference after multivariate analysis adjusted for age, sex, American Society of Anesthesiologists classification, TNM stage and adjuvant therapy. An increased peri-operative mortality, however, was observed in extended mesenteric resections, increasing from 0.8% in non-extended to 3.6% in more extended resection, P = 0.025.

CONCLUSION

The study showed no survival benefit by more extended mesenteric resection, indicating that there is no need to extend the mesenteric resection to involve the MCVs in cancer of the caecum or ascending colon. On the contrary, increased peri-operative mortality by more extensive mesenteric resection was noted suggesting that a more conservative approach may be favourable.

Wide excision in right-sided colon cancer is associated with decreased survival

BACKGROUND AND AIMS

Nodal involvement is the most important prognostic factor in colon cancer. Although theoretically appealing, it is not known if wider mesenteric excision improves the oncological result. The aim of this retrospective study was to investigate whether wider mesenteric excision yields a superior oncological result.

MATERIAL AND METHODS

Depending on the resection length, 333 cases of locally radical right-sided hemicolectomies due to adenocarcinoma were compared for perioperative morbidity and mortality, disease-free survival, and long-term survival.

RESULTS

Postoperative mortality was significantly higher in the quartile with the longest resections, p = 0.003. In a multivariate analysis adjusted for age, stage, emergency operation, adjuvant chemotherapy, and year of operation, a negative relationship between resection length and 5-year overall survival was noted, p = 0.01. No differences in the causes of death or in the incidence of local or distant recurrences were noted between groups.

CONCLUSIONS

Wider excision in right-sided hemicolectomies was not associated with any oncological benefit but an increased postoperative mortality and a decreased 5-year overall survival. These findings may suggest consideration to perform wide mesenteric resections routinely. Further research is warranted to define which patients benefit from wider resections.

Platelet shedding of CD40L is regulated by matrix metalloproteinase-9 in abdominal sepsis

BACKGROUND AND OBJECTIVES

Platelet-derived CD40L is known to regulate neutrophil recruitment and lung damage in sepsis. However, the mechanism regulating shedding of CD40L from activated platelets is not known. We hypothesized that matrix metalloproteinase (MMP)-9 might cleave surface-expressed CD40L and regulate pulmonary accumulation of neutrophils in sepsis.

METHODS

Abdominal sepsis was induced by cecal ligation and puncture (CLP) in wild-type and MMP-9-deficient mice. Edema formation, CXC chemokine levels, myeloperoxidase levels, neutrophils in the lung and plasma levels of CD40L and MMP-9 were quantified.

RESULTS

CLP increased plasma levels of MMP-9 but not MMP-2. The CLP-induced decrease in platelet surface CD40L and increase in soluble CD40L levels were significantly attenuated in MMP-9 gene-deficient mice. Moreover, pulmonary myeloperoxidase (MPO) activity and neutrophil infiltration in the alveolar space, as well as edema formation and lung injury, were markedly decreased in septic mice lacking MMP-9. In vitro studies revealed that inhibition of MMP-9 decreased platelet shedding of CD40L. Moreover, recombinant MMP-9 was capable of cleaving surface-expressed CD40L on activated platelets. In human studies, plasma levels of MMP-9 were significantly increased in patients with septic shock as compared with healthy controls, although MMP-9 levels did not correlate with organ injury score.

CONCLUSIONS

Our novel data propose a role of MMP-9 in regulating platelet-dependent infiltration of neutrophils and tissue damage in septic lung injury by controlling CD40L shedding from platelets. We conclude that targeting MMP-9 may be a useful strategy to limit acute lung injury in abdominal sepsis.

Population-based data from the Swedish Colon Cancer Registry

BACKGROUND

Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer.

METHODS

Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon.

RESULTS

This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term.

CONCLUSION

These population-based data represent good-quality reference points.

Collagen levels are normalized after decompression of experimentally obstructed colon

AIM

Our aim was to define the dynamics in collagen concentrations in the large bowel wall following decompression of experimental obstruction.

METHOD

Colonic obstruction was created in 28 male rats by the placement of a silicone ring around the distal colon. The ring was removed after 4 days to mimic endoscopical decompression by stent deployment. Colon circumference and collagen concentration were measured proximal to the obstructed segment immediately and at 3 and 10 days after decompression. The corresponding colonic sites of 23 sham-operated and eight nonoperated control animals were subjected to identical analyses.

RESULTS

Four days of obstruction resulted in a more than twofold increase in colonic circumference (20 vs 8 mm), with a concomitant 43% reduction (P = 0.001) in collagen concentration in the bowel wall proximal to the obstruction compared with sham animals. Three days after decompression, collagen concentrations remained reduced (P < 0.05), while there was no significant difference after 10 days with either sham-operated or nonoperated controls. Colonic circumference of the obstructed colon remained slightly distended (11 mm) on day 10 and tended to correlate (r(S) = 0.51, P = 0.053) with total matrix metalloproteinase activity.

CONCLUSION

The marked reduction in collagen concentration in an experimentally obstructed colon is normalized 10 days after decompression. These findings may have clinical implications for the timing of surgical resection.

Standard protocol for assessment of colon cancer improves the quality of pathology

AIM

Tumour stage is the most important prognostic factor in colon cancer. The aim of this study was to examine the impact on the quality of pathology of the use of a standardized pathological and anatomical (PAD) protocol.

METHOD

A standardized PAD protocol for colorectal cancer was developed and all patients subjected to colon resection due to adenocarcinomas between 2004 and 2006 were analysed regarding lymph node status, circumferential resection margin (CRM), and intravascular and perineural growth. Moreover, usage of the PAD protocol and whether a pathologist or biomedicine analytical technician (BMA) performed the lymph node dissection was noted, and also whether the surgical procedure was elective or acute.

RESULTS

During the study period 302 colon resections were carried out. The standard protocol was employed in 68% of the cases, varying from 0% to 100% between pathologists. The median number of investigated lymph nodes was 16 ± 11. When the lymph node dissection was performed by a BMA, significantly more lymph nodes were examined; 22 ± 15 and 14 ± 9, respectively (P < 0.01). There was a positive correlation between application of the standard protocol and the number of analysed lymph nodes (< 0.05). Comments on CRM, perineural growth and intravascular growth were also significantly more frequent when the protocol was used. Emergency surgery did not influence the handling of the specimens.

CONCLUSION

Minor changes in procedure in terms of a standard protocol for pathology and specimen dissection by BMAs, leading to an increased quality of the PAD-report, may also improve the long-term outcome for patients.

Abdominal plain film findings in acute ischemic bowel disease differ with age

PURPOSE

To evaluate the use and findings of abdominal plain film in acute ischemic bowel disease (AIBD) in different age subsets, and to correlate the clinical findings.

MATERIAL AND METHODS

Eighty-nine radiographically examined patients with AIBD at Malmö University Hospital, Sweden between 1987 and 1996.

RESULTS

In 89%, the plain film displayed pathologic signs. Bowel dilatation was more common in the elderly. Of 68 patients aged > or = 71 years, 19 (28%) had colon gas/fluid levels with/without colon dilatation, and of 19 patients > 84 years 16 (84%) had small-bowel dilatation. Of 20 patients aged < 71 years, 1 (5%) had colon gas/fluid levels with/without colon dilatation, and 11 (55%) small-bowel dilatation (P < 0.05; P < 0.05). Gasless abdomen was more common in the younger age group, noted in 5 of 20 (25%) patients aged < 71 years, compared to 2 of 68 (3%) patients aged > or = 71 years (P = 0.001). Of the patients with diarrhea, 13 of 33 (40%) had colon gas/fluid levels with/without colon dilatation compared to 2 of 29 (7%) without (P = 0.003). In the elderly (> or = 71 years), 48 of 53 (91%) patients with bowel dilatation on plain film died, compared to 11 out of 16 (69%) without this finding (P < 0.05).

CONCLUSION

Abdominal plain film findings differed with age. Bowel dilatation was more frequent in the elderly with AIBD, whereas gasless abdomen was more common in younger patients. The radiographic findings were associated with clinical symptoms and mortality.

Systemic interleukin-6 response to colorectal surgery originates from the bowel

BACKGROUND

Surgical trauma evokes a systemic cytokine response which is enhanced in patients with colorectal cancer. The aim of this study was to locate the origin of the systemic cytokine response to colorectal surgery.

METHODS

The concentrations of interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-alpha) were analysed in systemic and mesenteric venous blood in 12 patients operated on with colorectal resections due to cancer or benign lesions. Immunohistochemical staining and analysis of tissue concentrations of IL-6 and TNF-alpha in homogenates from tumours and benign specimens were performed.

RESULTS

Mesenteric venous blood contained higher concentrations of IL-6 compared to systemic venous blood after resection, but not before. Tissue concentration of IL-6 was higher in the tumours compared to the benign specimens and immunohistochemistry revealed an abundance of IL-6 and TNF-alpha in malignant epithelium compared to benign mucosa.

CONCLUSION

The higher concentration of IL-6 in venous blood from the mesenterium of the resected colonic segment compared to systemic levels, indicates that the bowel is the source of the IL-6 response to surgical trauma in colorectal surgery.

Enhanced cytokine response to surgical trauma in patients with colorectal cancer

OBJECTIVE

Cancer is an immunologic challenge, and it was hypothesized that the presence of a cancer could modulate the cytokine response to operative trauma.

SETTING

University hospital, Sweden.

SUBJECTS

Patients operated with colonic or rectal resections; 9 patients with colorectal cancer and 16 patients with benign lesions--8 of which were inflammatory.

INTERVENTION

Venous blood samples were collected preoperatively; every 30 min intraoperatively; 6 h postoperatively and daily for 6 days in the postoperative period.

MAIN OUTCOME MEASURES

IL-1beta and TNF-alpha were analyzed by commercial ELISAs, whereas IL-6 was analyzed by the B9 bio-assay.

RESULTS

Preoperative cytokine levels were similar in the malignant and benign groups, but intraoperative IL-6, IL-1beta and TNF-alpha serum levels and postoperative IL-6 and TNF-alpha serum levels were significantly (p < 0.05) higher in the malignant group.

CONCLUSION

The results indicate that colorectal malignancy enhances the IL-1beta, TNF-alpha and IL-6 response to surgical trauma.

Inhibition of matrix metalloproteinases enhances breaking strength of colonic anastomoses in an experimental model

BACKGROUND

The breaking strength of colonic anastomoses declines after operation to a minimum at days 3-4, with a subsequent risk of anastomotic dehiscence. The mechanism is thought to be collagen degradation by matrix metalloproteinases (MMPs). This study examined the pathogenic role of MMPs on the mechanical strength of colonic anastomoses by giving the synthetic broad-spectrum MMP inhibitor BB-1101 systemically.

METHODS

Forty-eight male Sprague-Dawley rats were treated daily for 7 days with BB-1101 30 mg/kg or vehicle alone (control) starting 2 days before operation. The breaking strength of standardized left-sided colonic anastomoses was measured on postoperative days 1, 3 and 7.

RESULTS

Serum BB-1101 levels were increased at 100 nmol/l in BB-1101-treated rats. The anastomotic breaking strength was 48 per cent higher (P = 0.02) in BB-1101-treated animals compared with controls on postoperative day 3. Neither collagen accumulation nor infiltration of neutrophils in the anastomotic area was influenced by BB-1101 treatment. Net deposition of new collagen in subcutaneous sponges was unaffected by the BB-1101.

CONCLUSION

The enhanced breaking strength of colonic anastomoses during the critical early postoperative phase found after administration of a broad-spectrum MMP inhibitor implies that MMPs might increase the risk of anastomotic dehiscence. Presented in part to the third joint meeting of the European Tissue Repair Society and the Wound Healing Society in Bordeaux, France, 24-28 August 1999, and published in abstract form in Wound Repair Regen 1999; 7: A321

Survival after operations for ischaemic bowel disease

OBJECTIVE

To find out what factors influence the outcome of operations for ischaemic bowel disease.

DESIGN

Retrospective study.

SETTING

University hospital, Sweden.

MAIN OUTCOME MEASURES

Morbidity and mortality.

SUBJECTS

74 patients, mean age 75 years (range 40-98), operated on for acute bowel ischaemia between 1987 and 1996.

RESULTS

A total of 75 emergency operations were done, including 42 bowel-resections, one percutaneous transluminal angioplasty, and one thrombectomy. Thirty-one patients had exploration alone because of extensive gangrene. These explorations were performed in 11 of 14 (79%) patients aged >84 years; 18 of 40 (45%) patients aged 71-84 years and 2 of 21 (9%) patients aged <71 years, (p < 0.001). Of the 14 patients over 84 years old only one survived more than 30 days, compared with 12 of 40 (30%) aged 71-84 years, and 17 of 21 (81%) younger than 71 years (p < 0.001). Operation within 6 hours of admission resulted in significantly better survival compared with operations done after more than 6 hours delay (p = 0.04).

CONCLUSIONS

Advanced age was a strong risk factor for death after operation for ischaemic bowel disease, and there was a higher incidence of unresectable gangrene. Delay in surgical intervention was associated with increasing mortality.

Postoperative downregulation of MHC class II antigen on monocytes does not differ between open and endovascular repair of aortic aneurysms

OBJECTIVES

To study immune cell response and histocompability class II (HLA-DR) expression after aortic aneurysm repair.

SETTING

University hospital, Sweden.

SUBJECTS

42 patients operated on for aortic aneurysm, 26 by an endovascular and 16 by an open technique.

MAIN OUTCOME MEASURES

Analysis of HLA-DR expression and concentrations of blood mononuclear cells by flow cytometry. Splanchnic pH analysed by tonometry and interleukin-6 and tumour necrosis factor-alpha measured by enzyme-linked immunosorbent assay.

RESULTS

The HLA-DR expression on lymphocytes did not change, whereas total HLA-DR expression on monocytes was downregulated, and more pronounced in five patients who developed severe postoperative complications. There were no differences in cell or HLA-DR responses between the two operations.

CONCLUSIONS

Both endovascular and open repair of aortic aneurysm produced similar downregulation of monocyte HLA-DR expression and similar responses in circulating mononuclear blood cells. There was pronounced downregulation of monocyte HLA-DR expression in patients with severe postoperative complications.

Postoperative fever, bowel ischaemia and cytokine response to abdominal aortic aneurysm repair--a comparison between endovascular and open surgery

OBJECTIVES

To study bowel ischaemia in transfemorally placed endoluminal grafting (TPEG) for abdominal aortic aneurysms, and any relation to cytokine response or postoperative fever.

DESIGN

Prospective not randomised. University hospital setting.

MATERIAL

Fourteen cases of conventional surgery and 23 cases of endovascular technique for infrarenal abdominal aortic aneurysm repair.

METHODS

Tonometry was used for sigmoid colon pH, and ELISAs for serum IL-6.

RESULTS

Mucosal pH in the sigmoid colon fell significantly during clamping and reperfusion in both groups. Lowest measured sigmoid colon pH was 7.10 in the open group, compared to 7.22 in the TPEG group (p < 0.05). The IL-6 levels in serum peaked after 4 h of reperfusion; 249 pg/ml in the open group, compared to 89 pg/ml in the TPEG group (p < 0.05). High levels of IL-6 in the postoperative period and persisting low sigmoidal pH were associated with serious complications. Postoperative temperature did not differ significantly between the groups, and no significant correlation could be found with sigmoid colon pH or IL-6 levels.

CONCLUSIONS

The less pronounced perioperative bowel ischaemia in TPEG patients indicates an advantage of the TPEG technique. Splanchnic ischaemia was not related to postoperative fever, nor the IL-6 or TNF response.

Malignant fibrous histiocytoma of soft tissue. Correlation between clinical variables and histologic malignancy grade

The prognosis for malignant fibrous histiocytoma (MFH) of soft tissue is correlated to histologic malignancy grade but also has been related to tumor size, depth, and location. In a consecutive series of 61 patients with MFH we found that large, deep-seated and thigh tumors were more often highly malignant histologically. This finding suggests that the prognostic significance which has been attributed to the clinical variables may be a function of their covariation with histologic malignancy grade.