Infrared Thermography Follow-Up After Lower Limb Revascularization

BACKGROUND

The purpose of this study was with a simple clinical setting to compare skin temperature changes in the feet before and after revascularization and to identify possible correlation between ankle brachial index (ABI) and toe pressure (TP) values and foot skin temperature patient with and without diabetes.

METHODS

Forty outpatient clinic patients were measured ABI, TP, and the skin temperature using infrared thermography (IRT) at the foot before and after revascularization. Patients in the revascularization group were divided into subgroups depending on whether they had diabetes or not and a wound or not.

RESULTS

There were clear correlation between increase of ABI and TP and increase of the mean skin temperature on the feet after revascularization. The temperature was higher and the temperature change was greater among patients with diabetes. Side-to-side temperature difference between the revascularized feet and contralateral feet decreased after treatment. The mean temperature was higher in the feet with wound whether patient had diabetes mellitus or not.

CONCLUSION

The simple, prompt, and noninvasive IRT procedure showed its potential as a follow-up tool among patients with diabetes or peripheral arterial disease and previous lower limb revascularization.

Restored pelvic anatomy is preserved after laparoscopic and robot-assisted ventral rectopexy: MRI-based 5-year follow-up of a randomized controlled trial

AIM

Our aim was to compare the long-term anatomical outcomes between robot-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse.

METHOD

This study is a follow-up of a single-centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end-point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP-Q) measures and functional results assessed using symptom questionnaires.

RESULTS

Twenty-six patients (14 RVMR and 12 LVMR) completed the 5-year follow-up and were included in the study. The MRI results, POP-Q measurements and symptom-specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI-20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI-6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal-Anal Distress Inventory (CRADI-8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes.

CONCLUSION

After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR.

Infrared Thermography and Vascular Disorders in Diabetic Feet

AIM

Diabetes mellitus (DM) and related foot complications constitute a growing healthcare burden. Diabetes mellitus is associated with lower-limb amputation, but diabetic foot assessment is challenging. Here, we evaluated a novel noninvasive diagnostic method-infrared thermography (IRT) -assessing its diagnostic potential compared to conventional noninvasive measurements.

METHODS

This study included patients with DM (n = 118) and healthy controls (n = 93). All participants underwent ankle brachial index and toe pressure (TP) measurements, and IRT using a standardized protocol with temperature measurement at five foot areas.

RESULTS

Compared to controls, patients with DM generally had warmer feet and exhibited a significantly greater temperature difference between feet (P < .001). Mean temperatures were highest in patients with DM with neuroischemia, followed by neuropathy. Patients with DM with angiopathy showed the lowest mean temperature-similar to controls and noncomplicated diabetics. Mean temperatures at all measurement sites were significantly higher with abnormal TP (<50 mmHg) than normal TP (≥50 mmHg) (P < .001). Infrared thermography revealed differences between angiosome areas, subclinical infections, and plantar high-pressure areas.

CONCLUSION

Infrared thermography revealed local temperature differences in high-risk diabetic feet. Normal skin surface temperature varies between individuals, but in combination with other tools, IRT might be useful in clinical screening.

CLINICALTRIALS ID

14212016.

Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta-analysis of European, North American and Australian cohorts

OBJECTIVE

To assess the separate and combined associations of maternal pre-pregnancy body mass index (BMI) and gestational weight gain with the risks of pregnancy complications and their population impact.

DESIGN

Individual participant data meta-analysis of 39 cohorts.

SETTING

Europe, North America, and Oceania.

POPULATION

265 270 births.

METHODS

Information on maternal pre-pregnancy BMI, gestational weight gain, and pregnancy complications was obtained. Multilevel binary logistic regression models were used.

MAIN OUTCOME MEASURES

Gestational hypertension, pre-eclampsia, gestational diabetes, preterm birth, small and large for gestational age at birth.

RESULTS

Higher maternal pre-pregnancy BMI and gestational weight gain were, across their full ranges, associated with higher risks of gestational hypertensive disorders, gestational diabetes, and large for gestational age at birth. Preterm birth risk was higher at lower and higher BMI and weight gain. Compared with normal weight mothers with medium gestational weight gain, obese mothers with high gestational weight gain had the highest risk of any pregnancy complication (odds ratio 2.51, 95% CI 2.31- 2.74). We estimated that 23.9% of any pregnancy complication was attributable to maternal overweight/obesity and 31.6% of large for gestational age infants was attributable to excessive gestational weight gain.

CONCLUSIONS

Maternal pre-pregnancy BMI and gestational weight gain are, across their full ranges, associated with risks of pregnancy complications. Obese mothers with high gestational weight gain are at the highest risk of pregnancy complications. Promoting a healthy pre-pregnancy BMI and gestational weight gain may reduce the burden of pregnancy complications and ultimately the risk of maternal and neonatal morbidity.

TWEETABLE ABSTRACT

Promoting a healthy body mass index and gestational weight gain might reduce the population burden of pregnancy complications.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

Randomised clinical trial: mesalazine versus placebo in the prevention of diverticulitis recurrence

BACKGROUND

Previous studies have reached conflicting conclusions regarding the efficacy of mesalazine in the prevention of recurrent diverticulitis.

AIM

To investigate the efficacy and safety of mesalazine granules in the prevention of recurrence of diverticulitis after acute uncomplicated diverticulitis.

METHODS

Two phase 3, randomised, placebo-controlled, double-blind multicentre trials (SAG-37 and SAG-51) investigated mesalazine granules in patients with prior episodes (<6 months) of uncomplicated left-sided diverticulitis. Patients were randomised to receive either 3 g mesalazine once daily or placebo (SAG-37, n=345) or to receive either 1.5 g mesalazine once daily, 3 g once daily or placebo for 96 weeks (SAG-51, n=330). The primary endpoint was the proportion of recurrence-free patients during 48 weeks (SAG-37 and SAG-51) or 96 weeks (SAG-51) of treatment.

RESULTS

Mesalazine did not increase the proportion of recurrence-free patients over 48 or 96 weeks compared to placebo. In SAG-37, the proportion of recurrence-free patients during 48 weeks was 67.9% with mesalazine and 74.4% with placebo (P=.226). In SAG-51, the proportion of recurrence-free patients over 48 weeks was 46.0% with 1.5 g mesalazine, 52.0% with 3 g mesalazine and 58.0% with placebo (P=.860 for 3 g mesalazine vs placebo) and over 96 weeks 6.9%, 9.8% and 23.1% respectively (P=.980 for 3 g mesalazine vs placebo). Patients with only one diverticulitis episode in the year prior to study entry had a lower recurrence risk compared to >1 episode. Safety data revealed no new adverse events.

CONCLUSION

Mesalazine was not superior to placebo in preventing recurrence of diverticulitis.

Genetic risk clustering increases children's body weight at 2 years of age - the STEPS Study

BACKGROUND

Genetic determinants have an impact on adult weight but the association between genetic determinants and weight at young age is still poorly understood.

OBJECTIVE

The objective of this study was to examine the association between genetic risk scores and early growth from birth to 2 years of age.

METHODS

Genetic risk scores of 83 adiposity-related or obesity-related single nucleotide polymorphisms (SNPs) (genetic risk score [GRS]83) were calculated for 1278 children. Specific phenotype score for 16 weight-related SNPs (weightGRS) was calculated. Anthropometric data were obtained at birth, 13 months and 2 years of age.

RESULTS

The GRS83 was associated with weight at 13 months (β = 0.080, P = 0.015) and 2 years (β = 0.080, P = 0.017) of age and with weight gain from birth to 13 months (β = 0.069, P = 0.036) and to 2 years of age (β = 0.074, P = 0.028). At 2 years of age, the GRS83 was also associated with weight for height (β = 0.065, P = 0.046), weight-for-height standard deviation score (SDS) (β = 0.074, P = 0.022) and body mass index SDS (β = 0.068, P = 0.045). WeightGRS was associated with higher body weight at 13 months (β = 0.081, P = 0.014) and 2 years of age (β = 0.086, P = 0.011). The genetic effect on weight varied from 0.69 to 1.89 kg at 2 years of age according to number of risk alleles. Children with high genetic risk for adiposity were heavier than children with low genetic risk at 2 years of age (12.8 vs. 13.4 kg, P = 0.017).

CONCLUSION

The GRS 83 revealed increased genetic risk for higher weight in children already at 13 months and 2 years of age, which may result in increased obesity risk later in life.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial

AIM

The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography.

METHOD

Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery.

RESULTS

Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10).

CONCLUSION

Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Is Inferior Mesenteric Artery Embolization Indicated Prior to Endovascular Repair of Abdominal Aortic Aneurysm?

Type II endoleak is a common condition occurring after endovascular repair of abdominal aortic aneurysms (EVAR), and may result in aneurysm sac growth and/or rupture in a small number of patients. A prophylactic strategy of inferior mesenteric artery (IMA) embolization before EVAR has been advocated, however, the benefits of this strategy are controversial. A clinical vignette allows the authors to summarize the available data about this issue and discuss the possible benefits and risks of prophylactic IMA embolization before EVAR. The authors performed a meta-analysis of available data which showed that the pooled rate of type II endoleak after IMA embolization was 19.9% (95% CI 3.4-34.7%, I2 93%) whereas it was 41.4% (95% CI 30.4-52.3%, I2 76%) in patients without IMA embolization (5 studies including 596 patients: p < .0001, OR 0.369, 95% CI 0.22-0.61, I2 27%). Since treatment for type II endoleaks is needed in less than 20% of cases and this complication can be treated successfully in 60-70% of cases resulting in an aneurysm rupture risk of 0.9%, these data indicate that embolization of patent IMA may be of no benefit in patients undergoing EVAR.

Lithography-free oxide patterns as templates for self-catalyzed growth of highly uniform GaAs nanowires on Si(111)

We report self-catalyzed growth of GaAs nanowires (NWs) on Si/SiOx patterns fabricated by a lithography-free method. The patterns are defined using droplet epitaxy of GaAs nanocrystals, spontaneous oxidation, and thermal annealing. We investigate the influence of the size and density of the nucleation sites on the NW growth process and show that this approach enables the fabrication of highly uniform GaAs NWs with controllable density. The pattern fabrication and NW growth process are studied and discussed in relation to the surface morphology and chemical properties of the Si/SiOx patterns. Furthermore, the optical quality of the NWs is investigated by photoluminescence experiments performed for GaAs–AlGaAs core–shell NWs.

High number of transplanted stem cells improves myocardial recovery after AMI in a porcine model

OBJECTIVE

The clinical data considering the bone marrow mononuclear cell (BMMNC) therapy in treatment for acute myocardial infarction (AMI) are controversial and the mechanisms remain unknown. Our objective was to study the cardiac function and changes in cytokine levels after administration of BMMNC in experimental AMI model.

DESIGN

Unlabeled or Super-Paramagnetic-Iron-Oxide-labeled BMMNCs or saline was injected into myocardium of 31 pigs after circumflex artery occlusion. Ejection fraction (EF) was measured preoperatively, postoperatively and at 21 days by echocardiography. Cardiac MRI was performed postoperatively and after 21 days in 7 BMMNC animals. Serum cytokine levels were measured at baseline, 24 h and 21 days. Cellular homing was evaluated comparing MRI and histology.

RESULTS

From baseline to 21 days EF decreased less in BMMNC group (EF mean control -19 SD 12 vs. BMMNC -4 SD 15 percentage points p = 0.02). Cytokine concentrations showed high variability between the animals. MRI correlated with histology in cell detection and revealed BMMNCs in the infarction area. By MRI, EF improved 11 percentage points. The improvement in EF was associated with the number of transplanted BMMNCs detected in the myocardium.

CONCLUSION

BMMNC injection after AMI improved cardiac function. Quantity of transplanted BMMNCs correlated with the improvement in cardiac function after AMI.

Surgery-related complications of ventral hernia reported to the Finnish Patient Insurance Centre

AIM

Our aim was to evaluate the incidence and type of severe complications in adult primary and incisional ventral hernia surgery reported to the National Patient Insurance Centre in Finland during 2003-2010.

MATERIAL AND METHODS

The Finnish National Patient Insurance Centre covers the whole country and handles financial compensation for patients' injuries without proof of malpractice. All the claims concerning ventral hernioplasties in the Centre between the years 2003 and 2010 were retrospectively analyzed. The annual numbers of primary and incisional ventral hernioplasties in Finland were obtained from the National Hospital Discharge Register.

RESULTS

During the study years, 25,738 ventral hernia operations were performed and 127 claims from the whole country were reported to the Patient Insurance Centre. Overall rate of claims was 4.9/1000 hernia procedures. For primary hernias, 16,243 ventral hernioplasties (817 laparoscopic, 15,426 open) were performed and 41 complications were reported. The most common complication was infection (n = 28, 68%) followed by pain and hernia recurrence (n = 6, 15% in both), large hematoma (7%), bowel lesion (5%), urological injuries (2%), or severe bleeding (2%). In incisional hernioplasties, the rate of claims was 9.1/1000 operations (9495 operations, 86 claims). The most common complication reported was infection (n = 42, 49%) followed by hernia recurrence in 25 cases (29%) and bowel lesion in 24 cases (28%). Major complications (n = 15, 17%) consisted mainly of bowel lesions in laparoscopic operations. There was significantly more claims after laparoscopic than open hernioplasties (p = 0.001).

CONCLUSIONS

The claims for financial compensation for injuries related to primary and incisional hernioplasties are quite uncommon. Major complications, though comparatively rare, are significantly more common after laparoscopic operations.

Detailed analysis of inflammatory cell infiltration in colorectal cancer

BACKGROUND

Higher-grade inflammatory infiltrate is a promising marker for better prognosis in colorectal cancer (CRC). However, the knowledge on the interrelationships between different inflammatory cells and classifications is fragmentary.

METHODS

We analysed the densities of eight types of inflammatory cells in a prospectively recruited group of 117 CRC patients and determined their interrelationships and contributions to Klintrup-Mäkinen (K-M) score of overall peritumoural inflammation. We characterised the inflammatory infiltrate in relation to stage and recurrences in 24-month follow-up.

RESULTS

There were high positive correlations between the inflammatory cell densities, with the exception of mast cells and CD1a+ immature dendritic cells. High K-M score associated with high peri- and intratumoural densities of CD3+, CD8+, CD68+, CD83+, and FoxP3+ cells and neutrophils. Advanced stage associated with low K-M score, as well as low CD3+, CD8+, CD83+, and FoxP3+ cell counts, of which low K-M score, low CD3(+) T-cell count, and low FoxP3+ T-cell count were linked to higher recurrence rate.

CONCLUSION

The density of CRC inflammatory infiltrate declines as stage advances. Especially, low K-M score and low T-cell counts predict higher recurrence rate. The high positive correlations between the individual inflammatory markers support the value of overall inflammatory reaction scoring.

Robotic-assisted and laparoscopic ventral rectopexy in the treatment of rectal prolapse: a matched-pairs study of operative details and complications

BACKGROUND

Laparoscopic ventral rectopexy has been proven to be safe and effective in the treatment of rectal prolapse or intussusception. Robotic-assisted surgery may offer potential benefits to this operation. This study describes the comparison of robotic-assisted and conventional laparoscopic ventral rectopexy in terms of clinical parameters, operative details, postoperative complications and short-term outcomes.

METHODS

Twenty patients operated on for rectal prolapse or intussusception using the Da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA, USA) were prospectively followed for 3 months. The cases were pair-matched with laparoscopically operated controls from registry files.

RESULTS

Mean operating time was 159 min (standard deviation; ±37 SD) and 153 min (±33 SD) and mean total time in the operating theatre 231 min (±39 SD) and 234 min (±41 SD) for robotic-assisted and laparoscopic operations, respectively. Mean blood loss was 25 ml (±49 SD) in robotic-assisted and 37 ml (±50 SD) in laparoscopic procedures. There was one (5 %) significant complication in each group. Mean length of hospital stay was 3.1 (±2 SD) and 3.3 (±1.3 SD) days for the robotic-assisted and laparoscopic groups, respectively. The subjective benefit rate was the same in both groups: 16/20 (80 %). One patient in the robotic-assisted group continued to have symptoms of obstructed defecation, and there was one recurrence of prolapse in the laparoscopic group.

CONCLUSIONS

Robotic-assisted laparoscopic ventral rectopexy is safe, feasible and not more time consuming than the laparoscopic technique even at the beginning of the learning curve. The short-term results are comparable with those of laparoscopy. We found no arguments to support the routine use of robotic assistance in rectopexy operations.

Activity of mesenchymal stem cells in a nonperfused cardiac explant model

Stem cell therapy represents a potential novel additional therapy for acute myocardial infarction. Cardiac applications of stem cell therapy are now undergoing clinical trials though many properties, including localization, possible adhesion, and infiltration of the injected stem cells in the myocardium, have not been studied in detail even in vitro. To study these mechanisms in a controlled microenvironment, we developed a model where mesenchymal stem cells (MSCs) were transported into live, cultured cardiac explants for further co-culture. About 10×10(3) porcine MSCs were injected into freshly excised and isolated cardiac explants of the pig. The explants were present in the culture medium for up to 7 days, with the time course of viability of the myocardial tissue, and the migration and the localization of the injected MSCs were analyzed with histological and immunohistological stainings. The myocyte structure was observed to be well preserved, and proliferation of capillaries and myofibroblasts was detected at the explant periphery. There were injected MSCs localized in the capillaries and in contact with the endothelial cells. The migration range and the number of adherent MSCs increased over time, suggesting active movement of MSCs in the explant. Our results suggest that this cardiac explant culture model is a feasible method for studying the effects of stem cells in the myocardium in vitro.

Does Preoperative Radiotherapy with Postoperative Chemotherapy Increase Acute Side-Effects and Postoperative Complications of Total Mesorectal Excision? Report of the Randomized Finnish Rectal Cancer Trial

Background and Aims:

In a randomized trial the effect of short-term preoperative radio therapy and postoperative chemotherapy was studied in patients undergoing total mesorectal excision (TME) for clinically resectable rectal cancer. The primary endpoint was overall survival. The secondary endpoints published herein were the incidence of postoperative complications and adverse events with perioperative adjuvant therapy.

Material and Methods:

In 1995–2002, 278 eligible patients with stage II and stage III rectal cancer were randomly assigned to TME alone (surgery group) or to preoperative 25Gy radiotherapy in 5 fractions and postoperative 5-fluorouracil and leucovorin chemotherapy in addition (RT+CTgroup).

Results:

Anastomotic leakage rate did not significantly differ between the surgery and the RT + CT group, 20.6% vs. 27.4%. Postoperative infections (15.5 vs. 26.2%, p = 0.037) and perineal wound dehiscence (15.9 vs. 38.5%, p = 0.045) were more common after radiotherapy. Grade 3–5 adverse events were uncommon with preoperative radiotherapy (one, 0.7% with reversible lumbar plexopathy) and postoperative chemotherapy (hematologic in 10.8%, with one septic death, and gastrointestinal in 4.8%).

Conclusions:

Perioperative adjuvant therapy was generally well tolerated and did not lead to an increase in serious surgical complications. Wound infections and perineal wound dehiscence were more common in irradiated patients.

Stage-dependent alterations of the serum cytokine pattern in colorectal carcinoma

Background:

Inflammation contributes to the pathogenesis of colorectal cancer (CRC), and cytokine levels are altered during colorectal carcinogenesis.

Methods:

The serum levels of 13 cytokines and their relation to clinical and pathological parameters, and systemic inflammatory response (mGPS, CRP and neutrophil–lymphocyte ratio), were analysed from a prospective series of 148 CRC patients and 86 healthy age- and sex-matched controls.

Results:

CRC patients had higher serum platelet-derived growth factor, interleukin (IL)-6, IL-7, and IL-8 levels and lower monocyte chemotactic protein-1 (MCP-1) levels than the controls. A logistic regression model for discriminating the patients from the controls – including the five most predictive cytokines (high IL-8, high IL-6, low MCP-1, low IL-1ra, and low IP-10) – yielded an area under curve value of 0.890 in receiver operating characteristics analysis. Serum cytokines showed distinct correlation with other markers of systemic inflammatory response, and advanced CRCs were associated with higher levels of IL-8, IL-1ra, and IL-6. A metastasised disease was accompanied by an orientation towards Th2 cytokine milieu.

Conclusion:

CRC is associated with extensive alterations in serum cytokine environment, highlighting the importance of studying relative cytokine level alterations. Serum cytokine profile shows promise in separating CRC patients from healthy controls but its clinical value is yet to be confirmed.

Computed tomography detects changes in contrast agent diffusion after collagen cross-linking typical to natural aging of articular cartilage

OBJECTIVE

The effect of threose-induced collagen cross-linking on the mechanical and diffusive properties of cartilage was investigated in vitro. In particular, we investigated the potential of Contrast Enhanced Computed Tomography (CECT) to detect changes in articular cartilage after increased collagen cross-linking, which is an age-related phenomenon.

METHODS

Osteochondral plugs (Ø=6.0 mm, n=28) were prepared from intact bovine patellae (n=7). Two of the four adjacent samples, prepared from each patella, were treated with threose to increase the collagen cross-linking, while the other two specimen served as paired controls. One sample pair was mechanically tested and then mechanically injured using a material testing device. Contrast agent [ioxaglate (Hexabrix™)] diffusion was imaged in the other specimen pair for 25 h using CECT. Water fraction, collagen and proteoglycan content, collagen network architecture and the amount of cross-links [hydroxylysyl pyridinoline (HP), lysyl pyridinoline (LP) and pentosidine (Pent)] of the samples were also determined.

RESULTS

Cartilage collagen cross-linking, both Pent and LP, were significantly (P<0.001) increased due to threose treatment. CECT could detect the increased cross-links as the contrast agent penetration and the diffusion flux were significantly (P<0.05) lower in the threose treated than in untreated samples. The equilibrium modulus (+164%, P<0.05) and strain dependent dynamic modulus (+47%, P<0.05) were both significantly greater in the threose treated samples than in reference samples, but there was no association between the initial dynamic modulus and the threose treatment. The water fraction, proteoglycan and collagen contents, as well as collagen architecture, were not significantly altered by the threose treatment.

CONCLUSIONS

To conclude, the CECT technique was found to be sensitive at detecting changes in cartilage tissue due to increased collagen cross-linking. This is important since increased cross-linking has been proposed to be related to the increased injury susceptibility of tissue.

Acute homing of bone marrow-derived mononuclear cells in intramyocardial vs. intracoronary transplantation

OBJECTIVES

Cell homing optimisation after transplantation is critical in myocardial infarction (MI) cell therapy.

DESIGN

Eight pigs were randomized to receiving autologous purified (111)indium-labeled bone marrow mononuclear cells (BMMCs) (10(8) cells/2 ml) by intramyocardial (IM) (n=4) or by intracoronary (IC) (n=4) transplantation after 90 minutes occlusion of the CX-coronary artery. Dual isotope SPECT imaging was performed 2 and 24 hours postoperatively. Two animals were additionally analyzed on the sixth postoperative day. Tissue samples from the major organs were analyzed.

RESULTS

In SPECT imaging revealed that BMMCs administered using IM injection remained in the injured area. In contrast, minor proportion of IC transplanted cells remained in the myocardium, as most of the cells showed homing in the lungs. Analysis of the biopsies showed a seven-fold greater number of cells in the myocardium for the IM method and a 10-fold greater number of cells in the lungs in the IC group (p < 0.001).

CONCLUSIONS

In producing persistently high cell homing at the infarction site, the IM transplantation is superior to the IC transplantation. However, the IC administration might be more specific in targeting injured capillaries and epithelial cells within the infarcted myocardium.

Local staging of rectal cancer using the black lumen magnetic resonance imaging technique

BACKGROUND AND AIMS

The treatment of rectal cancer is comprised of surgery and possible adjuvant therapy depending on the stage of the tumour. This prospective study evaluates the accuracy of magnetic resonance imaging (MRI) in the preoperative staging of rectal cancer using an endorectal and intravenous contrast.

MATERIALS AND METHODS

37 consecutive patients with rectal cancer were imaged using a mixture of ferumoxsil and methylcellulose endorectally, and a gadolinium contrast intravenously. 33 tumours were resected and 4 tumours were considered unresectable during operation. The images were reviewed for local staging of the tumours. A tumour confined to the rectal wall was classified as a negative finding and a tumour invading through muscularis propria as a positive finding. The results were correlated with the histopathologic t stage (n = 33), or the clinical status (n = 4).

RESULTS AND CONCLUSIONS

of 37 cases, 20 (51 %) were true positive, and 11 (28%) were true negative. There were 3 false negative and 3 false positive cases. The sensitivity was 87%, specificity 79%, and diagnostic accuracy 84%. for the non-contrast images the figures were 78%, 79% and 78%, respectively. We consider black lumen magnetic resonance imaging to be a useful method for preoperative local staging of rectal cancer.

Effects of pH Management During Selective Antegrade Cerebral Perfusion on Cerebral Microcirculation and Metabolism: Alpha-Stat Versus pH-Stat

BACKGROUND

Selective cerebral perfusion (SCP) is used for extending the period during which surgical procedures can be safely performed. We sought to determine the direct effects of pH management on cerebral microcirculation and metabolism during SCP.

METHODS

An experimental SCP porcine model was created by selectively allowing cold perfusate only into the bicarotid brachiocephalic trunk during the SCP period. Twenty-four piglets (6 to 8 weeks; mean weight, 26.1 +/- 4.1 kg) underwent 15-minute normothermic cardiopulmonary bypass, 45-minute cooling cardiopulmonary bypass, 60-minute SCP at 25 degrees C, and 45-minute rewarming cardiopulmonary bypass with either alpha-stat or pH-stat perfusion strategy randomly assigned. A cranial window was created over the parietal cortex for visualization of the cerebral vessels with intravital microscopy. Rhodamine-stained leukocytes were observed in cerebral postcapillary venules for adhesion and rolling. Microdialysis analysis was used for determination of brain metabolism.

RESULTS

Brain concentration of lactate was significantly higher in the alpha-stat group at 45 minutes of SCP, and at 15- and 45-minute rewarming intervals (p = 0.03; p = 0.003; and p = 0.05; respectively), reaching borderline statistical significance when assessed throughout the experiment (p = 0.06 for differences between groups). Further, at the end of cooling, the oxygen delivery tended to be higher in the pH-stat group (p = 0.07), whereas at the 30-minute rewarming interval, the oxygen extraction tended to be higher in the alpha-stat group (p = 0.06). There were no statistically significant differences between the groups in leukocyte-endothelial interaction, arterial diameter, or tissue oxygenation.

CONCLUSIONS

The higher concentration of brain lactate and the tendency to higher oxygen extraction levels during rewarming with alpha-stat strategy suggests anaerobic metabolism occurred during SCP. No major differences between pH management strategies in cerebral microcirculation could be shown during SCP.

Bone marrow–derived mononuclear cell transplantation improves myocardial recovery by enhancing cellular recruitment and differentiation at the infarction site

OBJECTIVE

Stem cell therapy in myocardial infarction is under intensive investigation; however, the mechanisms of recovery and the optimal transplantation technique remain controversial. The goal of this controlled and randomized study was to test the hypothesis that locally injected bone marrow-derived mononuclear cells can focus in on the damaged myocardium and improve cardiac function by means of active participation in remodeling.

METHODS

Myocardial infarction was introduced through occlusion of the circumflex coronary artery for 90 minutes in 14 piglets (24.0 +/- 4.9 kg) that were randomized to a cell-therapy group (n = 7) and a control group (n = 7). At reperfusion, autologous purified prelabeled or unlabeled cells (10(8) cells/2 mL) or saline were injected into the myocardium. Cardiac function was measured by using echocardiography preoperatively and postoperatively and at 3 weeks, when hearts were collected for histopathologic examination.

RESULTS

The ejection fraction recovered in the cell-therapy group (P = .02) but failed to recover in the control group, and at 3 weeks, it remained at the lower level compared with that in the cell-therapy group (P = .067). The number of living cells in the necrotic area was significantly greater in the cell-therapy group (P < .001). Labeled cells were detected in the infarcted area, and they showed signs of myocyte differentiation. Furthermore, the proportional area of muscle actin-positive cells at the granulation area was higher in the cell-therapy group (P = .035).

CONCLUSIONS

Autologous bone marrow-derived mononuclear cells at the infarcted area localize in the myocardium. The exact mechanism of recovery remains to be determined, but our findings may give new information concerning the cellular events that occur during cell therapy-enhanced recovery.

Leukocyte filtration to decrease the number of adherent leukocytes in the cerebral microcirculation after a period of deep hypothermic circulatory arrest

OBJECTIVE

Cardiopulmonary bypass and hypothermic circulatory arrest induce a systemic inflammatory response, including a cascade of leukocyte and endothelial cell activity, during the postischemic reperfusion phase. Accumulation of leukocytes in the brain can lead to neurologic problems after cardiac surgery. The beneficial effects of a leukocyte-depleting filter have been documented, but because of contradictory results the underlying function of the filter remains unclear.

METHODS

Twenty-two juvenile piglets (6 to 8 weeks) were randomly assigned to undergo cardiopulmonary bypass with or without a leukocyte-depleting filter 60 minutes before and 60 minutes after a 75-minute hypothermic circulatory arrest at 18 degrees C. The cerebral vessels were visualized with intravital microscopy through a cranial window placed over the parietal cortex. Rhodamine staining was used to observe adherent and rolling leukocytes in the cerebral postcapillary venules. The animals were electively killed 1 hour after weaning from cardiopulmonary bypass.

RESULTS

There were no significant differences between the study groups regarding hemodynamic data. Numbers of adherent activated leukocytes were lower in the leukocyte filtration group, reaching borderline statistical significance when assessed throughout the experiment (between-groups P = .069) and actual statistical significance when assessed during the rewarming period (between-groups P = .029).

CONCLUSION

The leukocyte-depleting filter succeeded in reducing the number of adherent leukocytes during the reperfusion period in an experimental operation with deep hypothermic circulatory arrest. Such a filter thus could mitigate cerebral reperfusion injury after cardiac surgery.

Propofol is associated with impaired brain metabolism during hypothermic circulatory arrest: an experimental microdialysis study

BACKGROUND

Propofol is a widely used anesthetic in cardiac surgery. It has been shown to increase cerebrovascular resistance resulting in decreased cerebral blood flow. Efficient brain perfusion and tissue oxygenation during cardiopulmonary bypass (CPB) is essential in surgery requiring hypothermic circulatory arrest (HCA). The effects of propofol on brain metabolism are reported in a surviving porcine model of HCA.

METHODS

Twenty female juvenile pigs undergoing 75 minutes of HCA at a brain temperature of 18 degrees C were assigned to either propofol- or isoflurane anesthesia combined with alpha-stat perfusion strategy during CPB cooling and rewarming. Brain microdialysis analysis was used for determination of brain metabolism, and tissue oxygen partial pressure and intracranial pressures were also followed-up until 8 hours postoperatively.

RESULTS

Brain concentrations of glutamate and glycerol were significantly higher in the propofol group throughout the experiment (P < .01 and P < .01, respectively). The lactate/pyruvate ratio was significantly higher in the propofol group at 6-, 7-, and 8-hour intervals (P < .05, P < .01, and P < .05, respectively). The intracranial pressure was significantly higher at the 8-hour postoperative interval (P < .05) in the propofol group. A trend toward higher brain oxygen concentrations was observed in the isoflurane group.

CONCLUSIONS

Anesthesia with propofol as compared with isoflurane is associated with impaired brain metabolism during experimental HCA.

Cognitive performance and attachment patterns at four years of age in extremely low birth weight infants after early intervention

This study aims at assessing the effects of an early occupational therapy intervention on the cognitive development and the development of attachment patterns in ELBW infants. The intervention, given weekly at home from six months to 12 months, aimed at supporting parent-child interaction and enhancing motor control and coordination. The study population consisted of 100 ELBW infants matched in pairs in accordance to their pre-perinatal risk scores and allocated successively to intervention or non-intervention groups. Cognitive development was assessed with the Bayley Scales at age two and with the WPPSI at age four. Attachment to primary caregiver was assessed with the Preschool Assessment of Attachment (PAA). Cognitive performance was within age norms in both groups at both ages. Intervention did not show any effect on cognitive performance at the age of two years. At the age of four years, cognitive level was overall, and most notably for verbal performance, higher in the intervention group than in the control group. There was an over-representation of the so-called atypical attachment patterns (those not fitting the normative A, B, or C categories) in the control group. The results are discussed in terms of finding more global ways to support the development of at risk pre-term children.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Cognitive development, temperament and behavior at 2 years as indicative of language development at 4 years in pre-term infants

This study focuses on the early temperamental (TTQ = toddler temperament questionnaire), behavioral (IBR = infant behavior record), and cognitive precursors of impaired language functioning in preschool-age pre-terms infants. The study group consisted of 63 pre-term infants with a mean birth weight of 1246 +/- 437 g born in 1989-1991 in the University Central Hospital of Helsinki. Children with major disabilities (CP or mental retardation) were excluded. At the age of 4 years, 22% showed impaired language function. Logistic regression analysis showed that the Bayley MDI score was the best predictor in identifying an increased risk for language impairment. Behavioral characteristics were more strongly associated with subsequent language impairment than temperament.

Colorectal carcinoma associated with serrated adenoma--prevalence, histological features, and prognosis

Serrated adenoma has been proposed to be a distinct entity among colorectal neoplasms. Progression to frank carcinoma has been suggested in individual cases, but the prevalence of carcinomas originating from serrated adenomas and their clinico-pathological characteristics are not known. In the present study, a large series of colorectal cancers was analysed for the occurrence of serrated adenoma in association with carcinoma and clinico-pathological features were compared in cases with and without serrated adenoma. Specimens from 466 colorectal carcinoma patients undergoing operations between 1986 and 1996 were re-evaluated for the presence of juxtaposed serrated adenoma and carcinoma. Clinico-pathological features such as location, Dukes' stage, histological grade, mucinous differentiation, and prognosis were evaluated. Twenty-seven carcinomas (5.8%) were found in association with an adjacent serrated adenoma. Eight of the patients were male and 19 were female. All of these adenocarcinomas showed a serrated appearance resembling that of serrated adenomas. Nine (33%) cases were mucinous and a mucinous component was present in 11 (41%) additional cases. The majority of the tumours were located either in the caecum (14 cases; 51%) or in the rectum (9 cases; 33%). DNA microsatellite instability was more common in carcinomas associated with serrated adenoma (37.5%) than in other carcinomas (11.0%). It is concluded that carcinoma associated with serrated adenoma is a distinct type of colorectal neoplasm, accounting for 5.8% of all colorectal carcinoma cases in this study. Predilection for the caecum and the rectum may reflect their aetiological factors. Female preponderance is contrary to that reported for hyperplastic polyps and serrated adenomas.

Classification of advanced colorectal carcinomas by tumor edge morphology: evidence for different pathogenesis and significance of polypoid and nonpolypoid tumors

BACKGROUND

Increasing evidence suggests that a substantial proportion of colorectal carcinomas develop without a preexisting polypoid adenomatous lesion, but it is difficult to detect the possible origin of advanced carcinomas. The purpose of this study was to test the validity and significance of a new histopathologic classification system based on the histologic analysis of the tumor edge.

METHODS

One hundred eighty-six unselected cases of colorectal carcinoma were included. A new classification method to distinguish polypoid and nonpolypoid growth type was based on the presence or absence of elevation of tumor as compared with adjacent mucosa. Inter- and intraobserver agreement of classification was tested. Association with other clinicopathologic features including histopathologic characteristics of the tumors, presence or absence of lesional and concurrent adenoma, K-ras mutations, and prognosis was evaluated.

RESULTS

Classification could be made in 75% of the tumors, and 25% were unclassifiable, mostly due to absence of tumor margin in sections. Of the classifiable carcinomas, 45% were classified as polypoid, of which 52% had lesional adenoma. Nonpolypoid tumors formed 48% of classifiable cases, and only 2% had lesional adenoma. Features of both polypoid and nonpolypoid carcinomas were present in 7% of cases. Concurrent extralesional adenomas were found more frequently in association with polypoid carcinomas. K-ras mutations were more common in polypoid (43%) than in nonpolypoid tumors (8%; P = 0.018). Nonpolypoid carcinomas were significantly (P = 0.03) more aggressive than polypoid carcinoma, with 38% and 20% recurrence rates, respectively.

CONCLUSIONS

The authors' results indicate that advanced colorectal carcinomas can be classified according to growth pattern by observing the tumor edge. This classification has prognostic significance because nonpolypoid carcinomas appeared to have a worse prognosis than polypoid ones.

Prognostic factors predicting survival in the treatment of retroperitoneal sarcoma

METHODS

Retroperitoneal soft tissue sarcomas are rare tumours. The management of these tumours has been difficult because of low resectability and a high recurrence rate. A retrospective review of a prospectively compiled database of 32 consecutive patients with retroperitoneal sarcomas treated at Oulu University Hospital between 1977 and 1996 was performed.

RESULTS

The resectability rate of primary tumours was 75%, and 44% of the patients underwent radical resection. The recurrence rate after radical resection was 57% and the resectability rate for recurrent tumours after radical primary operation, 50%. The actuarial overall 5-year survival rate was 31%, 10-year survival rate 19% and median survival 36 months. In univariate analysis the principal factors associated with prognosis were radical resection, recurrent disease, pre-operative loss of weight and histological tumour grade. Complete excision of the primary tumour was the only significant predictor of survival in multivariate analysis.

CONCLUSIONS

Complete resection of retroperitoneal sarcoma continues to be the most important prognostic factor. The inefficiency of adjuvant therapy, the high recurrence rate and the very low chance of curing the patient after recurrence make the prognosis of these patients poor.

Type I and III collagens in human colon cancer and diverticulosis

BACKGROUND

Collagens are major proteins in the extracellular matrix, providing tissues with tensile strength. They are also important for cell adhesion and the invasion of malignant tumours.

METHODS

Thirty-nine samples of human colon (24 diverticulosis, 6 malignant tumours, 9 controls) were collected during elective surgery. Immunoassays for different domains of type I and III collagens and procollagens were used in soluble tissue extracts and trypsin digests of tissue samples.

RESULTS

The contents of cross-linked type I and III collagen telopeptides and total collagen were similar in diverticulosis and healthy tissue, whereas in malignant tissue maturely cross-linked type III collagen was scarce. Furthermore, some of the cross-linked type I telopeptide antigens were exceptionally small in size, indicating that the cross-linking of type I collagen in collagen fibres is impaired in cancer. The rate of type I collagen synthesis was clearly increased in malignancy, but not significantly in diverticulosis. However, type III collagen synthesis was increased in diverticulosis, but not in malignancy.

CONCLUSIONS

In colon malignancy, the collagen cross-linking process was aberrant and the synthesis of type I collagen increased. In diverticulosis, the synthesis of type III collagen was increased, suggesting only moderately increased metabolic activity.

Adenoma of the papillae of Vater. Report of eleven cases

Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily by transduodenal excision without any recurrences so far. One of these seven patients was found to have adenocarcinoma in a histological examination. Active surgery for adenoma of the papillae of Vater is recommended because of the precancerous nature of the lesion, and because malignancy cannot always be detected by endoscopic biopsies. Transduodenal excision could be recommend for patients at high operative risk, especially in cases with small adenomas and low-grade dysplasia, where histologically free resection margins can be achieved, but pancreaticoduodenectomy should still be performed on patients at low operative risk.

Patency and complications of percutaneously inserted metallic stents in malignant biliary obstruction

PURPOSE

The aim of this study was to analyze the patency of percutaneously inserted metallic stents in malignant biliary obstruction and to evaluate all the complications associated with the stents and the reinterventions needed.

MATERIALS AND METHODS

Thirty-nine patients with 42 malignant strictures were treated percutaneously with 55 metallic self-expandable stents. Forty-eight were Wallstents and seven were Memotherm stents. Twenty-five strictures were hilar, 16 were in the common bile duct, and one was in the hepaticojejunal anastomosis. The patients were followed until death and the mean follow-up was 6.4 months.

RESULTS

Stent insertion was successful in 97% of the patients. Thirty percent had early complications (<30 days), and as many as 66% had late complications, including stent occlusions, which were seen in 10 patients. The patency rates of patients with cholangio-carcinoma were significantly lower than those of the patients with other diagnoses. There was also a tendency toward obstruction with less dilation of the stents, Y, T or tandem-style stent placement, an increasing number of stents, longer strictures, and hilar strictures. Thirty-one percent of the patients alive after the first 30 days had late reinterventions.

CONCLUSIONS

Although metallic stents offer an alternative in the palliation of malignant bile duct obstruction, there seem to be numerous early and late complications.

Morphological and genetic abnormalities in prediction of recurrence in radically operated colorectal cancer

BACKGROUND

We analyzed clinicopathological variables, cell proliferation activity and genetic aberrations related to colorectal cancer in order to recognize clinically usable predictive markers of cancer recurrence.

MATERIALS AND METHODS

A total of 111 patients radically operated upon because of primary colorectal cancer in 1986-1991 were studied. Loss of heterozygosity (LOH) at 18q21 and replication errors were studied by polymerase chain reaction and fragment analysis. Expression of p53 protein and that of Ki-67 were studied using immunohistochemical methods.

RESULTS

LOH at 18q21 was the only factor associated with recurrence (P = 0.03), and indicated a worse five-year cumulative survival rate (42%) than did LOH-negativity (72%) in cases of Dukes classes B and C. Expression of p53 protein indicated recurrence (P = 0.07), short disease-free time and poor survival (P = 0.03) in Dukes class A cases.

CONCLUSIONS

LOH at 18q21 appears useful in predicting recurrence and poor survival in cases of Dukes classes B and C, as does p53 expression in class A cases.

Clinicopathological features of primary gastric lymphoma

BACKGROUND AND OBJECTIVES

Surgery has been the mainstay of the treatment of primary gastric lymphoma, but the value of surgical treatment needs reevaluation.

METHODS

Thirty-two patients with primary non-Hodgkin B-cell lymphoma of the stomach were examined retrospectively to evaluate prognostic factors and their impact on survival. All patients had undergone abdominal exploration for radical surgery between 1979 and 1992. The prognostic factors in view of survival after treatment were determined with both univariate and multivariate analyses.

RESULTS

The resectability rate was 66% (21/32) and radical resections had been performed on 53% (17/32). The overall median survival was 65 months and the overall 5-year survival was 56%. The 5-year survival rates related to a modified Ann Arbor classification as follows: I 1E, 86%; I 2E, 100%; II 1E, 44%; II 2E, 37%; IIIE, 20%; and IVE, 0%. Univariate analysis using Kaplan-Meier estimates showed that radical surgery, Ann Arbor stage, patient's age, and lymph node involvement were significant prognostic factors. According to Cox proportional regression analysis, only Ann Arbor stage, radical surgery, and age were significant independent variables.

CONCLUSIONS

According to our experience, surgery is still needed for the treatment of primary gastric lymphomas, but the benefits of primary chemotherapy or adjuvant chemotherapy using cytotoxic drugs must be determined in large prospective controlled trials.

Loss of heterozygosity at 18q21 is indicative of recurrence and therefore poor prognosis in a subset of colorectal cancers

Adjuvant therapies are increasingly used in colorectal cancers for the prevention of recurrence. These therapies have side-effects and should, thus, be used only if really beneficial. However, the development of recurrence cannot be predicted reliably at the moment of diagnosis, and targeting of adjuvant therapies is thus based only on the primary stage of the cancer. Loss of heterozygosity (LOH) in the long arm of chromosome 18 is suggested to be related to poor survival and possibly to the development of metastases. We studied the value of LOH at 18q21 as a marker of colorectal cancer prognosis, association with clinicopathological variables, tumour recurrence and survival of the patients. Of the 255 patients studied, 195 were informative as regards LOH status when analysed in primary colorectal cancer specimens using the polymerase chain reaction (PCR) and fragment analysis. LOH at 18q21 was significantly associated with the development of recurrence (P = 0.01) and indicated poor survival in patients of Dukes' classes B and C, in which most recurrences (82%) occurred. An increased rate of tumour recurrence is the reason for poor survival among patients with LOH at 18q21 in primary cancer. These patients are a possible target group for recurrence-preventing adjuvant therapies.