OC-038 RISK FOR CONTRALATERAL INGUINAL HERNIA REPAIR FOLLOWING PRIMARY UNILATERAL HERNIA REPAIR – A REGISTER-BASED STUDY

Aim

To investigate the incidence as well as the factors predictive for a subsequent hernia repair on the contralateral side following a primary unilateral hernia repair.

Material & Methods

Prospective population-based study of data from the Swedish Hernia Register based on 151,297 patients operated with an index unilateral inguinal hernia mesh repair using open and endo-laparoscopic technique, during 2007–2019. Incidence, predictive factors and time to a contralateral hernia repair was analysed.

Results

There were 7.4% registered contralateral hernia repairs with a median time of 2.7 years to a subsequent contralateral repair following the index unilateral hernia repair. Median follow-up time was 7.5 years. Significant predictors for a subsequent contralateral hernia were, male sex (HR 1.78, 95% CI 1.61–1.97), high age (HR 1.01 95% CI 1.006–1.009), medial inguinal hernia (HR 1.05, 95% CI 1.003–1.098), combined inguinal hernia (HR 1.10, 95% CI 1.03–1.18), hernia defect size 1.5–3.0 cm (HR 1.10, 95% CI 1.03–1.17), hernia defect size > 3 cm (HR 1.36, 95% CI 1.27–1.45) and a repair on the left side (HR 1.30, 95% CI 1.25–1.35). Endo-laparoscopic repairs and obesity were associated with a lower incidence of a later contralateral repair.

Conclusion

If the relevant risk factors, i.e., male sex, high age, large hernia defect size, medial or combined hernia, are present at a unilateral endo-laparoscopic groin hernia repair and the decision has been shared with the patient, exploration of the contralateral groin and prophylactic mesh placement may be considered.

Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study

PURPOSE

Autologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response.

METHODS

ECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation.

RESULTS

At 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V.

CONCLUSION

This preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.

Antibiotic treatment for appendicitis in Norway and Sweden: a nationwide survey on treatment practices

Background

Appendicitis is one of the most common causes of acute abdomen. Uncomplicated appendicitis is as an inflamed appendix without perforation, gangrene or abscess formation. Recent trials show that one can safely treat uncomplicated appendicitis with antibiotics, given patient approval and appropriate follow-up. A recent study has also indicated no difference between antibiotic treatment and placebo. Our aim was to investigate if Norwegian and Swedish surgical departments treat uncomplicated appendicitis with antibiotics and to explore their opinions on this treatment practice.

Methods

A questionnaire was distributed to all heads of department in hospitals that treat appendicitis in Norway and Sweden. Answers were collected using a REDCap survey. Answers were compared between centers and nations and the results were presented anonymously.

Results

We sent the questionnaire to 94 eligible recipients and received 61 (65%) answers. In total, 8/61 (13%) departments stated that they have established antibiotic treatment as sole treatment for uncomplicated appendicitis. Almost half of the responders stated that they have used antibiotics sporadically to treat uncomplicated appendicitis. Lack of evidence and guidelines were noted as reasons why antibiotic treatment has not been implemented as sole treatment.

Conclusions

Most Norwegian and Swedish departments have not implemented antibiotic treatment as the sole treatment for uncomplicated appendicitis. Despite several recent large trials on this subject, lack of evidence and guidelines was the most frequently reported reason in our survey.

Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial

Purpose

Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia.

Methods

Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL).

Results

Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups.

Conclusion

The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM.

Trial Registration

The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.

Health economic analysis of total extraperitoneal repair versus Lichtenstein surgery for inguinal hernia: data from a randomized clinical trial

Background

The aim was to compare cost-effectiveness of Lichtenstein under local anaesthesia (LLA) with total extraperitoneal repair (TEP) under general anaesthesia for primary inguinal hernia in men. An endoscopic approach to inguinal hernia repair is often considered costlier. The cost of endoscopic hernia repair, however, has not been compared to open inguinal hernia repair in a cost-effective setting.

Methods

Data from an RCT comparing TEP and Lichtenstein in a cost-effective setting, with health economy as a secondary endpoint, were used. Data on costs were collected prospectively. Data on sick leave were obtained from the Swedish Social Insurance Agency in order to compare lengths of sick leave.

Results

In total, 384 patients were included and 374 (97.4 per cent) patients were available for analysis, 189 in the LLA group and 185 in the TEP group. The median operating time for LLA was 70 (i.q.r. 60–80) min compared with 60 (i.q.r. 50–75) min in the TEP group (P < 0.001). The median time in operating theatre was 114 (i.q.r. 95–-125) min for LLA and 125 (i.q.r. 110–145) min for TEP (P < 0.001). The median cost including all materials was 2433 (i.q.r. 2084–2734) Euros for LLA and 2395 (i.q.r. 2093–2784) Euro for TEP (P = 0.650). Mean sick leave was 4.2 days in the LLA group and 6.2 days in the TEP group (P = 0.830).

Conclusion

The overall cost to the hospital or length of sick leave did not differ between LLA and TEP.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a feasibility study

Background

Parastomal hernia is a common complication of stoma formation and the methods of repair available today are unsatisfactory with high recurrence and complication rates. To improve outcome after surgical repair of parastomal hernia, a surgical method using autologous full-thickness skin grafts as intraperitoneal reinforcement has been developed. The purpose of this study was to evaluate the feasibility of this novel surgical technique in the repair of parastomal hernia.

Methods

A pilot study was conducted between January 2018 and June 2019 on four patients with symptomatic parastomal hernia. They had a laparotomy with suture reduction of the hernia and reinforcement of the abdominal wall with autologous full-thickness skin. They were then monitored for at least 1 year postoperatively for technique-related complications and recurrence.

Results

No major technique-related complications were noted during the follow-up Two patients developed a recurrent parastomal hernia at the long term follow-up. The other two had no recurrence.

Conclusions

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair is feasible and should be evaluated in a larger clinical trial.

Long-term follow-up after surgical repair of abdominal rectus diastasis: a prospective randomized study

Background:

Abdominal rectus diastasis can lead to functional disability. There is no consensus regarding treatment. This was a prospective study on patients randomized to surgery using either Quill self-retaining sutures or retromuscular mesh for abdominal rectus diastasis repair. The primary aim of the study was to compare long-term recurrence after surgery. Secondary aims were abdominal muscle strength, pain, and quality of life.

Methods:

A total of 57 patients were eligible and 52 were investigated. A routine 1-year follow-up ruled out any patient with recurrence and this was followed up by clinical examination for recurrence and assessment of the secondary outcomes a median of 5 years (3.8–6.5 years) after surgery. Quality of life was assessed using the Short Form-36 questionnaire. Pain related to activity was evaluated using the Ventral Hernia Pain Questionnaire.

Results:

No recurrence of abdominal rectus diastasis was found. Significant improvements were seen between index surgery and long-term follow-up in all domains of Short Form-36. There were no significant differences in quality of life or self-reported muscle strength between the two surgical groups. Long-term pain remained unchanged compared to that at the 1-year follow-up. “Pain this week” had decreased significantly at long-term follow-up compared to prior to surgery (mesh p = 0.009, Quill p = 0.003).

Conclusions:

No recurrence of abdominal rectus diastasis appeared. There was no difference in quality of life or long-term pain between the two surgical groups. Implantation of retromuscular mesh entails more extensive surgery implying potentially higher risk for complications. This leads us to recommend reconstruction with double-row self-retaining sutures for the repair of abdominal rectus diastasis in patients with functional disability.

Mismatch repair status predicts survival after adjuvant treatment in stage II colon cancer patients

BACKGROUND AND OBJECTIVES

Stage II colon cancer is primarily a surgical disease. Only a still not well-defined subset of patients may benefit from postoperative adjuvant chemotherapy. The relationship between adjuvant chemotherapy and survival after relapse is furthermore still not definitely explored in this group of patients. A number of reports suggest some association between defective mismatch repair (dMMR) and colorectal cancer stage II prognosis, but due to contradictory results from existing studies, the exact predictive role is still not fully understood.

METHODS

Retrospective multicenter study including 451 stage II colon cancer patients. The proficiency or deficiency of mismatch repair was tested using immunohistochemistry and analyzed in relationship to two survival outcomes: overall survival (OS) and postrelapse survival.

RESULTS

Patients with dMMR (20.4%) derived no OS benefit from adjuvant chemotherapy (hazard ratio [HR], 1.05; 95% confidence interval [CI], 0.47-2.38; P = .897). Patients with proficient mismatch repair (pMMR) tumors receiving adjuvant chemotherapy had the significantly better OS in comparison to those not receiving chemotherapy (HR, 0.54; 95% CI, 0.35-0.82; P = .004). This relationship remained significant in multivariable analysis (HR, 0.42; 95% CI, 0.22-0.78; P = .007). Patients with pMMR relapsing after adjuvant treatment lived significantly longer than those relapsing without previous adjuvant treatment (HR, 0.55; 95% CI, 0.32-0.96; P = .033) and this result remained significant in the multivariable model (HR, 0.49; 95% CI, 0.26-0.93; P = .030).

CONCLUSION

In stage II CC patients, adjuvant chemotherapy improves therapeutic outcomes only in patients with pMMR tumors. Survival after relapse in patients having received adjuvant chemotherapy is significantly longer for patients with pMMR. No survival benefit from adjuvant chemotherapy was seen among patients with dMMR tumors.

Parastomal Hernia Repair; Seldom Performed and Seldom Reported: Results From a Nationwide Survey

Background:

Parastomal hernia is common, but there are few population-based studies showing the frequency and outcome of parastomal hernia repair in routine surgical practice. The aim of this study was to identify patients undergoing surgery for parastomal hernia in Sweden and to define risk factors for complication and recurrence.

Methods:

A broad search of the Swedish National Patient Register 1998–2007 for all possible parastomal hernia repairs using surgical procedure codes. Records of all patients identified were reviewed and those with a definite parastomal hernia procedure were included and analyzed.

Results:

A total of 71 patients were identified after review of the records. The most common reason for surgery was cosmetic and the most frequent method was relocation of the stoma. Parastomal hernia recurrence rate was 18% during follow-up of a minimum 2 years. Overall, a surgical complication occurred in 32%. Possible risk factors were analyzed including emergency surgery versus planned, gender, age, indication for surgery, and method of surgery; none of which was significant.

Conclusion:

The frequency of parastomal hernia procedures was much lower than suggested by previous studies. The number of procedures per surgeon was even lower than expected. No specific risk factor could be identified. Parastomal hernia auditing in the form of a nationwide quality register should be mandatory. Centralization should be considered.

Patient Reported Injuries After Ventral Hernia Repair

BACKGROUND AND AIMS:

The Swedish National Patient Insurance Company (LÖF) can compensate patients who believe they have been exposed to an avoidable injury or malpractice in healthcare. Its register covers 95% of Swedish healthcare providers.

MATERIAL AND METHODS:

Data on patients operated for primary or incisional ventral hernia in Sweden between 2010 and 2015 and who had filed a claim, were retrieved from LÖF. A total of 290 cases were identified and included. Files include a copy of records, relevant imaging, and an expert advisor's opinion.

RESULTS:

Inadvertent enterotomy occurred during 25 repairs and in these cases, laparoscopic repair was clearly overrepresented ( p  < 0.001). Complications related to the surgical site (infection and ugly scar) were predominantly related to open repairs ( p  < 0.001). Twenty percentage (57/290) of the claims were directly related to an anesthetic mishap. Univariate ordinal regression showed that the odds of receiving a high reimbursement was significantly increased if laparoscopic repair was performed p  < 0.001 (odds ratio: 0.37; 95% confidence interval: 0.21-0.65). Sixty-three percentage of claims were filed by women.

CONCLUSION:

Inadvertent enterotomy is overrepresented, and the probability that a claim filed for an avoidable injury leads to high reimbursement is greater if laparoscopic repair is performed rather than open ventral hernia repair. The high amount of injuries related to general anesthesia during umbilical hernia repair may be reduced with an increased proportion executed in local anesthesia.

Prediction of outcome after curative surgery for colorectal cancer: preoperative haemoglobin, C-reactive protein and albumin

AIM

The aim was to evaluate a scoring system using the values of preoperative haemoglobin, C-reactive protein (CRP) and albumin to predict colorectal cancer recurrence and survival.

METHOD

Data on all curative resections for Stages I-III colorectal cancer performed at a tertiary referral hospital in 2007-2010 were recorded in the Swedish Colorectal Cancer Registry and were matched to local databases for laboratory results and blood transfusion. Patients who died within 30 days or during primary hospital admission were excluded. Preoperative haemoglobin, CRP and albumin levels were recorded for 417 patients. A score (0-3) was derived on the presence of anaemia (Hb < 120 g/l for women and < 130 g/l for men), raised CRP (> 10 mg/ml) and low albumin (< 35 g/dl). The risks for recurrence and impaired overall survival were assessed using Cox regression analyses.

RESULTS

Impaired overall survival was found when one, two or three of the criteria anaemia, elevated CRP and low albumin were present prior to surgery [hazard ratio (HR) 3.61, 95% CI 1.66-7.85; HR 3.91, 95% CI 1.75-8.74; HR 4.85, 95% CI 2.15-10.93, respectively]. The risk for recurrence, however, was not related to the presence of these criteria.

CONCLUSION

Overall survival after curative surgery for Stages I-III colorectal cancer is impaired when anaemia, elevated CRP or low albumin exist prior to surgery.

Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study

PURPOSE

Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair.

METHODS

Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment.

RESULTS

There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit.

CONCLUSION

No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.

Giant ventral hernia-relationship between abdominal wall muscle strength and hernia area

Background

Symptoms arising from giant ventral hernia have been considered to be related to weakening of the abdominal muscles. The aim of this study was to investigate the relationship between the area of the abdominal wall defect and abdominal wall muscle strength measured by the validated BioDex system together with a back/abdominal unit.

Methods

Fifty-two patients with giant ventral hernia (>10 cm wide) underwent CT scan, clinical measurement of hernia size and BioDex measurement of muscle strength prior to surgery. The areas of the hernia derived from CT scan and from clinical measurement were compared with BioDex forces in the modalities extension, flexion and isometric contraction. The Spearman rank test was used to calculate correlations between area, BMI, gender, age, and muscle strength.

Result

The hernia area calculated from clinical measurements correlated to abdominal muscle strength measured with the Biodex for all modalities (p-values 0.015–0.036), whereas no correlation was seen with the area calculated by CT scan. No relationship was seen between BMI, gender, age and the area of the hernia.

Discussion

The inverse correlation between BioDex abdominal muscle strength and clinically assessed hernia area, seen in all modalities, was so robust that it seems safe to conclude that the area of the hernia is an important determinant of the degree of loss of abdominal muscle strength. Results using hernia area calculated from the CT scan showed no such correlation and this would seem to concur with the results from a previous study by our group on patients with abdominal rectus diastasis. In that study, defect size assessed clinically, but not that measured by CT scan, was in agreement with the size of the diastasis measured intra-operatively.

The point at which the area of a hernia begins to correlate with loss of abdominal wall muscle strength remains unknown since this study only included giant ventral hernias.

Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study

AIM

The study aimed to investigate whether continuing potentially inappropriate medication (PIM) is associated with length of hospital stay (LOS) and postoperative mortality in elderly people undergoing colorectal cancer surgery.

METHOD

The Swedish National Colorectal Cancer Register and the Swedish Prescribed Drug Register provided matched data on 7279 patients aged 75 years or more who had undergone bowel resection for colorectal cancer between 2007 and 2010. Patients were divided into two groups depending on whether or not they were taking PIM at the time of surgery. The primary efficacy variables were the LOS and 30-day postoperative mortality.

RESULTS

Of the 7279 patients, 22.5% (1641) of the patients were exposed to at least one PIM and the total number of drugs taken in this group was six, compared with three in the non-PIM group (P < 0.001). Postoperative mortality was higher in the PIM group (7.1% vs 4.5%, P < 0.001), and LOS was longer (10 days vs 9, P = 0.001). When adjusted for independent predictors, the differences in LOS (odds ratio 1.14; 95% confidence interval 1.00-1.29, P = 0.046) and postoperative mortality (odds ratio 1.43; 95% confidence interval 1.11-1.85, P = 0.006) remained significant.

CONCLUSION

The use of PIM prior to surgery is associated with increased postoperative mortality and prolonged hospital stay. Although no causal relationship is proved, the results add a further aspect to preoperative optimization of elderly patients about to have major colorectal surgery.

Risk factors for reoperation due to chronic groin postherniorrhaphy pain

BACKGROUND

Chronic groin postherniorrhaphy pain (CGPP) is common and sometimes so severe that surgical treatment is necessary. The aim of this study was to identify risk factors for being reoperated due to CGPP.

METHODS

All 195,707 repairs registered in the Swedish Hernia Register between 1999 and 2011 were included in the study. Out of these, 28,947 repairs were excluded since they were registered as procedures on the same patient after a previous repair. Age, gender, hernia anatomy (indirect reference), method of repair (anterior sutured repair reference) and postoperative complications were included in a multivariate Cox analysis with reoperation due to CGPP as endpoint.

RESULTS

Of the patients included in the study cohort, 218 (0.13%) later underwent reoperation due to CGPP, including 31 (14%) women. Median age at the primary repair was 61.5 years. Risk factors for being reoperated were age < median [hazard ratio (HR) 3.03, 95% confidence interval (CI) 2.22-4.12], female gender (HR 2.13, CI 1.41-3.21), direct hernia (HR 1.35, CI 1.003-1.81), other hernia (HR 6.03, CI 3.08-11.79), Lichtenstein repair (HR 2.22, CI 1.16-4.25), plug repair (HR 3.93, CI 1.96-7.89), other repair (HR 2.58, CI 1.08-6.19), bilateral repair (HR 2.58, CI 1.43-4.66) and postoperative complication (HR 4.40, CI 3.25-5.96).

CONCLUSIONS

Risk factors for being reoperated due to CGPP in this cohort included low age, female gender, a direct hernia, a previous Lichtenstein or plug repair, bilateral repair and postoperative complications. Further research on how to avoid CGPP and explore the effectiveness of surgery for CGPP is necessary.

A comparison between intrastomal 3D ultrasonography, CT scanning and findings at surgery in patients with stomal complaints

PURPOSE

Since there are no reliable investigative tools for imaging parastomal hernia, new techniques are needed. The aim of this study was to assess the validity of intrastomal three-dimensional ultrasonography (3D) as an alternative to CT scanning for the assessment of stomal complaints.

METHOD

Twenty patients with stomal complaints, indicating surgery, were examined preoperatively with a CT scan in the supine position and 3D intrastomal ultrasonography in the supine and erect positions. Comparison with findings at surgery, considered to be the true state, was made.

RESULTS

Both imaging methods, 3D ultrasonography and CT scanning, showed high sensitivity (ultrasound 15/18, CT scan 15/18) and specificity (ultrasound 2/2, CT scan 1/2) when judged by a dedicated radiologist. Corresponding values for interpretation of CT scans in routine clinical practice was for sensitivity 17/18 and for specificity 1/2.

CONCLUSION

3D ultrasonography has a high validity and is a promising alternative to CT scanning in the supine position to distinguish a bulge from a parastomal hernia.

Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival

AIM

The hypothesis tested in this study was that major blood loss during surgery for rectal cancer increases the risk for surgical complications and for small bowel obstruction (SBO) as a result of adhesions or tumour recurrence, and reduces overall survival.

METHOD

Data were retrieved from the Uppsala/Örebro Regional Rectal Cancer Registry for all patients undergoing radical resection for rectal cancer during 1997-2003 (n = 1843) and were matched against the Swedish National Patient Registry regarding surgery and admission for SBO. These patient records were scrutinized to determine the etiology of surgery for SBO. The registry was scrutinized for blood loss and other surgical complications associated with surgery. Uni- and multivariate Cox analysis and logistic regression were used.

RESULTS

Ninety-four (5.1%) patients underwent surgery for SBO > 30 days after the index operation: 82 for adhesions and 12 for tumour recurrence. The volume of blood lost did not influence the risk of surgery for SBO as a result of adhesions, but blood loss above the median (≥ 800 ml) increased the risk for surgery for SBO caused by tumour recurrence (hazard ratio = 10.52; 95% CI: 1.36-81.51). Increased blood loss increased the risk of surgical complications (OR = 1.78; 95% CI: 1.35-2.35 with blood loss of ≥ 450 ml) but did not reduce overall survival. Irradiation before surgery increased blood loss, complications and admission for SBO.

CONCLUSION

Major blood loss during surgery for rectal cancer increases the risk of later surgery for SBO caused by tumour recurrence and surgical complications, but overall survival is not affected.

Management of colon cancer in the elderly: a population-based study

AIM

Although the median age of patients diagnosed with colon cancer is over 70 years, little is known about specific characteristics and management in the elderly. The aim of this study was to define the characteristics of colon cancer in elderly patients and compare the quality of preoperative assessment and surgery with that of younger patients undergoing surgery for colon cancer.

METHOD

Data on 15,255 patients diagnosed with colon cancer between 2007 and 2010 were retrieved from the Swedish National Colon Cancer Register. Of these, 12,959 underwent surgical resection: 6141 were 75 years or older while 6818 were younger. The χ(2) test, Mann-Whitney U-test and univariable and multivariable logistic regression analyses were used for between-group comparison.

RESULTS

Older patients were more likely to be female (54% older/48% younger) and have right-sided cancer (60% older/49% younger). Among patients who underwent resection, the elderly were less often evaluated regarding tumour stage prior to surgery (59% older/65% younger) and they were less often evaluated at a multidisciplinary team conference (26% older/34% younger). Elderly patients more frequently underwent emergency surgery (22% older/19% younger) despite having an earlier cancer stage. When adjusted for stage, fewer elderly patients underwent a radical curative procedure (OR for noncurative resection 1.19; 95% CI 1.06-1.33).

CONCLUSION

Routine management of patients with colon cancer is age-dependent. Patients aged 75 years and older are less often completely staged and less often evaluated at a multidisciplinary team conference prior to surgery. Adjusted for stage, fewer elderly patients undergo curative resection.

Effect of an elastic girdle on lung function, intra-abdominal pressure, and pain after midline laparotomy: a randomized controlled trial

PURPOSE

Girdles and abdominal binders may reduce pain and stabilize the abdominal wall after laparotomy, but a risk for increased intra-abdominal pressure and decreased lung function is also hypothesized. The aim of this study was to investigate the effect of an abdominal girdle after midline laparotomy in a randomized controlled trial.

METHODS

Twenty-three patients undergoing laparotomy were randomized to wear an elastic girdle postoperatively and 25 were randomized to no girdle. Pulmonary function was evaluated with; forced vital capacity (FVC), forced expiratory volume during one second (FEV1), peak expiratory flow (PEF), and cough PEF. Pain was recorded using a visual analog scale (VAS). All patients completed the ventral hernia pain questionnaire (VHPQ) before surgery and at the end of the study. Intra-abdominal pressure was measured via an indwelling urinary catheter. Wound healing was assessed from photographs.

RESULTS

FVC, FEV1, PEF, and cough PEF were reduced by about 30 % after surgery, but there were no differences between patients with or without a girdle (ANOVA). Intra-abdominal pressure and wound healing were the same in both groups. Pain was significantly lower on day 5 in the girdle group (p = 0.004).

CONCLUSIONS

An individually fitted elastic girdle used after midline laparotomy was found to be safe, as this did not affect lung function, coughing, intra-abdominal pressure, or wound healing. The immediate decline in lung function after surgery is restrictive and due to anesthesia and the surgical procedure. Pain was significantly decreased in the girdle group. The study is registered at ClinicalTrials.gov, number NCT01517217.

The DQB1(*)03:02 HLA haplotype is associated with increased risk of chronic pain after inguinal hernia surgery and lumbar disc herniation

Neuropathic pain conditions are common after nerve injuries and are suggested to be regulated in part by genetic factors. We have previously demonstrated a strong genetic influence of the rat major histocompatibility complex on development of neuropathic pain behavior after peripheral nerve injury. In order to study if the corresponding human leukocyte antigen complex (HLA) also influences susceptibility to pain, we performed an association study in patients that had undergone surgery for inguinal hernia (n = 189). One group had developed a chronic pain state following the surgical procedure, while the control group had undergone the same type of operation, without any persistent pain. HLA DRB1genotyping revealed a significantly increased proportion of patients in the pain group carrying DRB1(*)04 compared to patients in the pain-free group. Additional typing of the DQB1 gene further strengthened the association; carriers of the DQB1(*)03:02 allele together with DRB1(*)04 displayed an increased risk of postsurgery pain with an odds risk of 3.16 (1.61-6.22) compared to noncarriers. This finding was subsequently replicated in the clinical material of patients with lumbar disc herniation (n = 258), where carriers of the DQB1(*)03:02 allele displayed a slower recovery and increased pain. In conclusion, we here for the first time demonstrate that there is an HLA-dependent risk of developing pain after surgery or lumbar disc herniation; mediated by the DRB1(*)04-DQB1(*)03:02 haplotype. Further experimental and clinical studies are needed to fine-map the HLA effect and to address underlying mechanisms.

Degree of specialisation of the surgeon influences lymph node yield after right-sided hemicolectomy

AIM

To investigate the degree to which specialisation or case-load of the surgeon is associated with the number of lymph nodes isolated from pathology specimens after right-sided hemicolectomy.

METHOD

Data from 6 hospitals with well-defined catchment areas included in the Uppsala/Örebro Regional Oncology Centre Colon Cancer Register 1997-2006 were used to assess 821 patients undergoing right-sided hemicolectomy for stages I-III colon cancer. Factors influencing the lymph node yield were evaluated.

RESULTS

A surgeon with colorectal accreditation and a university pathology department were both associated with a significantly higher proportion of patients having 12 or more lymph nodes isolated from surgical specimens after right-sided hemicolectomy in both unadjusted and multivariate analyses. Emergency surgery did not affect the lymph node yield.

CONCLUSION

The degree of specialisation of the surgeon influences the number of lymph nodes isolated from specimens obtained during routine right-sided colon cancer surgery.

Manifestations of acute appendicitis: a prospective study on acute abdominal pain

BACKGROUND/AIMS

The aim of this prospective study was to identify the clinical symptoms and signs most important for the prediction of appendicitis among patients with acute abdominal pain.

METHODS

Clinical findings in 2,478 patients admitted to the emergency department of Mora Hospital from February 1997 to June 2000, with acute abdominal pain of up to 7 days' duration, were registered in a database. The medical records were reviewed after 1 year.

RESULTS

A total of 432 patients were suspected of having appendicitis and in 221 this diagnosis was confirmed. Some 53 patients, with another preliminary diagnosis, were eventually found to suffer from appendicitis, making a total of 274 patients with appendicitis. Appendectomy was performed in 316 patients and was negative in 14%. Clinical diagnosis of appendicitis had a sensitivity of 0.81, a specificity of 0.90, a positive predictive value of 0.51, a positive likelihood ratio of 8.1, and a diagnostic accuracy of 0.89. The highest odds ratios were found for isolated tenderness in the right iliac fossa (3.29), rebound tenderness (3.00), right-sided rectal tenderness (2.53), migration of pain to the right iliac fossa (2.18), and local guarding (2.11).

CONCLUSION

Clinical findings indicating localised inflammation in the right iliac fossa were reliable in predicting acute appendicitis. The patients' history of pain combined with a careful clinical examination still plays an important role in detecting appendicitis among patients with acute abdominal pain.

Betamethasone in hernia surgery: a randomized controlled trial

BACKGROUND

Post-operative pain and nausea may be a problem in day-case surgery. This study aims to investigate the effect of betamethasone on pain and nausea in inguinal hernia surgery.

METHODS

Patients aged 18-70 years scheduled for open inguinal hernia surgery at two Swedish hospitals, March 2005-December 2009, were eligible for inclusion. Patients were randomized, to either treatment with 12 mg betamethasone intravenously or placebo. Post-operative pain was assessed using a visual analogue scale on the recovery ward, each day the first post-operative week and at 1 month after surgery. One year after surgery, residual pain was estimated by the Inguinal Pain Questionnaire.

RESULTS

A total of 398 patients were included (21 women, 377 men). Pain at rest on the day of surgery was significantly lower in the treatment group (p = 0.012). The pain was also significantly lower in the treatment group the day after surgery (p < 0.001), but not during the remaining part of the first post-operative week. Bleeding complications were reported by 17 patients (8.5%) in the Betamethasone group and seven (3.5%) in the placebo group (p = 0.028). One month after surgery, 21 out of 173 (12%) in the betamethasone group still had pain, compared to 33 out of 159 (21%) in the placebo arm (p = 0.049). After 1 year, no significant difference in pain was seen.

CONCLUSION

A 12 mg betamethasone reduced pain during the first 24 h and at 1 month after inguinal hernia surgery. If combined with diclofenac, however, this dose may increase the risk for bleeding complications.

The Easy-X magnetic stoma connector system. A future concept for stomal dressing?

AIM

A considerable proportion of stoma patients are disabled for various reasons and are elderly. To be able to dress their stoma themselves is of crucial importance for their integrity and social life. This study evaluates a novel stomal dressing system based on a magnetic connector--the Easy-X system.

METHOD

Twenty patients (8 women, mean age of 40-89 years) with a well-functioning colostomy tested the Easy-X system for 6 weeks. The system was judged by the patients using a multiple choice scale, and by the stoma nurses using a 10-grade VAS.

RESULTS

Eighteen of 20 patients completed the trial. Ten patients rated the Easy-X as better than their ordinary system, 3 as equal to and 4 deemed it inferior. Despite this, only three were prepared to change to the Easy-X system. Eleven of 18 patients experienced discomfort with the new adhesive plate. Three patients suffered leakage less often and five patients more often than with their ordinary system. Stoma nurse ratings were available for 14 patients. Their evaluation of the magnetic connector in the Easy-X system was positive in eight cases, neutral in one case and negative in three cases. Global impression ratings were 3 positive, 3 negative and 5 neutral.

CONCLUSION

The Easy-X system showed potential advantages over conventional stomal dressing systems, but the system must be improved in terms of a varied assortment of dressing products enabling individual fitting before a larger trial can be carried out on disabled patients. Furthermore, the increased use of metal has to be handled with an ecologic recycling system. WHAT IS NEW IN THIS PAPER: A new stomal dressing system with a magnetic connector has potential advantages over conventional stomal dressings for disabled persons.

Intrastomal 3D ultrasound; an inter- and intra-observer evaluation

BACKGROUND

The aim of this study was to determine intra- and interobserver reliability in 3D intrastomal ultrasound imaging of parastomal hernia and protrusion.

METHOD

A total of 40 patients were investigated. Two or three physicians evaluated the images twice, 1 month apart.

RESULTS

Inter-observer agreement was 72 % with a kappa value 0.59. For the last 10 patients there was an agreement of 80 % with a kappa value of 0.70. Intraobserver agreement was 80 % for one observer and 95 % for the other. The learning curve levelled out at around 30 patients.

CONCLUSION

Considering the learning curve of 30 patients, 3D intrastomal ultrasound is a reliable investigation method. 3D intrastomal ultrasonography has the potential to be the investigation of choice to differentiate between a bulge, a hernia, or a protrusion.

Patients with rectal cancer receiving adjuvant chemotherapy have an increased survival: a population-based longitudinal study

BACKGROUND

The aim of this study was to investigate whether or not the use of adjuvant chemotherapy in stage III rectal cancer varies between regions and over time, and if this has had an effect on survival rates.

PATIENTS AND METHODS

Patients from the Uppsala/Örebro region below 75 years-of-age, operated 1995-2002 and registered in the Swedish Rectal Cancer Register, were monitored between 1995 and September 2008. A multivariate Cox proportional hazard regression model was used for analysis. Overall survival was described using the Kaplan-Meier method.

RESULTS

Four hundred and thirty-six patients with stage III rectal cancer were included. Adjuvant chemotherapy was given to 42% of the patients (proportions varying from 13% to 77% among counties), and there were substantial increases over time. The 5-year overall survival was 65.8% [95% confidence interval (CI) 50-84] for patients having adjuvant chemotherapy compared with 45.6% (95% CI 39-52) for patients not treated with chemotherapy. The multivariate hazard ratio for death was 0.65 (95% CI 0.5-0.8) for patients treated with adjuvant chemotherapy.

CONCLUSIONS

The use of adjuvant chemotherapy for rectal cancer has increased, but varies considerably between hospitals/counties. In this cohort, those having adjuvant chemotherapy had a longer overall survival.

Glasshouse vs field experiments: do they yield ecologically similar results for assessing N impacts on peat mosses?

• Peat bogs have accumulated more atmospheric carbon (C) than any other terrestrial ecosystem today. Most of this C is associated with peat moss (Sphagnum) litter. Atmospheric nitrogen (N) deposition can decrease Sphagnum production, compromising the C sequestration capacity of peat bogs. The mechanisms underlying the reduced production are uncertain, necessitating multifactorial experiments. • We investigated whether glasshouse experiments are reliable proxies for field experiments for assessing interactions between N deposition and environment as controls on Sphagnum N concentration and production. We performed a meta-analysis over 115 glasshouse experiments and 107 field experiments. • We found that glasshouse and field experiments gave similar qualitative and quantitative estimates of changes in Sphagnum N concentration in response to N application. However, glasshouse-based estimates of changes in production--even qualitative assessments-- diverged from field experiments owing to a stronger N effect on production response in absence of vascular plants in the glasshouse, and a weaker N effect on production response in presence of vascular plants compared to field experiments. • Thus, although we need glasshouse experiments to study how interacting environmental factors affect the response of Sphagnum to increased N deposition, we need field experiments to properly quantify these effects.

Surgeon and hospital-related risk factors in colorectal cancer surgery

AIM

The aim of this study was to identify surgeon and hospital-related factors in a well-defined population-based cohort; the results of this study could possibly be used to improve outcome in colorectal cancer.

METHOD

Data from the colonic (1997-2006) and rectal (1995-2006) cancer registers of the Uppsala/Örebro Regional Oncology Centre were used to assess 1697 patients with rectal and 2692 with colonic cancer. Putative risk factors and their impact on long-term survival were evaluated using the Cox proportional hazard model.

RESULTS

The degree of specialization of the operating surgeon had no significant effect on long-term survival. When comparing the surgeons with the highest degree of specialization, noncolorectal surgeons demonstrated a slightly lower long-term survival for rectal cancer stage I and II (HR, 2.03; 95% CI, 1.05-3.92). Surgeons with a high case-load were not associated with better survival in any analysis model. Regional hospitals had a lower survival rate for rectal cancer stage III surgery (HR, 1.47; 95% CI, 1.08-2.00).

CONCLUSION

Degree of specialization, surgeon case-load and hospital category could not be identified as important factors when determining outcome in colorectal cancer surgery in this study.

Transcutaneous implant evacuation system: a new approach to continent stoma construction

AIM

Several attempts have been made to construct a mechanical continent stoma without success. A system based on a titanium implant has been developed in an animal model. Following evaluation of this device in animals, the transcutaneous implant evacuation system (TIES) has now been tested in humans.

METHOD

The implant consists of a titanium cylinder including a mesh and a plastic cap. This design allows the intestine and subcutaneous tissue to grow into the device. Four patients with inflammatory bowel disease underwent surgery. The indications for surgery were malfunctioning pouches or skin problems around the stoma. Following abdominal surgery, implantation of the device was made behind the external fascia with diversion of the ileum through the device to create a permanent stoma.

RESULTS

Primary surgery was uncomplicated. Skin tissue growth into the implant was delayed in one case and one patient had impaired healing between intestine and the device. In these cases minor surgical correction was necessary. The tested cap design in the current device was inconvenient and needs to be further developed. No local infections occurred.

CONCLUSION

This first clinical study of the TIES device has shown few device-related complications and no significant safety concerns. In our experience bridging of connective tissue between the intestine and skin is crucial for healing. Further development of the lid, the implant and the implantation method within clinical trials is necessary before the device can be introduced in general practice.

Role of the multidisciplinary team in breast cancer management: results from a large international survey involving 39 countries

BACKGROUND

The optimal management of patients with breast cancer (BC) requires the expertise of specialists from different disciplines. This has led to the evolution of multidisciplinary teams (MDTs), allowing all key professionals to jointly discuss individual patients and to contribute independently to clinical decisions. Data regarding BC MDTs in different regions and countries are scarce.

METHODS

The investigators of a large global phase III adjuvant BC trial being conducted by the Breast International Group were invited to respond to a questionnaire about the extent, structure, and function of BC MDTs.

RESULTS

One hundred and fifty-two responses from 39 countries were received, and remarkable differences were noted in different geographic regions. Sixty-five percent of the respondents from eastern Europe, 63% from western Europe, 35% from Asia, and 25% from South America declared that MDT was a mandatory part of BC care in their country. Ninety percent of the respondents from Europe stated their MDTs met weekly, compared with only half of the respondents from Asia.

CONCLUSION

This survey is perhaps the first large-scale effort to collect information regarding BC MDTs from different parts of the world and provides objective information of frequency, composition, function, and working mechanism of BC MDTs.

Endoanal ultrasonography may distinguish Crohn's anal fistulae from cryptoglandular fistulae in patients with Crohn's disease: a cross-sectional study

BACKGROUND

The aim of the study was a cross-sectional investigation into the types of anal fistulae in patients with Crohn's disease using 3-dimensional endoanal ultrasonography.

METHODS

The study population consisted of 45 patients with established Crohn's disease referred in a 2-year period for treatment of anal fistula. The fistulae were classified according to the presence of three criteria: 1. bifurcation or secondary extension; 2. cross-sectional width ≥ 3 mm; and 3. content of hyperechoic secretions.

RESULTS

The fistulae of 24 patients (53%) satisfied two or three criteria and were classified as true Crohn's fistulae, while the fistulae of 21 patients satisfied one or none of the criteria and were the cryptoglandular type. The fistulae in the two or three criteria group had been in existence for 8.4 years on average and those in the cryptoglandular group for 4.5 years on average (P = 0.283). The corresponding numbers of previous operations for fistula were 5.7 (range 0-32) and 1.5 (range 0-6), respectively (P = 0.0211). The presence of colitis or proctitis was similar across the groups, but the perianal Crohn's disease activity index was higher with a Crohn's type of fistula (P = 0.0097). Also, a larger proportion had been treated with anti-TNF-monoclonal antibody (0.0169).

CONCLUSIONS

Endoanal ultrasonography was capable of discerning two subgroups of fistula in Crohn's patients. These groups were clinically different indicating that the prospect of surgical cure is also different.

Climatic modifiers of the response to nitrogen deposition in peat-forming Sphagnum mosses: a meta-analysis

Peatlands in the northern hemisphere have accumulated more atmospheric carbon (C) during the Holocene than any other terrestrial ecosystem, making peatlands long-term C sinks of global importance. Projected increases in nitrogen (N) deposition and temperature make future accumulation rates uncertain. Here, we assessed the impact of N deposition on peatland C sequestration potential by investigating the effects of experimental N addition on Sphagnum moss. We employed meta-regressions to the results of 107 field experiments, accounting for sampling dependence in the data. We found that high N loading (comprising N application rate, experiment duration, background N deposition) depressed Sphagnum production relative to untreated controls. The interactive effects of presence of competitive vascular plants and high tissue N concentrations indicated intensified biotic interactions and altered nutrient stochiometry as mechanisms underlying the detrimental N effects. Importantly, a higher summer temperature (mean for July) and increased annual precipitation intensified the negative effects of N. The temperature effect was comparable to an experimental application of almost 4 g N m(-2)  yr(-1) for each 1°C increase. Our results indicate that current rates of N deposition in a warmer environment will strongly inhibit C sequestration by Sphagnum-dominated vegetation.

Recurrent groin hernia surgery

Background

The reoperation rate after recurrent groin hernia surgery is more than twice that recorded for primary groin hernia procedures. The aim was to define the outcome from routine redo hernia surgery by analysing a large population-based cohort from a national hernia register.

Methods

All recurrent groin hernia operations registered in the Swedish Hernia Register from 1992 to 2008 were analysed using multivariable analysis with stratification for preceding repair.

Results

Altogether 174 527 hernia operations were recorded in the Swedish Hernia Register between 1992 and 2008, including 19 582 reoperations. The preceding repair was included in the register for 5565 of these recurrent repairs. With laparoscopic repair as reference standard, the hazard ratio for recurrence was 2·55 (95 per cent confidence interval 1·66 to 3·93) after sutured repair, 1·53 (1·20 to 1·95) after Lichtenstein repair, 2·31 (1·76 to 3·03) after plug repair, 1·36 (0·95 to 1·94) after open preperitoneal mesh and 3·08 (2·22 to 4·29) after other repairs. Laparoscopic and open preperitoneal repair were associated with a lower risk of reoperation following a preceding open repair (P &lt; 0·001), but no technique differed significantly from the others following a preceding preperitoneal repair.

Conclusion

The laparoscopic and the open preperitoneal mesh methods of repair for recurrent groin hernias were associated with the lowest risk of reoperation. Although the method of repair in previous surgery must be considered, these techniques are the preferred methods for recurrent groin hernia surgery.

Imaging of parastomal hernia using three-dimensional intrastomal ultrasonography

BACKGROUND

Parastomal hernia is common in patients with a permanent stoma. At present there is no standard method for imaging a parastomal hernia. The aim of this study was to investigate the value of three-dimensional intrastomal ultrasonography in differentiating between a parastomal hernia and a bulge.

METHODS

Twenty patients were divided into four groups according to ultrasonography setting and probe cover. All patients were tested using three different ultrasound probe frequencies (9, 13 and 16 MHz). The intrastomal examination was performed during provocation in both the supine and upright positions, with a protector or water-containing balloon surrounding the probe.

RESULTS

The sharpest images were obtained using the rectal setting with a water-containing balloon surrounding the probe at 9 MHz in supine and erect positions, for evaluation of both fascia and muscle; in some instances even implanted mesh was detectable. When switched to render mode, the pictures improved in sharpness and it was easier to identify anatomical landmarks.

CONCLUSION

Intrastomal ultrasonography using the rectal setting and a frequency of 9 MHz is a feasible method for imaging a parastomal hernia and differentiating it from an abdominal bulge. The image quality improves when render mode is used.

Different techniques for mesh application give the same abdominal muscle strength

PURPOSE

This study investigates abdominal muscle strength after surgery for giant hernia with the onlay, sublay or intraperitoneal (IPOM) method. Theoretically, placement of the mesh may result in different possibilities regarding function and postoperative physical activity related to abdominal muscle function.

METHOD

Twenty-four patients operated for large ventral hernias using the onlay, sublay or IPOM technique were evaluated 1 year following surgery for abdominal wall strength using Biodex system 4.

RESULTS

Despite the different surgical techniques used, no differences were observed in abdominal wall strength between the groups.

CONCLUSION

The postoperative strength of abdominal wall muscles is independent of the method used for reconstruction of large abdominal wall hernia, and the choice of surgical technique should be directed by anatomical circumstances.

Persistent pain after groin hernia surgery: a qualitative analysis of pain and its consequences for quality of life

BACKGROUND

Despite a high prevalence of persistent groin pain after hernia repair, the specific nature of the pain and its clinical manifestation are poorly known. The aim of this study was to determine the type of post-herniorrhaphy pain and its influence on daily life.

METHODS

In order to assess long-term pain qualitatively and to explore how it affects quality of life, 100 individuals with persisting pain, identified in a cohort study of patients operated for groin hernia, were neurologically examined, along with 100 pain-free controls matched for age, gender and type of operation. The patients were asked to answer the SF-36 questionnaire, the hospital anxiety and depression scale, the Swedish Scales of Personality (SSP) and a standardised questionnaire for assessing everyday life coping. The patients were approached approximately 4.9 years after surgery.

RESULTS

Twenty-two patients from the pain group had become pain free by the time of examination, whereas 76 patients still had pain, of whom 47 (68%) suffered from neuropathic pain and 11 from nociceptive pain. The remaining patients suffered from mixed pain, neuropathic and nociceptive, or were found to have another reason for pain. All dimensions of SF-36 were poorer for the pain group than the control group.

CONCLUSION

Persistent post-herniorrhaphy pain is mainly neuropathic and has a substantial impact on health-related quality of life.

Impact of time in the development of acute appendicitis

BACKGROUND

The aim of this study was to elucidate the natural history of appendicitis.

METHODS

Data was collected prospectively from consecutive patients admitted to hospital for acute abdominal pain. The degree of appendiceal inflammation in relation to preoperative duration of pain was analysed.

RESULTS

The study comprised 253 patients operated on for acute appendicitis that could recall the onset of abdominal pain. There was a longer duration of pre-hospital pain in patients, irrespective of age, with perforated appendicitis compared to patients with phlegmonous or gangrenous appendicitis (p < 0.001). In the multivariate analysis, patient age and preoperative duration of pain were independent risk factors for perforation.

CONCLUSION

Patient delay in presentation is the predominant factor determining the incidence of complicated appendicitis, and this delay is not influenced by age or gender.

Risk factors for anastomotic leakage after rectal cancer surgery: a case-control study

BACKGROUND

With introduction of the total mesorectal excision technique and preoperative radiotherapy in rectal cancer surgery, the local recurrence rate has decreased and the overall survival has improved. One drawback, however, is the high anastomotic leakage rate of approximately 10-18%. Male gender and low anastomoses are known risk factors for such leakage. The aim of this study was to identify potentially modifiable risk factors.

METHOD

In a case-control study, data from the Swedish Rectal Cancer Registry (1995-2000) were analysed. Cases were all patients with anastomotic leakage after an anterior resection (n = 134). Two controls were randomly selected for each case. The medical records (n = 402) were checked against a study protocol. Due to incorrect recording two cases and 28 controls were excluded from further analyses.

RESULTS

In the multivariate analysis significant risk factors were American Society of Anesthesiologists score > 2 [OR = 1.40 (95% CI 1.05-1.83)], preoperative radiotherapy [OR = 1.34 (95% CI 1.06-1.69)], intraoperative adverse events [OR = 1.85 (95% CI 1.32-2.58)], level of anastomosis <or= 6 cm [OR = 1.39 (95% CI 1.01-1.90)] and severe bleeding [OR = 1.45 (95% CI 1.14-1.84)]. Diverting stoma protected from leakage [OR = 0.68 (95% CI 0.52-0.88)]. Male gender was a risk factor in the univariate but not in the multivariate analysis [OR = 1.30 (95% CI 1.04-1.63) and OR = 1.26 (95% CI 1.00-1.58), respectively]. Except for a protective stoma, none of the variables considered as possible targets for improvement, such as postoperative epidural anaesthesia, observation at intensive care unit for more than 24 h, and intraabdominal drainage, proved to be protective factors either in the univariate or in the multivariate analyses.

CONCLUSION

The most important risk factors for leakage were adverse intraoperative events, low anastomoses and preoperative radiotherapy. A diverting stoma is protective and can reduce the consequences when leakage occurs. Further analyses with focus on the surgical technique and individual surgeon may be valuable in identifying targets for improvement.