Optimal timing of aortic valve replacement for aortic stenosis – are we operating late?

OBJECTIVE

To evaluate the adherence to current guidelines for surgery in patients with aortic valve stenosis.

DESIGN

From 1 January 1997 to 31 May 1999, 99 patients were accepted for aortic valve surgery with preserved left ventricular function and normal coronary angiogram. On admission for operation, 20 patients were evaluated regarding symptoms, exercise capacity, and left ventricular morphology and function.

RESULTS

There were 14 men and 6 women, mean age 64.3 years. Years from symptom onset varied from 2.1 to 3.2. Dyspnoea was the most common limiting symptom. Thirty per cent of the patients were classified as NYHA IIIB. Physical capacity was reduced to 79% of the expected. Left ventricular hypertrophy was present in 14/20 patients. Left ventricular systolic function was reduced with mean ejection fraction of 0.46. Diastolic dysfunction (E/A ratio <1) was present in 12 patients.

CONCLUSION

Many patients accepted for aortic valve replacement due to aortic stenosis show advanced disease and are referred for surgery later in the disease process than is recommended in the current guidelines.

Temporal trends in non-small cell lung cancer survival in Sweden

We modeled temporal trends in the 1- and 5-year survival of 32 499 patients with adenocarcinoma and squamous cell carcinoma of the lung in the Swedish Cancer Register between 1961 and 2000. The 1-year relative survival for adenocarcinoma improved from 37% for patients diagnosed 1961–1965 to 45% for those diagnosed 1996–2000 and from 39 to 45% for squamous cell carcinoma. The adjusted excess mortality ratios for the period 1996–2000 compared with 1961–1965 were 0.80 for adenocarcinoma and 0.81 for squamous cell carcinoma. Thus, a previous report in a Dutch study of a relatively worsening prognosis for adenocarcinoma over time could not be confirmed.

FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease

OBJECTIVE

To develop a scoring system for risk stratification and evaluation of the effect of an early invasive strategy for treatment of unstable coronary artery disease (CAD).

DESIGN

Retrospective analysis of a randomised study (FRISC II; fast revascularisation in instability in coronary disease).

SETTING

58 Scandinavian hospitals.

PATIENTS

2457 patients with unstable CAD from the FRISC II study.

MAIN OUTCOME MEASURES

One year rates of mortality and death/myocardial infarction (MI).

METHODS

Patients were randomly assigned to an early invasive or a non-invasive strategy. From the non-invasive cohort independent variables of death or death/MI were identified.

RESULTS

Seven factors, age > 70 years, male sex, diabetes, previous MI, ST depression, and increased concentrations of troponins and markers of inflammation (interleukin 6 or C reactive protein), were associated with an independent increased risk for death or death/MI. In patients with > or = 5 of these factors the invasive strategy reduced mortality from 15.4% (20 of 130) to 5.2% (7 of 134) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.15 to 0.78, p = 0.006). Death/MI was also reduced in patients with 3-4 factors from 15.7% (80 of 511) to 10.8% (58 of 538) (RR 0.69, 95% CI 0.50 to 0.94, p = 0.02). Neither death nor death/MI was reduced in patients with 0-2 risk factors.

CONCLUSION

In unstable CAD, this scoring system based on factors independently associated with an adverse outcome can be used shortly after admission to the hospital for risk stratification and for selection of patients to an early invasive treatment strategy.

Increased risk of heart failure as a consequence of perioperative myocardial injury after coronary artery bypass grafting

OBJECTIVE

To analyse the relation between perioperative myocardial injury (PMI) and the risk of subsequent heart failure after coronary artery bypass grafting (CABG).

DESIGN AND SETTING

Clinical data were documented prospectively in all patients and stored in a computer. All hospital readmissions were identified and the registered primary diagnoses were analysed. Survival information on all patients was obtained by use of combined registers. The study was carried out at the cardiac surgical referral centre of University Hospital, Uppsala, Sweden.

PATIENTS

7493 patients discharged alive after primary CABG between 1987 and 1996 were followed up until the first hospital readmission for heart failure, death, or 31 December 1996 was reached.

MAIN OUTCOME MEASURES

Hospital readmission for heart failure or late mortality.

RESULTS

Of the patients studied 576 (7.7%) were readmitted for heart failure. Actuarial freedom from readmission for heart failure after four years was 93%, and after seven years, 89%. Of the 576 patients, 114 (20%) had had PMI, which increased the risk of heart failure independently (hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.8 to 2.8). Increased age, female sex, diabetes, previous myocardial infarction, dyspnoea, preoperative atrial fibrillation, left ventricular dysfunction, and triple vessel disease were independent risk factors for heart failure. The use of an internal mammary artery decreased the risk. PMI implied increased mortality (HR 1.4, 95% CI 1.1 to 1.8). Late mortality was greatly increased in patients readmitted for heart failure.

CONCLUSION

PMI increased the risk of heart failure and late death after CABG, and heart failure had a notable adverse effect on late survival.

Effect of delays on prognosis in patients with non-small cell lung cancer

BACKGROUND

The effect of delay on survival in lung cancer remains uncertain. It is suggested that prompt management of non-small cell lung cancer (NSCLC) can influence prognosis. This study was undertaken to examine the relation between delay and prognosis in patients with NSCLC and to investigate the delay time from first symptom and from first hospital visit to start of treatment.

METHODS

Two types of delay (symptom to treatment delay and hospital delay) were investigated in 466 patients treated for NSCLC at two institutions in central Sweden. Delays in relation to clinical characteristics were compared and the effects of delay times and other relevant factors on survival were assessed in multivariate analyses.

RESULTS

Thirty five per cent of patients received treatment within 4 weeks of the first hospital visit and 52% within 6 weeks. Median symptom to treatment delay was 4.6 months and median hospital delay 1.6 months. Older age, advanced tumour stage, and non-surgical treatment were independently related to poor survival. Both prolonged hospital delay and symptom to treatment delay provided additional information when considered separately. In a final multivariate model only increased symptom to treatment delay gave significant information of a better prognosis. There was an association between a short delay and a poor prognosis which was most pronounced in patients with advanced disease.

CONCLUSION

When considering the whole study population and all stages of tumour together, shorter delay was associated with a poorer prognosis. This is likely to reflect the fact that patients with severe signs and symptoms receive prompt treatment. These findings indicate that the waiting time for treatment in patients with NSCLC is longer than recommended.

Quality of life following lung cancer surgery

BACKGROUND

Patients with non-small cell bronchogenic carcinoma have a limited survival. Quality of life (QoL) is therefore an issue of importance in this group of patients. The aim of the present study was to evaluate QoL in lung cancer patients after open surgery.

METHODS

During a 4 year period (1997-2000) 194 patients with primary bronchogenic carcinoma of the lung underwent surgery at the Department of Thoracic and Cardiovascular Surgery in Uppsala, Sweden; 132 patients were alive on 1 April 2001. These patients received the Short Form-36 (SF-36) health questionnaire, Hospital Anxiety and Depression (HAD) scale, and special questions related to pulmonary symptoms (response rate 85%). Patients who underwent coronary bypass surgery (CABG) served as a comparison group (response rate 91%). Corresponding estimates of QoL in healthy controls were obtained from the SF-36 manual for the Swedish population.

RESULTS

Lung cancer patients differed from CABG patients in only one subgroup of the SF-36 (role physical), but had poorer QoL than healthy controls. No difference in anxiety was found between the lung cancer patients and the CABG patients, but the latter were more likely to suffer from depression (5.0% v 3.0%). Current smokers scored lower in the mental health dimension assessment.

CONCLUSION

Lung cancer patients who undergo open traditional surgical resection have a QoL comparable to that of CABG patients. Lung cancer patients have poorer physical function because of reduced pulmonary function, but show no sign of increased anxiety or depression. Those who continued to smoke after surgery had impaired mental health.

Impact of perioperative myocardial injury on early and long-term outcome after coronary artery bypass grafting

AIMS

To establish the influence of perioperative myocardial injury on short- and long-term survival after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

The correlation of postoperative serum aspartate aminotransferase and creatine kinase MB to early cardiac-related death and to late survival was evaluated in 4911 patients who underwent CABG consecutively during a 6-year period. There were 93 early deaths (1.9%), 73 of them cardiac-related (1.5% of 4911). After a mean follow-up of 5 years, 409 additional deaths (8.5% of 4818) had occurred. Elevated enzyme levels on day 1 postoperatively highly increased the risk of early cardiac death (serum aspartate aminotransferase >or=2.35 microkat.l(-1): odds ratio 9.2; serum creatine kinase MB >or=61 microg.l(-1): odds ratio 6.0), and increased the risk of late death by approximately 50% (serum aspartate aminotransferase >or=2.35 microkat.l(-1): relative hazard 1.5; serum creatine kinase MB >or=61 microg.l(-1): relative hazard 1.4). This increased risk of death was independent of other risk factors and remained constant over time.

CONCLUSIONS

Enzyme elevation after CABG implied an increased risk of both early and late death. The long-term effect persisted many years after surgery.

Benefits of extended treatment with dalteparin in patients with unstable coronary artery disease eligible for revascularization

AIMS

The FRISC II trial demonstrated that, for patients with unstable coronary artery disease, an early invasive strategy following acute treatment with dalteparin and aspirin, was superior to a more conservative approach. We evaluated whether it is beneficial to extend treatment with dalteparin to patients eligible for revascularization but for whom these procedures are performed after the initial hospital stay.

METHODS AND RESULTS

As a subanalysis of FRISC II, the efficacy and clinical safety of extended dalteparin treatment (5000 or 7500 IU.12h(-1) to day 90) compared with placebo was assessed in 1601 patients randomized to a non-invasive group who underwent revascularization only when necessary because of recurring symptoms, (re)infarction, or severe ischaemia. By day 90, 440 patients had undergone revascularization: 267 of these procedures occurred during the double-blind period. All patients initially received acute treatment (5-7 days from day 1) with dalteparin (120 IU/kg(-1) 12h(-1)). The incidence of death and/or myocardial infarction was monitored until revascularization or day 45 and until revascularization or day 90. There was a significant difference in the estimated probability of death and/or myocardial infarction until revascularization or day 90 in favour of dalteparin (log-rank test, P=0.0415) and there was a significant reduction in death and/or myocardial infarction in favour of extended dalteparin treatment at day 45, with a 57% relative risk reduction (P=0.0004). At day 90 the relative risk reduction was 29%. The safety profile of extended dalteparin treatment was similar to that of acute usage.

CONCLUSION

Extended dalteparin treatment for up to 45 days is effective and safe as a bridging therapy for patients with unstable coronary artery disease awaiting revascularization.

Outcome after lung cancer surgery. Factors predicting early mortality and major morbidity

OBJECTIVE

This study was undertaken to assess mortality, complications and major morbidity during the first 30 days after lung cancer surgery and to estimate the significance of presurgical risk factors.

METHODS

The study was based on all patients referred for surgery for primary lung cancer from 1 January 1987 to 1 September 1999. There were in total 616 patients with primary lung cancer. Three-hundred and ninety-four were men and 222 women. Postoperative events studied were divided into major and minor complications or death during the first 30 days after surgery. The significance of risk factors for an adverse outcome (defined as death or major complication in the first 30 days postoperatively) was assessed by uni- and multivariate logistic regression analyses.

RESULTS

During the study period an increasing number of women and of patients older than 70 years underwent surgery. Overall 30-day mortality was 2.9, 0.6% after single lobectomy and 5.7% after pneumonectomy. Major complications occurred in 54 patients (8.8%). Fifty-eight patients (9.5%) had an adverse outcome during the first 30 days. Male gender, smoker, FEV(1)< or =70% of expected value, squamous cell carcinoma and pneumonectomy were risk factors predicting adverse outcome in the univariate model. Pneumonectomy and FEV(1)< or =70%, were the only independently significant factors for adverse outcome. Only pneumonectomy was independently associated with an increased risk for early death.

CONCLUSION

Our results show low mortality and morbidity after lung cancer surgery. However, patients with reduced lung capacity and those undergoing pneumonectomy should be treated with great care, as they run a considerable risk of major complications or death during the first 30 days postoperatively. Older age (>70 years) does not appear to be a contraindication to lung cancer surgery, but patients in this group should undergo careful preoperative evaluation.

Trends in lung cancer incidence in Sweden with special reference to period and birth cohorts

OBJECTIVE

Sweden has one of the largest population-based cancer registers in the world that provides an opportunity to examine the trend of lung cancer incidence during a 35-year period. The primary aim of the present study was to estimate the effects of birth cohort, year of diagnosis (period), and age on the time trends of lung cancer incidence rates, and to analyze the gender-specific incidence of different histopathological types of lung cancer.

RESULTS

Among men the age-standardized incidence rate increased steadily up to 1982, when a peak of 49 cases per 100,000 person-years was reached. Among women the incidence rate was lower and showed a monotonic increase throughout the observation period. The fastest rate of increase was noted among the youngest women. In women, but not in men, there was a steady increase in risk with each successive birth cohort. For both sexes there were large changes in the histopathological distributions of cases. The most notable was a major increase in adenocarcinomas.

CONCLUSIONS

The overall age-adjusted incidence rate of lung cancer in Sweden has stabilized in men during the past two decades while rates are still increasing in women. In view of the continued high prevalence of smoking among young women, a future definite increase in the overall number of lung cancer cases in women can be expected.

Is early invasive treatment of unstable coronary artery disease equally effective for both women and men? FRISC II Study Group Investigators

BACKGROUND

The Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC II) trial compared the effectiveness of an early invasive versus a noninvasive strategy in terms of the incidence of death and myocardial infarction (MI) in patients with unstable coronary artery disease (CAD).

OBJECTIVES

In this subanalysis, we sought to evaluate gender differences in the effect of these different strategies.

METHODS

The patients (749 women and 1,708 men) were randomized to early invasive or noninvasive strategies. Coronary angiography was performed within the first 7 days in 96% and 10% of the invasive and noninvasive groups, respectively, and revascularization was performed within the first 10 days in 71% and 9% of the invasive and noninvasive groups, respectively.

RESULTS

Women presenting with unstable CAD were older, but fewer had previous infarctions, left ventricular dysfunction and elevated troponin T levels. Women had fewer angiographic changes. There was no difference in MI or death at 12 months among women in the invasive and noninvasive groups (12.4% vs. 10.5%, respectively), in contrast to the favorable effect in the invasively treated group of men (9.6% vs. 15.8%, p < 0.001). In an interaction analysis, there was a different effect of the early invasive strategy for the two genders (p = 0.008).

CONCLUSIONS

Women with symptoms and/or signs of unstable CAD are older, but still have less severe CAD and a better prognosis compared with men. In contrast to its beneficial effect in men, an early invasive strategy did not reduce the risk of future events among women. Further research is warranted to identify the most appropriate treatment strategy in women with unstable CAD.

Routes and sources of Staphylococcus aureus transmitted to the surgical wound during cardiothoracic surgery: possibility of preventing wound contamination by use of special scrub suits

OBJECTIVES

To trace the routes of transmission and sources of Staphylococcus aureus found in the surgical wound during cardiothoracic surgery and to investigate the possibility of reducing wound contamination, with regard to total counts of bacteria and S. aureus, by wearing special scrub suits.

METHODS

A total of 65 elective operations for coronary artery bypass graft with or without concomitant valve replacement were investigated. All staff present in the operating room wore conventional scrub suits during 33 operations and special scrub suits during 32 operations. Bacteriological samples were taken from the hands of the scrubbed team after surgical scrub but before putting on sterile gowns and gloves and from the patients' skin (incisional area of sternum and vein harvesting area of legs) after preoperative skin preparation with chlorhexidine gluconate. Air samples were taken during operations. Bacteriological samples also were taken from the subcutaneous walls of the surgical wound just before closing the wound. Total counts of bacteria on sternal skin and wound walls (colony-forming units [CFUs]/cm2) were calculated, as well as total counts of bacteria in the air (CFUs/m3). Strains of S. aureus recovered from the different sampling sites were compared by pulsed-field gel electrophoresis (PFGE).

RESULTS

Special scrub suits significantly reduced total counts of bacteria in air compared to conventional scrub suits (P=.002). The number of air samples in which S. aureus was found was significantly reduced by special scrub suits compared with conventional scrub suits (P=.016; relative risk, 4.4; 95% confidence interval [CI95], 1.3-14.91). By use of PFGE, it was possible to identify two cases of possible airborne transmission of S. aureus when wearing conventional scrub suits, whereas no case was found when wearing special scrub suits. When exposed to airborne S. aureus, the concomitant sternal carriage of S. aureus was a risk factor for having S. aureus in the wound.

CONCLUSIONS

Use of tightly woven special scrub suits reduces the dispersal of total counts of bacteria and of S. aureus from staff in the operating room, thus possibly reducing the risk of airborne contamination of surgical wounds. The importance of careful preoperative disinfection of the patient's skin should be stressed.

Source and route of methicillin-resistant Staphylococcus epidermidis transmitted to the surgical wound during cardio-thoracic surgery. Possibility of preventing wound contamination by use of special scrub suits

The objective of this study was to trace the source and route of transmission of methicillin-resistant Staphylococcus epidermidis (MRSE) in the surgical wound during cardio-thoracic surgery, and to investigate the possibility of reducing wound contamination by wearing special scrub suits. In total 65 elective operations for coronary artery bypass grafting (CABG) with or without concomitant valve replacement were investigated. All staff present in the operating room wore conventional scrub suits during 33 operations and special scrub suits during 32 operations. Samples were taken from the hands of the scrubbed team after surgical scrub but before putting on sterile gowns and gloves, and from patients' skin (incisional area of sternum and vein harvesting area of legs) after preoperative skin preparation with chlorhexidine gluconate. Air samples were taken during operations. Samples were also taken from the wound just before closure. Total counts of bacteria on sternal skin and from the wound (cfu/cm2) were calculated as well as total counts of bacteria in the air (cfu/m3). Strains of MRSE recovered from the different sampling sites were compared by pulsed field gel electrophoresis (PFGE). It was found that wearing special scrub suits did not reduce the number of air-samples where MRSE was found compared with conventional scrub suits. The risk factor most strongly associated with MRSE in the wound at the end of the operation was preoperative carriage of MRSE on sternal skin; RR 2.42 [95% CI 1.43-4.10], P= 0.021. By use of PFGE, it was possible to identify the probable source for four MRSE isolates recovered from the wound. In three cases the source was the patients own skin. Finding MRSE in air-samples, or on the hands of the scrubbed team, were not risk factors for the recovery of MRSE in the wound at the end of operation. In conclusion, with a total bacterial air count around 20 cfu/m3 and a low proportion of MRSE, the reduction of total air counts by use of tightly woven special scrub suits did not reduce air counts of MRSE or wound contamination with MRSE. The patients' sternal skin was the main source for wound contamination with MRSE

Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during Instability in Coronary artery disease

BACKGROUND

The Fragmin and Fast Revascularisation during Instability in Coronary artery disease II trial (FRISC II) compared an early invasive with an early non-invasive strategy in unstable coronary-artery disease. We report outcome at 1 year.

METHODS

2457 patients were randomly assigned invasive or non-invasive treatment and 3 months of dalteparin or placebo. Complete information at 1 year was available for 1222 in the invasive group and 1234 in the non-invasive group. Analyses were by intention to treat.

FINDINGS

Revascularisation was done within the first 10 days in 71% of the invasive group and 9% of the non-invasive group and within the first year in 78% and 43%. During the first year, 27 (2.2%) patients in the invasive group and 48 (3.9%) in the non-invasive group died (risk ratio 0.57 [95% CI 0.36-0.90], p=0.016). 105 (8.6%) versus 143 (11.6%) had myocardial infarction (0.74 [0.59-0.94], p=0.015). The composite of death or myocardial infarction occurred in 127 (10.4%) versus 174 (14.1%) patients (0.74 [0.60-0.92], p=0.005). There were also reductions in readmission (451 [37%] vs 704 [57%]; 0.67 [0.62-0.72]), and revascularisation after the initial admission (92 [7.5%] vs 383 [31%]; 0.24 [0.20-0.30]). The results did not interact with the dalteparin/placebo allocation.

INTERPRETATION

After 1 year in 100 patients, an invasive strategy saves 1.7 lives, prevents 2.0 non-fatal myocardial infarctions and 20 readmissions, and provides earlier and better symptom relief at the cost of 15 more patients with coronary-artery bypass grafting and 21 more with percutaneous transluminal angioplasty. Therefore, an invasive approach should be the preferred strategy in patients with unstable coronary-artery disease and signs of ischaemia on electrocardiography or raised levels of biochemical markers of myocardial damage.

Long-term follow-up of morbidity and mortality after aortic valve replacement with a mechanical valve prosthesis

AIMS

The aim of this study was to determine the incidence of valve-related complications in patients with a mechanical aortic valve prosthesis and to identify risk factors for an adverse outcome.

METHODS AND RESULTS

In the 424 patients, event-free survival rates 5 and 10 years after aortic valve replacement were 62% and 37%, respectively. The linearized incidence of thromboembolic events was 4.4% per patient-year, and of anticoagulant-related haemorrhage 8.5% per patient-year. Advanced NYHA functional class, atrial fibrillation, pure aortic regurgitation and thromboembolism prior to surgery decreased event-free survival. A history of pre-operative thromboembolism increased the risk for a first embolic event after aortic valve replacement (relative hazard [RH] 3.2), but was even more strongly associated with the risk for repeated events (> or =2 events, RH 5.4). After each thromboembolic episode that occurred, the risk for a subsequent one was increased. The risk for at least one, and up to three or more haemorrhages was increased in patients with a pre-operative history of bleeding (RH 3.3-5.1) and of atrial fibrillation (RH 1.8-3.9). The risk for a subsequent event was increased by a history of repeated haemorrhages, a short interval since previous bleeding, and high age.

CONCLUSIONS

There were few factors strongly related to valve related morbidity. However, previous bleedings and previous thromboembolism were powerful risk factors for repeated events.

Observed and relative survival after aortic valve replacement

OBJECTIVES

We sought to evaluate the effects of a number of factors that can potentially determine the optimal time for aortic valve replacement (AVR) and the observed and relative survival after the operation.

BACKGROUND

Aortic valve replacement is performed in patients within a wide age span, but the proportion of elderly patients is increasing. In survival analyses, adjustment for the effects of age is therefore essential. Analysis of relative survival provides additional information on excess or disease-specific mortality and its risk factors.

METHODS

Survival was analyzed in 2,359 patients (1,442 without and 917 with concomitant coronary artery bypass graft surgery) undergoing their first AVR. By relating observed survival to that expected among the general Swedish population stratified by age, gender and five-year calendar period, the relative survival and disease-specific survival were estimated.

RESULTS

Early mortality after AVR (death within 30 days) was 5.6%. Relative survival rates (excluding early deaths) after 5, 10 and 15 years were 94.6%, 84.7% and 74.9%, respectively. There was an excess risk of dying during the entire follow-up period. Advanced New York Heart Association functional class, preoperative atrial fibrillation and pure aortic regurgitation were independent risk factors for observed and relative survival. Patients in the oldest age group showed decreased observed survival but excellent relative survival.

CONCLUSIONS

Old age was not a risk factor for excess mortality after AVR, whereas atrial fibrillation decreased relative survival substantially.

Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing

Methicillin-resistant Staphylococcus epidermidis (MRSE) is a common cause of deep sternal infections. The aim of the present investigation was to evaluate staff in an operating suite for thoracic and cardiovascular surgery as a possible source of MRSE and the possibility of reducing the amount of MRSE shed into the air by wearing tightly woven scrub suits. A second aim was to compare the results of dispersal obtained in a test chamber with those from an operating room. We studied carriage of MRSE in the nose and on different skin sites and made an experimental study of dispersal of MRSE during exercise in a test chamber and during operations, using two different types of scrub suits. Dispersal of MRSE [defined as > 1% of the total count of colony forming units (CFU) shed into the air] occurred in 25% of women and 43% of men. Nasal carriage was found among 28% in women and 33% in men. Among five skin-sampling sites, carriage of MRSE was most frequent on the cheek (50%) and in the axilla (24%) and least frequent in the perineum (5%). Dispersal of MRSE was however more strongly associated with carriage in the perineum (P = 0.097) than on the cheek (P = 0.5) and in the axilla (P = 0.21). With regard to shedding of bacteria into the air, there was a significant difference in favour of the tightly woven clothes regarding total counts of CFU both in the test chamber (P = 0.02) and the operating theatre (P = 0.002). Regarding MRSE, no such difference was found. We found there were too many dispersers of MRSE among operating department staff to exclude them from work. Although tightly woven scrub suits significantly reduced the amount of bacteria shed into the air, the amount of MRSE was not significantly reduced. Full-scale experiments in operating rooms are not needed when evaluating the protective capacity of different scrub suits as results from a test chamber give conclusive information.

[Early management of unstable coronary artery disease. Coronary angiography is the first measure in high-risk patients]

Unstable coronary artery disease is currently the major cause of admissions to coronary intensive care units, accounting for 30-40 per cent of cases. The underlying cause is rupture of an atherosclerotic plaque, coronary blood flow being impeded by a superimposed thrombus. New and more effective antithrombotic drugs are becoming increasingly available. Simultaneous early coronary angioplasty, stenting or bypass surgery provide the most effective amelioration of symptoms. Early revascularisation has not hitherto been found to reduce the risk of myocardial infarction or mortality in patients without signs of severe ischaemia. In this large category of cardiac patients, treatment strategy selection is of considerable importance to the effective utilisation of resources.

Acute renal failure and outcome of continuous arteriovenous hemodialysis (CAVHD) and continuous hemofiltration (CAVH) in elderly patients following cardiovascular surgery

A total of 111 elderly patients from the cardiac surgery intensive care unit (ICU) with acute renal failure (ARF) were studied during a period of 7 years (1988-1994). Forty-two patients being operated for coronary bypass (CBP) (31 M, 11 F), 26 patients for valve replacement (VR) (18 M, 8 F), 20 patients for a combined operation of coronary bypass and valve replacement (CBP+VR) (14 M, 6 F) and 23 patients for resection of aneurysm of the abdominal aorta (ROAOAA) (11 M, 12 F). Average age of the patients was 70 +/- 4 yr (65-80). Their blood pressure on the first day of continuous renal replacement therapy (CRRT) was 75 +/- 19 mmHg (50-95) and was maintained at about 95 +/- 15 mmHg (70-120) by using vasopressor drugs. From the results of this study a survival of 38% was registered within the CBP group, 65% within the VR group, 45% within the CBP+VR group and 91% within the ROAOAA group. The overall survival in all of the patients was 58%. It was a high mortality (62%) within CBP group compared to that of 35%, 55% and 9% within the VR, CBP+VR and ROAOAA groups, respectively. This is because more patients with predisposing preoperative risk factors, e.g., hypertension (33%) and Diabetes (17%) etc were found in the CBP group, in addition to their post operative complications of which bleeding necessitating reoperations was encountered in 31%. Multiple organ failure (MOF) was a common major problem of which respiratory failure needing artificial ventilation was encountered in about 90% of the patients. The overall mortality was 42% in which the major cause of death was MOF/circulatory failure. Heart failure was the second cause of death. Other secondary complications, e.g., liver failure (n = 6) and atrial fibrillation (n = 11) etc. might have added to the high mortality in this study. The effect of CRRT on uremic control was measured by following-up of the daily levels of the serum urea and creatinine and a steady-state uremic control was achieved. We conclude that CRRT can be considered as a reliable artificial renal support for ARF in ICU elderly patients.

Influence of left ventricular function on survival after coronary artery bypass grafting

BACKGROUND

Preoperative left ventricular function is a most important predictor for survival in patients with ischemic heart disease. To elucidate the optimal timing of recommended coronary artery bypass grafting, we investigated the influence of different aspects of preoperative left ventricular function on relative survival.

METHODS

To calculate the relative survival and estimate the disease-specific survival, we compared 6,514 patients who survived the first month after primary coronary artery bypass grafting with the general Swedish population stratified by age, sex, and 5-year calendar period. In particular we studied the relation between relative survival and different aspects of left ventricular performance, namely left ventricular function at rest, New York Heart Association functional class, and number of previous myocardial infarctions.

RESULTS

The three variables (left ventricular function at rest, New York Heart Association functional class, and number of previous myocardial infarctions) as well as age and follow-up year gave independent information concerning relative survival. The results from this multivariate analysis were used to define a risk score for each patient. Patients were categorized into different risk groups. Patients in the low-risk group (30% of the total) showed a survival better than that of the population at large for 9 years after operation. The medium-risk group had no or low excess mortality for about 7 years, and the high-risk group (25%) showed increased excess mortality immediately after operation.

CONCLUSIONS

If primary coronary artery bypass grafting is performed before the left ventricular function and physical performance deteriorate, survival is excellent.

Sternal wound complications--incidence, microbiology and risk factors

OBJECTIVE

Sternal wound complications, i.e. instability and/or infection (mediastinitis), are important causes of morbidity in patients undergoing cardiac surgery via median sternotomy. Coagulase negative staphylococci, a normal inhabitant of the skin, have evolved as a cause of sternal wound infections. Since these opportunistic pathogens often are multiresistant, they can cause therapeutic problems.

METHODS

From 1980 through 1995 open heart surgery, was performed on 13,285 adult patients. Reoperation necessitated by sternal wound complications occurerd in 203 patients (1.5%). The incidence was 1.7% (168/9987) after coronary artery bypass grafting (CABG group) and 0.7% (35/3413) after heart valve surgery with or without concomitant CABG (HVR group).

RESULTS

Factors independently related to sternal complications in the CABG group (variable odds ratio [95% C.I.]): year of surgery, 1.9 [1.3-2.8] in 1990-1992, 2.0 [1.4-2.9] in 1993-1995; female sex, 0.4 [0.2-0.6]; diabetic disease, 1.8 [1.2-2.5]; bilateral ITA procedure, 3.3 [1.1-7.7]; and postoperative dialysis, 3.1 [1.4-6.9]. In the HVR group they were: use of ITA graft, 3.7 [1.7-7.7]; early re-exploration because of bleeding 3.0 [1.1-8.2]; and postoperative dialysis 3.1, [1.4-9.3]. Multivariate models were used to compute the risk for sternal complications in each patient. However, the prognostic models based on these risk scores provided low sensitivity and low predictive value. Patients with sternal wound complications showed no increased early mortality but worse long-term survival even after adjustment for other factors (relative hazard in CABG group 1.9 [1.2-2.8]; in HVR group 2.1 [1.1-4.3].

CONCLUSIONS

The use of ITA grafts seems to be one of the most important factors related to sternal wound complications. However, patients at truly increased risk for this complication could not be identified on the basis of the risk factors considered in this study.

Long-term relative survival after primary heart valve replacement

OBJECTIVE

Determination of the optimal timing of primary heart valve replacement is an important issue. The present paper provides a synopsis over early and late survival after primary heart valve replacement, including an evaluation of the excess mortality among heart valve replacement patients compared with the general population.

METHODS

Survival was analyzed in 2365 patients (1568 without and 797 with concomitant coronary artery bypass grafting (CABG)) who underwent their first heart valve replacement. Observed survival was related to that expected among persons from the general Swedish population stratified by age, sex, and 5-year calendar period, to calculate the relative survival and estimate the disease-specific survival.

RESULTS

Early mortality (death within 30 days after surgery) was 5.9% after aortic valve replacement, 10.4% after mitral valve replacement and 10.6% after combined aortic and mitral valve replacement. Relative survival rates (excluding early deaths) were 84% 10 years after aortic, 68.5% after mitral and 80.9% after both aortic and mitral valve replacement. A multivariate model based on observed survival rates was produced for each group, using the Cox proportional hazards model. Concomitant CABG, advanced New York Heart Association (NYHA) class, preoperative atrial fibrillation, pure aortic regurgitation and higher age increased the late observed survival after aortic valve replacement. NYHA class was the only factor independently related to observed late deaths after mitral valve replacement, and mitral insufficiency the only corresponding factor after both aortic and mitral valve surgery.

CONCLUSION

The use of relative survival rates tended to modify the difference between subgroups compared with observed survival rates. Relative survival rates reduced the effect of concomitant CABG on survival, but enhanced for example the effect of aortic regurgitation. In patients > or = 70 years of age and patients submitted to aortic or mitral valve replacement with mild or no symptoms, the survival rate was similar for many years to that in the Swedish population at large.

Survival after coronary artery bypass grafting. Experience from 4661 patients

The duration of the reduction of mortality after coronary artery bypass grafting (CABG) is an important issue and this study was undertaken to evaluate time in relation to excess mortality among CABG patients compared with the general population. Survival was analysed in 4661 patients who had undergone their first isolated CABG. Observed survival was related to that expected among subjects from the general Swedish population stratified by age, sex and 5-year calendar period, to calculate relative survival and estimate disease-specific survival. Relative survival (including all deaths) was 94.6% at 5 years, 82.5% at 10 years, and 59.9% at 15 years. A multivariate model based on relative survival rates adjusted for age, year of surgery, severity of coronary disease, left ventricular function, and smoking habits was used. Compared with the first year of follow-up, the relative hazard (a measure of the risk of death) was at a minimum 2 years after surgery, but was dramatically increased after about 8 years. Relative survival was worsened by smoking at the time of operation and by moderate or severe left ventricular dysfunction pre-operatively. The survival rate was higher among patients operated on after 1985 than among those operated on earlier.

Surgical treatment of left ventricular aneurysm--assessment of risk factors for early and late mortality

Consecutive patients operated on for left ventricular aneurysm from 1970 through August 1989 (n = 303) were evaluated with respect to survival. Early mortality, i.e. within 30 days, was 8.9%; 23% in patients who underwent aneurysm resection alone, 8.1% in cases of aneurysm resection with coronary artery bypass grafting (CABG), and 6.3% in those undergoing CABG only. Multivariate logistic regression revealed that advanced New York Heart Association (NYHA) functional class, non-use of the internal mammary artery as a graft and thromboendarterectomy increased the early risk. The total observed survival was 86% at 1 year, 72% at 5 years and 45% at 10 years. Multivariate analysis based on observed survival, using the Cox proportional hazards model, identified advanced NYHA functional class and non-use of the internal mammary artery as independent indicators of poor survival. Relative mortality, defined as the ratio of observed mortality in the study group to mortality among comparable persons from the general Swedish population, was used as a measure of disease-specific mortality. An apparent excess mortality in patients operated on for left ventricular aneurysm was found. A notable finding was that the use of the internal mammary artery to graft the left anterior descending artery improved the outcome substantially in patients with a left ventricular aneurysm.

Risk factors for operative mortality and morbidity in patients undergoing coronary artery bypass surgery for stable angina pectoris

Risk factors for a poor early outcome of surgery for stable angina pectoris were evaluated in 2659 consecutive patients from a defined population. The total operative mortality (death within 30 days after surgery) was 2.6% and the frequency of myocardial injury (increase in S-ASAT to greater than 2.0 mu kat l-1 and in S-CKMB to greater than 1.5 mu kat l-1 within 48 h postoperatively or death in the operating room) 14%. Mortality was related to New York Heart Association (NYHA) classification (P less than 0.001), age (less than or greater than 70 years, P = 0.001), duration of symptoms (less than or greater than 8 years, P = 0.001), aortic cross-clamp (ACC) time (P less than 0.001), and cardiopulmonary bypass (CBP) time (P less than 0.001). A multivariate analysis showed that the combination of NYHA class, ACC time and age best predicted operative mortality. Myocardial injury was related to NYHA functional class (P less than 0.001), duration of symptoms (P less than 0.001), regrafting procedure (P less than 0.001), cardiac related dyspnoea (P = 0.015), ACC time (P = 0.001), CPB time (P = 0.001), relative volume of cardioplegic solution (P less than 0.001), and thromboendarterectomy procedure (P = 0.004). The set of variables that best predicted myocardial injury consisted of ACC time, relative volume cardioplegic solution, NYHA class, regrafting procedure and duration of symptoms. However, these risk factors indicated only moderately high risks, and high-risk patients could not be selected with sufficient accuracy.

Early results of mitral valve replacement

Early results of mitral valve replacement were reviewed in 336 unselected patients, 261 without and 75 with concomitant coronary artery bypass grafting (MVR and MVR + CABG groups). Early (less than 30 days) mortality was 7% in the MVR and 16% in the MVR + CABG group, with cardiac failure as the dominant cause. In multivariate analysis, the variables most strongly related to early mortality were congestive heart failure, diabetes and previous cardiac surgery in the MVR group and congestive heart failure in MVR + CABG. In the cases with fatal outcome the incidence of peroperative technical complications was 32% at MVR and 17% at MVR + CABG. The incidence of myocardial injury was 21% and 35% in the respective groups, and the early mortality in these cases was 19% vs 23%. Half of all fatal cases showed signs of peroperative myocardial injury. Multivariate analysis showed factors independently related to myocardial injury to be year of surgery and aortic cross-clamp time in MVR and previous cardiac surgery in MVR + CABG. Operation before cardiac reserves are reduced, optimal peroperative myocardial preservation and avoidance of technical errors should improve results of MVR.

Early results of aortic valve replacement with or without concomitant coronary artery bypass grafting

Early results of aortic valve replacement were reviewed in 962 unselected patients, 659 without concomitant coronary bypass surgery (AVR group) and 303 with combined valve replacement and coronary artery bypass grafting (AVR + CABG). The early (less than 30-day) mortality was 4.6% in the AVR, and 5.9% in the AVR + CABG group. Multivariate analysis showed coronary artery stenoses and NYHA functional class to be independent predictors of early mortality in the AVR group, and the number of distal anastomoses as the strongest predictor in AVR + CABG. The incidence of peroperative technical complications in the cases with fatal outcome was 27% in the AVR and 6% in the AVR + CABG group. The incidence of myocardial injury (new Q wave or evidence of increased enzyme leakage) was 11% in AVR and 21% in AVR + CABG. Independent predictors of postoperative myocardial injury were aortic cross-clamp time, year of surgery, coronary artery stenoses and NYHA class in AVR and aortic cross-clamp time and year of surgery in AVR + CABG. The study suggests that coronary artery disease increases risk in aortic valve replacement with or without CABG. Replacement should be undertaken before endstage of the disease (NYHA IV), with CABG if significant coronary disease is present, and in multivessel disease the number of distal anastomoses should be restricted in order to shorten aortic cross-clamp time.

Predictive value of factors affecting early results and complications in eight years of coronary artery bypass surgery

All cases of coronary bypass procedures without concomitant heart valve replacement occurring in a defined geographical area over a 8-year period (1980-1987) were reviewed and the 30-day mortality and complication rates associated with them were analyzed. The study comprised 3,484 patients with the diagnoses: stable (2477) or unstable (724) angina pectoris, angina pectoris combined with left ventricular aneurysm (165) or with an other complicating factor (96), postinfarction septal defect (13) and postinfarction mitral valve insufficiency (9). The total operative mortality during the study period was 3.1%. Persistent new Q waves in the electrocardiogram developed in 2.4% and increased enzyme release indicating myocardial injury (S-ASAT greater than 2.0 microkat/L and S-CKMB isoenzyme greater than 1.5 microkat/L) occurred in 15%. There were 478 complications in 378 patients (11%). Indication for surgery, year of surgery, NYHA class, congestive heart failure, age, sex, aortic cross-clamp time, and cardiopulmonary bypass time were significantly related to operative mortality (p less than 0.05). The same variables except sex were related to complications. Myocardial infarction (new persistent Q wave) was predictable by NYHA class, aortic cross-clamp time, and cardiopulmonary bypass time. The same variables and also year of surgery, regrafting procedure, congestive heart failure, and thromboendarterectomy were predictors of myocardial injury (enzyme release).

Management of anal epidermoid carcinoma--an evaluation of treatment results in two population-based series

Between 1978 and 1984, two unselected population-based groups of patients with anal epidermoid carcinoma were analysed: (1) a retrospective group (Stockholm region, 90 cases), where the treatment varied considerably (partly radiation therapy +/- chemotherapy +/- surgery, partly surgery alone), and (2) a prospective group (Uppsala region, 51 cases) mainly treated by primary irradiation +/- chemotherapy followed by surgery in some cases. At diagnosis, 106 of the patients were free from metastases. Two of these patients died before treatment began. Of the remaining 104 patients, 77 received primary radiotherapy +/- chemotherapy, 44 to a dose of 30-40 Gy and 33 to a higher dose level, 55-65 Gy. Radiotherapy was followed by surgery in 28 cases. Twenty-seven patients were operated on primarily. The projected 5-year survival rate was significantly higher in the Uppsala than in the Stockholm region (all patients: 55% versus 43%; patients with no initial dissemination: 75% versus 48%). The prognosis was better in patients initially treated with radiotherapy than in those initially treated with surgery. Long-term disease-free survival was 88% in patients treated with radiation alone to an adequate (high) dose level. Multivariate analyses indicated that besides stage and sex, initial treatment and region gave statistically significant prognostic information. There was no evidence that chemotherapy (Bleomycin) conferred any additional benefit. It is concluded that the initial treatment in anal carcinoma should be radiotherapy (+/- chemotherapy). In patients with no initial dissemination, this therapy seems to improve 5-year survival by 25-30% compared with primary surgery.

Preoperative prediction of late cancer-specific deaths in patients with rectal and rectosigmoid carcinoma

The possibility of predicting late cancer-specific deaths from (a) the preoperative serum levels of three tumour markers, carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and an antigen defined by the C-50 antibody (CA-50), from (b) one clinical factor of independent prognostic relevance, polypoid tumour growth, and from (c) Dukes' stage was evaluated in 276 patients with rectal carcinoma operated upon with curative intent ("potentially curable"), and in the 251 of those patients who were considered to be "potentially cured" after surgery. Using the Cox regression model, the preoperative serum levels of the tumour markers strongly predicted the cancer-specific mortality within the first year after surgery. This ability of S-CEA and S-CA-50 diminished for the mortality during the second year after surgery, and virtually disappeared thereafter. The ability of S-TPA to predict cancer-specific deaths did not change as dramatically with time as that of the other two markers, particularly in the group of "potentially cured" patients. Patients with polypoid tumour growth had a good prognosis which did not appear to change with time. Similarly, the prognostic information provided by Dukes' staging system was valid at all studied time intervals after surgery, although it declined after the second year. The importance of these results in relation to the selection of patients for adjuvant treatment is discussed.

Can mortality from rectal and rectosigmoid carcinoma be predicted from histopathological variables in the diagnostic biopsy?

The prognostic information provided by histopathological variables in the diagnostic biopsy was evaluated retrospectively in 276 consecutive patients "potentially curable" by surgery using criteria recently proposed by Jass et al. concerning the main specimen. In 252 (91%) cases, the biopsy material was appropriate for the intended assessment. The majority of tumours were tubular (67%), tubular configuration mostly irregular (76%) and the tumour cells usually had small nuclei (81%). Remnants of adenomatous structures were identified in 21%. Most tumours were moderately differentiated (57%), and poorly differentiated tumours were somewhat more common (27%) than highly differentiated ones (16%). There was no real correlation between these histopathological variables, as expressed in biopsy, and Dukes' stage. Patients with a well-differentiated tumour had somewhat better survival than those with a moderately or poorly differentiated one (p = 0.04). Tumour type tended to influence cancer-specific mortality in that patients with papillary tumour had a slightly better prognosis than those with a different type. An attempt was also made to classify the patients into two groups on the basis of the observers' subjective impression of the tumour pattern and the expected outcome. Among the 143 patients in whom the over-all subjective impression was an "aggressive tumour pattern", 43% died (median follow-up 47 months). The cancer-specific death rate in patients in whom the tumour pattern was "non-aggressive" was 27% (p = 0.04). In summary, the extent to which these variables predicted mortality was far from clinically useful.

Preoperative prediction of outcome in patients with rectal and rectosigmoid cancer

This study evaluated the possibility of dividing patients with primary rectal carcinoma into prognostic groups before surgery based on preoperative serum levels of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and an antigen defined by the monoclonal antibody C-50 (CA-50), as well as on some easily available clinical characteristics providing prognostic information. The evaluation was made both for patients who were "potentially curable" by surgery and, among those, for patients who were "potentially cured." Using the Cox regression model, the serum levels of the three tumor markers, together with the knowledge of whether or not the tumor was polypoid were combined to make up the set of variables that best predicted patient outcome. These variables and their associated regression coefficients were used to classify the patients according to prognosis. The cancer-specific mortality rate for the 24% of potentially curable patients with the best prognosis was 15%; for the 26% of potentially curable patients with the worst prognosis, the cancer-specific mortality rate was 57%. For potentially cured patients among those who were potentially curable, the cancer-specific mortality rates for patients with the best and worst prognoses were 14% and 47%, respectively. The information provided by these preoperatively available variables together was comparable with that given by Dukes' staging system, but the latter system was more informative. On the other hand, some of the preoperative variables provided information not provided by Dukes' staging system.

A clinical study of CA-50 as a tumour marker for monitoring of colorectal cancer

Using a radioimmunoassay we have determined serum levels of the carcinoma-associated antigen CA-50 in 266 patients with colorectal cancer. Elevated CA-50 levels were found in Dukes' A (15%), Dukes' B (43%), Dukes' C (31%) and Dukes' D (65%). Patients who had developed a recurrence had 66% elevated levels. 25% of resected patients with no evidence of disease also had elevated CA-50 levels. From 139 patients operated on for a Dukes' A-C, a rise in CA-50 levels from the pre- to the 6-9 month post-operative sample was demonstrated in 12 cases in the absence of any clinical evidence for a recurrence. On follow-up, a recurrence later developed in all these cases with lead times of CA-50 titre rises ranging from 5 to 40 months. A rise in CA-50 levels after resection of a Dukes' A-C is indicative of a recurrence and may precede any clinical evidence of disease by several months or years. Data is also presented from 552 cases with colorectal cancer analysed with a immunoradiometric assay.

Preoperative serum markers in carcinoma of the rectum and rectosigmoid. I. Prediction of tumour stage

Preoperative serum concentrations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and a monoclonal-antibody-defined carcinoma-associated carbohydrate antigen, CA-50, were measured in 272 consecutive patients with histopathologically proven rectal carcinoma. The levels of all three tumour markers correlated directly to the stage of the disease. The serum TPA reflected both the local tumour burden and any metastatic spread, as shown by analysing mean levels of S-TPA and by the use of a Walker and Duncan regression model. S-CA-50 separated patients with and without distant metastases, but not with regard to the local tumour burden. Although the level of S-CEA correlated to the tumour stage, it did not discriminate patients with respect to locally advanced growth or generalized disease. In a multivariate analysis, the serum level of TPA was found to be the most informative preoperatively. Both S-CA-50 and S-CEA gave information additional to that provided by S-TPA in the prediction of the tumour stage (Dukes' stage A-D), and S-CA-50 was also useful in the prediction of metastatic disease.

Preoperative serum markers in carcinoma of the rectum and rectosigmoid. II. Prediction of prognosis

The prognostic value of a single preoperative determination of the serum (S) concentration of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and the carcinoma-associated carbohydrate antigen CA-50, either alone or in combination was evaluated in 327 consecutive patients with carcinoma of the rectum. A strong correlation was found between the serum level of each of these tumour markers separately, and prognosis, both in terms of crude survival in all patients and in disease-free survival in 'potentially cured' patients. The prognostic information provided by S-TPA and S-CA-50 was stronger, however, than that given by S-CEA. In a multivariate approach, S-TPA was found to be most informative. With use of the Cox regression model, the critical serum values that best separated patients in regard to mortality were CEA 18 micrograms/l, TPA 120 U/l and S-CA-50 40 U/ml. The critical values that best discriminated disease-free survival in 'potentially cured' patients were CEA 12 micrograms/l, TPA 110 U/l and S-CA-50 28 U/ml. The clinical usefulness of these and other cut-off levels is discussed.

Anal epidermoid carcinoma: a population-based clinico-pathological study of 164 patients

The clinical and pathological features of 164 patients with anal epidermoid carcinoma were investigated in a population-based study between 1978 and 1984. Twenty-three tumours, the majority of which were small and well differentiated squamous cell carcinomas, were situated in the perianal region. Twenty of these patients are alive and disease-free. Of 141 tumours in the anal canal two-thirds were of the cloacogenic type, i.e. displaying transitional cell differentiation. The overall 5-year survival was between 40 and 50% for both cloacogenic and squamous cell carcinomas, respectively. However, poorly differentiated squamous cell carcinomas and cloacogenic carcinomas without any squamous cell differentiation (subtype A) had a more aggressive course, especially in men, than the other subgroups. Clinical stage also had an impact on prognosis. Both stage, sex, degree of differentiation and histologic subtypes revealed independent prognostic information. Although the primary aim of this study was not to evaluate therapy, it was noted that patients primarily treated with irradiation (with or without chemotherapy) had a more favourable course than patients treated with surgery alone.

Preoperative clinical and pathological variables in prognostic evaluation of patients with rectal cancer. A prospective study of 327 consecutive patients

The prognostic information provided by a number of easily identified and preoperatively available characteristics was recorded prospectively and evaluated in 327 consecutive patients with rectal carcinoma. With use of the Cox regression model, the two variables indicating surgical non-curability, namely immobility of the tumour to the adjacent tissues and preoperatively diagnosed metastatic spread, showed the strongest relation to prognosis. Other variables predictive of a poorer outcome in all patients were abnormal liver function tests, large tumour size (number of degrees of the bowel wall circumference affected by the tumour), non-polypoid tumour growth, tumour ulceration, tumour stricture, tumour growth anteriorly and low histological differentiation in the preoperative biopsy. These variables, together with age, also gave information concerning the group of patients of interest for pre- or peroperatively initiated adjuvant therapy, i.e. patients potentially curable by surgery (locally resectable tumour and no known metastases). In this group, the two preoperatively available variables with the best prognostic value, polypoid tumour growth and age, appeared inferior to the postoperatively determined tumour stage (Dukes' staging). However, some clinical variables gave information additional to that provided by the tumour stage.

CA-50 as a tumour marker for monitoring colorectal cancer: antigen rises in patients postoperatively precede clinical manifestations of recurrence

Using a monoclonal antibody-based radioimmunoassay inhibition method we have determined preoperative serum levels of the carcinoma-associated carbohydrate antigen CA-50 in 266 patients with primary colorectal cancer. CA-50 levels exceeding the mean value for blood donor sera by more than 2 standard deviations (greater than or equal to 17 U/ml) were found in 47% of these patients, with 15%, 43% and 31% being elevated in patients with Dukes' A, Dukes' B and Dukes' C cancer, respectively, and 63% and 66% being elevated in patients with more advanced localized or disseminated cancer. Only 5% of patients with benign colorectal disease had elevated CA-50 level and these were patients with ulcerative colitis of a duration of more than 10 years. Among patients who had developed a recurrence after operation for a primary Dukes' A-C colorectal cancer 66% had elevated levels, and 25% of resected patients with no clinical evidence of disease at corresponding times after operation also had CA-50 levels above the normal concentrations. From 139 patients operated for a Dukes' A-C colorectal cancer a definitive rise in CA-50 levels from the pre- to a 6-9 months postoperative sample was demonstrated in 12 cases in the absence of any clinical evidence for a recurrence. On prolonged follow-up a clinically manifest recurrence later developed in all of these cases with lead times of CA-50 titre rises ranging from 5 to 40 months. Our findings suggest that a rise in CA-50 levels after resection of a Dukes' A-C primary colorectal cancer is indicative of a recurrence and may precede any clinical evidence of disease by many months or years. Thus CA-50 may be a clinically useful tool for monitoring of patients with colorectal cancer.

Abdominal vs. perineal drainage in rectal surgery

The efficiency of abdominal contra perineal drainage of the pelvic cavity after abdominoperineal resection for carcinoma of the rectum was evaluated retrospectively with regard to the frequency of perineal wound sepsis and length of hospital stay. Thirty-two (45 percent) of 71 patients with perineal drainage developed perineal wound sepsis, compared with four (12 percent) of 32 patients with abdominal drainage (P less than 0.01). Patients with perineal drainage stayed longer in the hospital (mean, 33 days) than those with abdominal drainage (mean, 24 days) (P less than 0.004). Furthermore, postoperative recovery was more comfortable in patients with abdominal drainage. Abdominal drainage therefore is recommended after abdominoperineal resection.

Double stapling technique in the management of rectal tumours

Before the circular stapling device was introduced, 25% of patients with rectal carcinoma underwent sphincter saving surgery. Stapling technique has been commonly used since 1980 and in the subsequent 5 years anterior resection was performed on 62% of patients treated for rectal carcinoma. "Single stapled" anastomosis, i.e. with a proximal and a distal purse-string suture, was performed in 33 cases, and in 22 cases a "double stapling" technique was used, i.e. the rectum was closed with a straight stapled suture and a circular anastomosis was then made through the stapled suture row of the closed rectum. No difference was found between the two stapling techniques regarding anastomotic dehiscence, pelvic abscess, postoperative fever, perioperative mortality or tendency to anastomotic stenosis. Among the patients with tumour 5-8 cm from the anal verge, a significantly higher proportion underwent a sphincter-preserving procedure with double stapling than with single stapling technique.

Sequential methotrexate--5-FU--leucovorin (MFL) in advanced colorectal cancer

Methotrexate (MTX) (250 mg/m2) was given as an i.v. infusion over 2 hr. At hour three and 23, 5-FU (500 mg/m2, maximally 1000 mg) was given as a bolus i.v. injection. The Leucovorin rescue was initiated hour 24. The chemotherapy course was repeated every 14 days for eight courses, then every third to fourth week. At least four courses of the regime were given to 50 patients with measurable advanced colorectal carcinoma. Toxicity was usually very mild but in seven patients an increase of serum creatinine was registered. Two of these patients had a severe period of uremia. With a more careful observation of kidney function, these episodes should have been foreseen. An objective response rate of 50% with six complete remissions (CR) and 19 partial remissions (PR) was found. Eighty-eight per cent (21/24) of the patients with tumour-related symptoms experienced symptomatic relief. The median response duration amounts to 5 months. It is concluded that the MFL regime is effective in inducing anti-tumour response in patients with advanced colorectal cancer.