Effects of high-intensity exercise training on physical fitness, quality of life and treatment outcomes after oesophagectomy for cancer of the gastro-oesophageal junction: PRESET pilot study

Background

Treatment for cancer of the gastro‐oesophageal junction (GOJ) can result in considerable and persistent impairment of physical fitness and health‐related quality of life (HRQoL). This controlled follow‐up study investigated the feasibility and safety of postoperative exercise training.

Methods

Patients with stage I–III GOJ cancer were allocated to 12 weeks of postoperative concurrent aerobic and resistance training (exercise group) or usual care (control group). Changes in cardiorespiratory fitness, muscle strength and HRQoL were evaluated. Adherence to adjuvant chemotherapy, hospitalizations and 1‐year overall survival were recorded to assess safety.

Results

Some 49 patients were studied. The exercise group attended a mean of 69 per cent of all prescribed sessions. After exercise, muscle strength and cardiorespiratory fitness were increased and returned to pretreatment levels. At 1‐year follow‐up, the exercise group had improved HRQoL (+13·5 points, 95 per cent c.i. 2·2 to 24·9), with no change in the control group (+3·7 points, −5·9 to 13·4), but there was no difference between the groups at this time point (+9·8 points, −5·1 to 24·8). Exercise was safe, with no differences in patients receiving adjuvant chemotherapy (14 of 16 versus 16 of 19; relative risk (RR) 1·04, 95 per cent c.i. 0·74 to 1·44), relative dose intensity of adjuvant chemotherapy (mean 57 versus 63 per cent; P = 0·479), hospitalization (7 of 19 versus 6 of 23; RR 1·41, 0·57 to 3·49) or 1‐year overall survival (80 versus 79 per cent; P = 0·839) for exercise and usual care respectively.

Conclusion

Exercise in the postoperative period is safe and may have the potential to improve physical fitness in patients with GOJ cancer. No differences in prognostic endpoints or HRQoL were observed. Registration number: NCT02722785 ( https://www.clinicaltrials.gov).

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery

AIM

Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers.

METHOD

This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement.

RESULTS

Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring.

CONCLUSION

A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction

Background

Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro‐oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients.

Methods

Patients were allocated to a standard‐care control group or an exercise group, who were prescribed standard care plus twice‐weekly high‐intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient‐reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured.

Results

The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy — Esophageal (FACT‐E) total score compared with the baseline level.

Conclusion

Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.

Ghrelin secretion in humans - a role for the vagus nerve?

BACKGROUND

Ghrelin, an orexigenic peptide, is secreted from endocrine cells in the gastric mucosa. Circulating levels rise in the preprandial phase, suggesting an anticipatory or cephalic phase of release, and decline in the postprandial phase, suggesting either the loss of a stimulatory factor or inhibition by factors released when nutrients enter the intestine. We hypothesized that vagal signals are not required for the (i) preprandial increase or (ii) postprandial suppression of ghrelin levels. Further, we wanted to investigate the hypothesis that (iii) glucagon-like peptide-1 might be implicated in the postprandial decline in ghrelin levels.

METHODS

We measured ghrelin levels in plasma from sham-feeding and meal studies carried out in vagotomized individuals and controls, and from a GLP-1 infusion study carried out in fasting healthy young individuals.

KEY RESULTS

We find that (i) ghrelin secretion is unchanged during indirect vagal stimulation as elicited by modified sham-feeding in vagotomized individuals and matched controls, (ii) ghrelin secretion is similarly suppressed after meal ingestion in vagotomized individuals and controls, and (iii) infusion of GLP-1 does not lower ghrelin levels.

CONCLUSIONS & INFERENCES

We conclude that for postprandial suppression of circulating ghrelin levels, a circulating factor (but not GLP-1) or short (duodeno-gastric) reflexes seem to be implicated.

Recurrence following curative intended surgery for an adenocarcinoma in the gastroesophageal junction: a retrospective study

Recurrence following a resection for an adenocarcinoma of the gastroesophageal junction leads to reduced long-term survival. This study aims to identify risk factors associated with recurrence, recurrence localization, time to recurrence, and long-term survival. All patients undergoing curative intended resection for an adenocarcinoma of the gastroesophageal junction at Rigshospitalet between June 2003 and December 2011 were identified through a prospectively maintained nationwide database and enrolled in this study. Only histologically verified recurrence was considered eligible. Recurrence within six months, microscopically incomplete resection margins, and death within eight weeks were excluded. A total of 348 patients were included in this study. Biopsy-verified recurrence occurred in 120 patients (34.5%), with 32 local (9.2%), and 88 distant (25.3%) recurrences. Lymph node metastases was associated with an increased risk of recurrence (hazard ratio; [95% confidence interval]: HR = 2.7; [1.7-4.3], P < 0.001). Median time to local versus distant recurrence was 18 months (interquartile range (IQR): 9-37 months) versus 17 months (IQR: 11-27 months), P = 0.96, respectively. A trend toward local recurrence was identified if patients had anastomotic leakage (HR = 2.64; [0.89-7.86], P = 0.08). Survival was inversely associated with recurrence, but a survival comparison between local and distant recurrences showed no significant difference: median survival time was 28 months (IQR: 17-43 months) versus 24 months (IQR: 16-36 months), P = 0.45, respectively. A trend toward local recurrence was seen if the patient had an anastomotic leakage event. However, no factors were associated with site-specific recurrence (local vs. distant).

The occurrence of Enterococcus faecium and faecalis Is significantly associated With anastomotic leakage After pancreaticoduodenectomy

BACKGROUND AND AIMS

Enterococcus has emerged as a virulent species; Enterococcus faecium especially has arisen as a source of nosocomial infections. Furthermore, specific Enterococcus faecalis species are significantly associated with anastomotic leakage in rodent studies. The objective of this study was to investigate whether the occurrence of Enterococci ( E. faecium and E. faecalis) obtained from drain samples was associated with leakage in humans undergoing pancreaticoduodenectomy.

MATERIALS AND METHODS

All patients undergoing pancreaticoduodenectomy had a peritoneal drain sample sent for culturing between postoperative days 3 and 10. Postoperative pancreatic fistulas were defined and classified according to the International Study Group of Pancreatic Fistula. Bile leakage was radiologically verified. Postoperative complications were classified according to the Dindo-Clavien classification.

RESULTS

A total of 70 patients were eligible and enrolled in this study. Anastomosis leakage was observed in 19 patients; 1 leakage corresponding to the hepaticojejunostomy and 18 pancreatic fistulas were identified. In total, 10 patients (53%) with leakage had Enterococci-positive drain samples versus 12 patients (24%) without leakage [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 1.4-19.4, p = 0.02]. Preoperative biliary drainage with either endoscopic stenting or a percutaneous transhepatic cholangiography catheter was associated with the occurrence of Enterococci in drain samples (OR = 5.67, 95% CI = 1.8-12.9, p = 0.003), but preoperative biliary drainage was not associated with leakage (OR = 0.45, 95% CI = 0.1-1.7, p = 0.23).

CONCLUSION

Enterococci in drain sample cultures in patients undergoing pancreaticoduodenectomy occurs significantly more among patients with anastomotic leakage compared to patients without leakage.

Changes in treatment and outcome of oesophageal cancer in Denmark between 2004 and 2013

Background

Since 2003, care for patients with oesophageal cancer has been centralized in a few dedicated centres in Denmark. The aim of this study was to assess changes in the treatment and outcome of patients registered in a nationwide database.

Methods

All patients diagnosed with oesophageal cancer or cancer of the gastro-oesophageal junction who underwent oesophagectomy in Denmark between 2004 and 2013, and who were registered in the Danish clinical database of carcinomas in the oesophagus, gastro-oesophageal junction and stomach (DECV database) were included. Quality-of-care indicators, including number of lymph nodes removed, anastomotic leak rate, 30- and 90-day mortality, and 2- and 5-year overall survival, were assessed. To compare quality-of-care indicators over time, the relative risk (RR) was calculated using a multivariable log binomial regression model.

Results

Some 6178 patients were included, of whom 1728 underwent oesophagectomy. The overall number of patients with 15 or more lymph nodes in the resection specimen increased from 38·1 per cent in 2004 to 88·7 per cent in 2013. The anastomotic leak rate decreased from 14·8 to 7·6 per cent (RR 0·66, 95 per cent c.i. 0·43 to 1·01). The 30-day mortality rate decreased from 4·5 to 1·7 per cent (RR 0·51, 0·22 to 1·15) and the 90-day mortality rate from 11·0 to 2·9 per cent (RR 0·46, 0·26 to 0·82). There were no statistically significant changes in 2- or 5-year survival rates over time.

Conclusion

Indicators of quality of care have improved since the centralization of oesophageal cancer treatment in Denmark.

ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS)

BACKGROUND

Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens.

METHODS

This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research.

DISCUSSION

This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG).

TRIAL REGISTRATION

NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.

Severe Postoperative Complications may be Related to Mesenteric Traction Syndrome during Open Esophagectomy

BACKGROUND

During abdominal surgery, traction of the mesenterium provokes mesenteric traction syndrome, including hypotension, tachycardia, and flushing, along with an increase in plasma prostacyclin (PGI₂). We evaluated whether postoperative complications are related to mesenteric traction syndrome during esophagectomy.

METHODS

Flushing, hemodynamic variables, and plasma 6-keto-PGF_1α were recorded during the abdominal part of open ( n = 25) and robotically assisted ( n = 25) esophagectomy. Postoperative complications were also registered, according to the Clavien-Dindo classification.

RESULTS

Flushing appeared in 17 (open) and 5 (robotically assisted) surgical cases ( p = 0.001). Mean arterial pressure was stable during both types of surgeries, but infusion of vasopressors during the first hour of open surgery was related to development of widespread (Grade II) flushing ( p = 0.036). For patients who developed flushing, heart rate and plasma 6-keto-PGF_1α also increased ( p = 0.001 and p < 0.001, respectively). Furthermore, severe postoperative complications were related to Grade II flushing ( p = 0.037).

CONCLUSION

Mesenteric traction syndrome manifests more frequently during open than robotically assisted esophagectomy, and postoperative complications appear to be associated with severe mesenteric traction syndrome.

A bridging stent to surgery in patients with esophageal and gastroesophageal junction cancer has a dramatic negative impact on patient survival: A retrospective cohort study through data acquired from a prospectively maintained national database

This study aimed to assess the impact of esophageal stenting on postoperative complications and survival in patients with obstructing esophageal and gastroesophageal junction (GEJ) cancer. All patients treated without neoadjuvant therapy that had an R0-resection performed for esophageal and GEJ cancer between January 2003 and December 2010 were identified from a prospectively maintained database. Data on stenting, postoperative mortality, morbidity, recurrence-free survival, complications, and length of hospital stay were collected. Kaplan-Meier plots for survival and recurrence-free survival curves were constructed for R0 resected patients. Data were compared between the stent and no-stent group by nonparametric tests. Two hundred seventy three consecutive R0 resected patients with esophageal or GEJ cancer were identified. Of these patients, 63 had a stent as a bridge to surgery. The male/female ratio was 2.64 (198/75) with a median age in the stent group (SG) of 65.1 versus 64.3 in the no stent group (NSG). Patients were comparable with respect to gender, age, smoking, TNM-classification, oncological treatment, hospital stay, tumor location, and histology. The median survival in the SG was 11.6 months compared with 21.3 months for patients treated without a bridging stent (P < 0.001). There were no statistically significant differences in 30-day mortality between the two groups, but NSG patients exhibited a significantly better two-year survival (P = 0.017). The median recurrence-free survival was 9.1 months for the SG compared with 15.2 months for the NSG. The use of a stent as a bridging procedure to surgery in patients treated without neaoadjuvant therapy for an esophageal or GEJ cancer that later underwent R0 resection decreased the two year survival and the recurrence-free survival.

The Multidisciplinary Team Conference's Decision on M-Staging in Patients with Gastric- and Gastroesophageal Cancer is not Accurate without Staging Laparoscopy

BACKGROUND

The implementation of the multidisciplinary team conference has been shown to improve treatment outcome for patients with gastric- and gastroesophageal cancer. Likewise, the staging laparoscopy has increased the detection of patients with disseminated disease, that is, patients who do not benefit from a surgical resection. The aim of this study was to compare the multidisciplinary team conference's decision in respect of M-staging with the findings of the following staging laparoscopy.

METHODS

Patients considered operable and resectable within the multidisciplinary team conference in the period 2010-2012 were retrospectively reviewed. Patient data were retrieved by searching for specific diagnosis and operation codes in the in-house system. The inclusion criteria were as follows: biopsy-verified cancer of the esophagus, gastroesophageal junction or stomach, and no suspicion of peritoneal carcinomatosis or liver metastases on multidisciplinary team conference before staging laparoscopy. Furthermore, an evaluation with staging laparoscopy was required.

RESULTS

In total, 222 patients met the inclusion criteria. Most cancers were located in the gastroesophageal junction, n = 171 (77.0%), and most common with adenocarcinoma histology, n = 196 (88.3%). The staging laparoscopy was M1-positive for peritoneal carcinomatosis in eight patients (16.7%) with gastric cancer versus nine patients (5.3%) with gastroesophageal junction cancer. Furthermore, liver metastases were evident in zero patients (0.0%) and four patients (2.3%) with gastric- and gastroesophageal junction cancer, respectively. The staging laparoscopy findings regarding peritoneal carcinomatosis were significantly different between gastric- and gastroesophageal junction cancers, p = 0.01. No significant differences were found regarding T-/N-stage or histological tumor characteristics between the positive- and negative-staging laparoscopy group.

CONCLUSION

The M-staging of the multidisciplinary team conference without staging laparoscopy lacks accuracy concerning peritoneal carcinomatosis. Staging laparoscopy remains an essential part of the preoperative detection of disseminated disease in patients with gastric- and gastroesophageal cancer.

Dysphagia is not a Valuable Indicator of Tumor Response after Preoperative Chemotherapy for R0 Resected Patients with Adenocarcinoma of the Gastroesophageal Junction

Background:

Monitoring treatment response to preoperative chemotherapy is of utmost importance to avoid treatment toxicity, especially in non-responding patients. Currently, no reliable methods exist for tumor response assessment after preoperative chemotherapy. Therefore, the aim of this study was to evaluate dysphagia as a predictor of tumor response after preoperative chemotherapy and as a predictor of recurrence and survival.

Methods:

Patients with adenocarcinoma of the gastroesophageal junction, treated between 2010 and 2012, were retrospectively reviewed. Dysphagia scores (Mellow-Pinkas) were obtained before and after three cycles of perioperative chemotherapy together with clinicopathological patient characteristics. A clinical response was defined as improvement of dysphagia by at least 1 score from the baseline. The tumor response was defined as down staging of T-stage from initial computer tomography (CT) scan (cT-stage) to pathologic staging of surgical specimen (pT-stage). Patients were followed until death or censored on June 27th, 2014.

Results:

Of the 110 included patients, 59.1% had improvement of dysphagia after three cycles of perioperative chemotherapy, and 31.8% had a chemotherapy-induced tumor response after radical resection of tumor. Improvement of dysphagia was not correlated with the tumor response in the multivariate analysis (p = 0.23). Moreover, the presence of dysphagia was not correlated with recurrence (p = 0.92) or survival (p = 0.94) in the multivariate analysis.

Conclusion:

In our study, improvement of dysphagia was not valid for tumor response evaluation after preoperative chemotherapy and was not correlated with the tumor response. The presence of dysphagia does not seem to be a predictor of recurrence or survival.

Comparative Investigation of Postoperative Complications in Patients With Gastroesophageal Junction Cancer Treated With Preoperative Chemotherapy or Surgery Alone

Background and aim:

Gastroesophageal junction cancer is one of the leading causes to cancer-related death and the prognosis is poor. However, progress has been made over the last couple of decades with the introduction of multimodality treatment and optimized surgery. Three-year survival rates have improved to 50% in patients receiving neoadjuvant therapy. Only a few studies have focused on the difference of postoperative complications in patients receiving neoadjuvant therapy in relation to a comparative surgery-only group. The aim of this study was to compare the prevalence of postoperative complications of patients with cancer at the gastroesophageal junction treated with either neoadjuvant chemotherapy or surgery alone in patients from “The Danish Clinical Registry of Carcinomas of the Esophagus, the Gastro-Esophageal Junction and the Stomach.”

Materials and methods:

A historical follow-up study, comparing postoperative complications between two cohorts before and after implementation of chemotherapy was completed.

Results:

In all, 180 consecutive patients treated with perioperative chemotherapy and a comparative surgery-only group of patients were identified from The Danish Clinical Registry of Carcinomas of the Esophagus, the Gastro-Esophageal Junction and the Stomach. No difference was found in demographics between the two groups, except for alcohol consumption and a lower T and N stage in the surgery-only group, and no difference in complication rates was found. Furthermore, no variable in the multivariate analysis was significantly associated with anastomotic leakage which was considered the most severe complication.

Conclusion:

Since perioperative chemotherapy does not appear to increase surgical complications, the future challenges include defining the optimal combination of chemo- and/or radiotherapy, but more importantly also to select the patients who will benefit the most from the different neoadjuvant strategies.

Focused Assessment with Sonography for Trauma in patients with confirmed liver lesions

BACKGROUND AND AIMS

The objective was to determine the sensitivity and specificity of Focused Assessment with Sonography for Trauma (FAST) in patients with confirmed liver lesions and also to compare results from surgeons trained in FAST with results from radiologists trained in general abdominal ultrasound as part of the specialist training. Explorative laparotomy or CT served as gold standard.

MATERIALS AND METHODS

This retrospective study included all patients admitted to our institution from 2003 to 2010 registered with the diagnosis "Injury of the liver or gallbladder". Of 405 patients, 135 patients were eligible for analysis. Seventy-two patients were examined by radiologists and 63 by surgeons.

RESULTS

We found FAST to have a sensitivity, specificity, PPV, and NPV of 79.6%, 100%, 100%, and 68.9%. There was no statistically significant difference between FAST performed by radiologists and surgeons trained in FAST.

CONCLUSION

FAST remains an important screening tool in abdominal trauma including liver lesions, and can be performed at a satisfactory level by surgeons trained in the FAST procedure only.

Post-endoscopic retrograde cholangiopancreaticography complications in liver transplanted patients, a single-center experience

BACKGROUND

Complications in the biliary tract occur in 5%-30% after liver transplantation and the main part of the complications is successfully managed with endoscopic retrograde cholangiopancreaticography (ERCP). The incidence and risk factors for post-ERCP complications in liver transplantation patients are not well described. Our objective was to define the frequency of post-ERCP complications in liver transplantation patients at the Abdominal Center, Rigshospitalet, the only Liver Transplantation Center in Denmark.

METHODS

Retrospective study of all ERCPs performed in liver transplantation patients during a 9-year period.

RESULTS

A total of 292 ERCPs were included. Overall post-ERCP complications occurred in 24 procedures (8.2%): pancreatitis in 8 (2.7%), bleeding in 5 (1.7%), and cholangitis in 13 (4.5%) procedures. Simultaneous pancreatitis and cholangitis, and simultaneous bleeding and cholangitis occurred after two procedures, respectively. Multivariate analysis concerning overall complications identified biliary sphincterotomy (p = 0.006) and time since liver transplantation within 90 days postoperatively (p = 0.044) as risk factors for post-ERCP complications. Specifically concerning post-ERCP pancreatitis (PEP), it was found that pre-ERCP cholangitis was another independent risk factor for PEP (p = 0.026). Stent in the biliary tract prior to ERCP seemed to be protective (p = 0.041).

CONCLUSIONS

Complications were of surprisingly mild degree. The rates of post-ERCP complications in our study were in line with previous studies with liver transplantation patients. Cholangitis prior to ERCP may be another risk factor for post-ERCP pancreatitis.

Survival after adjuvant chemoradiotherapy or surgery alone in resectable adenocarcinoma at the gastro-esophageal junction

BACKGROUND AND AIMS

Longterm survival after curative resection for adenocarcinoma at the gastro-esophageal junction (GEJ) range between 18% and 50%. In the pivotal Intergroup-0116 Phase III trial by Macdonald et all, adjuvant chemoradiotherapy improved both disease-free and overall survival in curatively resected patients with mainly gastric adenocarcinoma. We compared survival data for curatively resected patients with adeno-carcinoma solely at the gastro-esophageal junction (GEJ), treated with surgery alone or surgery and adjuvant chemoradio-therapy.

METHODS

From 2003 to 2009, 211 patients underwent curative resection. Surgery alone was performed in 95 pa-tients and 116 patients received adjuvant therapy after resection. All patients underwent Lewis-Tanner operation with D1 node resection including coliac nodes (D1+). Informations about recurrence and death were collected from the Danish Cancer Register and the Central Death Register. Patients who died after experiencing severe complications after surgery were excluded from the survival analysis. Patients with T0N0 or T1N0 were also excluded because patients of this category were not given adjuvant therapy according to the Macdonald protocol.

RESULTS

Patients with positive node status in the resected specimen, the 3-year disease-free survival after adjuvant chemoradiotherapy (n = 91) or surgery alone (n = 43) was 24% and 37%, respectively. Median time of survival was prolonged by 10 month in favour of those who received chemoradiotherapy. However, after controlling for the confounding effect of age and node status, only positive node status in the resected specimen had significant partial effect on survival.

CONCLUSION

Chemoradiotherapy according to the Intergroup-0116 protocol might still be a reasonable option after curative resection in patients with GEJ adenocarcinomas and positive lymph node status, who did not receive neoadjuvant chemotherapy.

Evaluation of contrast-enhanced ultrasound of the pancreas combined with concurrent hormone stimulation

PURPOSE

To evaluate the potential of combined administration of the gastrointestinal hormones secretin (Secrelux) and c-terminal cholecystokinin (CCK-8 s) together with contrast-enhanced ultrasound (CE-US) to generate an extended contrast enhancement of healthy pancreatic tissue.

MATERIALS AND METHODS

14 anaesthetised pigs weighing 30-35 kg were studied. After laparotomy, the pancreas was located and a B-mode examination followed by a CE-US examination of the gland was made using SonoVue 1.5 ml. After an injection of Secrelux 1 U/kg and CCK-8 s 100 pmol/kg, a second CE-US examination was conducted. The hormones and the contrast agent were administered through a catheter in the superior vena cava. The sonographic images were stored for later evaluation.

RESULTS

The study showed that CE-US increased the echogenicity of the pancreas by an average of 15.6 decibel (dB) (confidence intervals [CI]: 13.72, 17.42) p < 0.0001, an increase of 24%. The administration of Secrelux and CCK-8 s in combination with CE-US further increased the echogenicity of the pancreas by an average of 3% (CI: 0.36, 5.36) p = 0.028. A new sequence of hormones and CE-US 20 min after the previous injection did not induce further enhancement. The area under the curve (AUC) was significantly larger using both hormones and CE-US compared with CE-US alone by an average of 66 dBx sec (CI: 28,103) p = 0.002.

CONCLUSION

It is possible to generate an extended contrast enhancement of healthy pancreatic tissue using CE-US combined with the administration of the gastrointestinal hormones secretin (Secrelux) and c-terminal cholecystokinin (CCK-8 s). Our results may improve the ability to discriminate between healthy pancreatic tissue and areas with a changed blood flow due to either neoplasm or other pathological lesions.

Diagnostic performance of computed tomography colonography and colonoscopy: a prospective and validated analysis of 231 paired examinations

BACKGROUND

Detection of colorectal tumors with computed tomography colonography (CTC) is an alternative to conventional colonoscopy (CC), and clarification of the diagnostic performance is essential for cost-effective use of both technologies.

PURPOSE

To evaluate the diagnostic performance of CTC compared with CC.

MATERIAL AND METHODS

231 consecutive CTCs were performed prior to same-day scheduled CC. The radiologist and endoscopists were blinded to each other's findings. Patients underwent a polyethylene glycol bowel preparation, and were scanned in prone and supine positions using a single-detector helical CT scanner and commercially available software for image analysis. Findings were validated (matched) in an unblinded comparison with video-recordings of the CCs and re-CCs in cases of doubt.

RESULTS

For patients with polyps >/=5 mm and >/=10 mm, the sensitivity was 69% (95% CI 58-80%) and 81% (68-94%), and the specificity was 91% (84-98%) and 98% (93-100%), respectively. For detection of polyps >/=5 mm and >/=10 mm, the sensitivity was 66% (57-75%) and 77% (65-89%). A flat, elevated low-grade carcinoma was missed by CTC. One cancer relapse was missed by CC, and a cecal cancer was missed by an incomplete CC and follow-up double-contrast barium enema.

CONCLUSION

CC was superior to CTC and should remain first choice for the diagnosis of colorectal polyps. However, for diagnosis of lesions >/=10 mm, CTC and CC should be considered as complementary methods.

Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members

BACKGROUND/AIMS

Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units.

RESULTS

The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy.

CONCLUSIONS

In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

Detection rate of periintestinal lymph nodes

AIM

Compared to standard two-dimensional (2D) endosonography, three-dimensional (3D) endosonography has been presented as a possible improvement regarding imaging of the gastrointestinal (G-I) tract and detection of metastatic lymph nodes. The aim of this study was to evaluate the efficacy of detecting periintestinal lymph nodes in surgical specimens using 3D endosonography.

PATIENTS AND METHODS

Surgical specimens from 31 patients with malignant G-I tumours were investigated by 3-D endosonography and histology with focus on the presence of periintestinal lymph nodes and presence of metastasis. The specimens were scanned submerged into water. Position and size of the lymph nodes were mapped on a photo of the specimen both by the pathologist and the examiners.

RESULTS

Three-dimensional endosonography detected 48 out of 60 malignant lymph nodes (80.0 %), and 110 out of 219 benign lymph nodes (50.2 %). The positive predictive value for an endosonographic finding interpreted as a lymph node was 0.97.

CONCLUSION

The detection rates for periintestinal lymph nodes were relatively high and seemed superior to the one usually assigned to 2D endosonography. Although distinguishing between metastatic and non-metastatic lymph nodes remains a problem, all patients with histologically confirmed metastasis to lymph nodes were detected by 3D endosonography, and the technique thus seems suitable for grouping of patients prior to surgery.

Missed lesions and false-positive findings on computed-tomographic colonography: a controlled prospective analysis

BACKGROUND AND STUDY AIMS

The aim of the present study was to analyze the reasons for false findings on computed-tomographic (CT) colonography.

PATIENTS AND METHODS

A total of 100 consecutive CT colonography examinations were carried out before conventional colonoscopies scheduled on the same day. Before the study, an experienced radiologist received training in analyzing CT colonographies. The radiologists and endoscopists were blinded to each others' findings. The patients received standard polyethylene glycol bowel preparation and were scanned in the prone and supine positions using a helical CT scanner and commercially available software for image analysis. Each pair of examinations was later followed by an unblinded analysis, comparing the CT colonographies with video recordings of the conventional colonographies in order to determine the reasons for tumors being missed or false-positive diagnoses arising on CT colonography.

RESULTS

Ninety polyps were detected in 41 patients. For patients with tumors > or = 5 mm and > or = 10 mm, the sensitivity was 67 % and 75 %, respectively, and the specificity was 84 % and 95 %, respectively. The most important reasons for the 38 false findings of tumors > or = 5 mm were perception errors (21 of 38) and misinterpretation of flat lesions in particular, including a high-grade dysplasia and a flat elevated Dukes A carcinoma. Residual stool was frequently the reason for misinterpreting lesions > or = 10 mm (four of 10).

CONCLUSIONS

Perception errors were the main reason for false findings of lesions > or = 5 mm, including one flat malignant lesion. Residual stool caused four of 10 false findings for lesions > or = 10 mm. Reading CT colonographies requires a high level of expertise, and conventional colonography is still regarded as the gold standard for detecting colorectal lesions.

Lymphoscintigraphy using technetium-99m human serum albumin in chylothorax

Chylous effusion is an infrequent complication of abdominothoracic surgery. When conservative therapy cannot cure the patient, surgical closure of the thoracic duct must be performed. If radiological lymphography is impossible to perform, lymphoscintigraphy with Tc-99m human serum albumin is a good alternative. Here, we present two patients who developed chylothorax after abdominothoracic surgery. Successful surgery was performed after lymphoscintigraphy had demonstrated the disruption of the thoracic duct.

Bicarbonate attenuates intracellular acidosis

BACKGROUND

This study was prompted by concern that administration of bicarbonate for correction of lactate acidosis aggravates a low intracellular pH (pHi). In healthy subjects we evaluated skeletal muscle pHi using 31P-magnetic resonance spectroscopy during 5-minute rhythmic handgrip to provoke intracellular acidosis.

METHODS

Subjects were randomized to treatment with bicarbonate or saline infused intravenously in a cross-over study design with 1 h between trials.

RESULTS

In response to rhythmic handgrip, muscle venous O(2) hemoglobin saturation decreased from 51 +/- 4% to 36 +/- 2% and lactate increased from 1.0 +/- 0.1 to 4.9 +/- 0.5 mmol/l with a reduction in pH from 7.43 +/- 0.01-7.23 +/- 0.01 (P<0.05). pHi decreased from 7.06 +/- 0.02-6.36 +/- 0.08 (P<0.05). Infusion of bicarbonate increased the arterial blood concentration from 26 +/- 1 to 39 +/- 1 mmol/l (P<0.05). The arterial CO(2) partial pressure decreased from 5.6 +/- 0.2 to 5.2 +/- 0.3 kPa during rhythmic handgrip, whereas it increased to 5.9 +/- 0.2 kPa (P<0.05) during infusion of bicarbonate. Bicarbonate treatment also increased pH of arterial and venous blood (7.55 +/- 0.01 vs. 7.44 +/- 0.02 and 7.31 +/- 0.01 vs. 7.23 +/- 0.02, respectively; P<0.05). In the last min of rhythmic handgrip the decrease in pHi was attenuated by the administration of bicarbonate (6.60 +/- 0.11 vs. 6.40 +/- 0.12; P<0.05).

CONCLUSION

During exercise-induced metabolic acidosis, intravenous administration of bicarbonate increased the buffering capacity of blood and attenuated the decrease in intracellular muscle pH, although there was a small increase in the arterial carbon dioxide pressure.

Hemodynamic changes during a single treatment with the molecular adsorbents recirculating system in patients with acute-on-chronic liver failure

The aim of this pilot study is to evaluate the circulatory safety of treatment with the molecular adsorbents recirculating system (MARS) by determining the effect on systemic hemodynamics of a single MARS treatment in patients with acute-on-chronic liver failure (AOCLF). In eight patients admitted with AOCLF, a single 10-hour MARS treatment was performed. Systemic hemodynamic variables were determined before and during treatment. Bilirubin and urea were monitored as measures of protein-bound and water-soluble toxins. During MARS treatment, mean arterial pressure increased from 67 +/- 9 to 76 +/- 6 mm Hg (P < .05). Systemic vascular resistance index increased from 757 +/- 134 to 884 +/- 183 dyne x s/cm(5)/m(2) (P < .05), whereas cardiac index remained constant (5.9 +/- 0.7 v 6.0 +/- 1.1 L/min/m(2)). No episode of dialysis-induced hypotension was observed. Systemic oxygen consumption remained constant (92 +/- 30 v 93 +/- 11 mL/min/m(2)). Bilirubin levels decreased from 537 +/- 192 to 351 +/- 106 micromol/L (P < .05), and urea levels, from 19.1 +/- 13.9 to 6.7 +/- 5.1 mmol/L (P < .05). In conclusion, MARS treatment proved safe in critically ill patients with no attributing side effects.

Cerebral blood flow velocity increases during a single treatment with the molecular adsorbents recirculating system in patients with acute on chronic liver failure

The aim of this uncontrolled pilot study is to determine the effect of treatment with the molecular adsorbents recirculating system (MARS) on cerebral perfusion in patients with acute on chronic liver failure (AOCLF). In 8 patients (median age, 44 years; range, 35 to 52 years) admitted with AOCLF, a single 10-hour MARS treatment was performed. Hepatic encephalopathy (HE) was graded according to the Fogarty criteria. Changes in cerebral perfusion were determined by transcranial Doppler as mean flow velocity (V(mean)) in the middle cerebral artery. Arterial ammonia and bilirubin levels were monitored as a measure of the capability of the MARS to remove water-soluble and protein-bound toxins. During MARS treatment, HE grade improved in 3 patients and remained unchanged in 5 patients (P =.11). V(mean) increased from 42 cm/sec (range, 26 to 59 cm/sec) to 72 cm/sec (range, 52 to 106 cm/sec; P <.05), whereas arterial ammonia level decreased from 88 micromol/L (range, 45 to 117 micromol/L) to 71 micromol/L (range, 26 to 98 micromol/L; P <.05) and bilirubin level from 537 micromol/L (range, 324 to 877 micromol/L) to 351 micromol/L (range, 228 to 512 micromol/L; P <.05). In conclusion, cerebral perfusion is increased and levels of ammonia and bilirubin are reduced during MARS treatment in patients with AOCLF.

Double-stapled esophagogastric anastomosis for resection of esophagogastric or cardia cancer: new application for an old technique

In colorectal surgery, the double-stapled technique is used extensively, because it is a fairly safe and simple procedure and is useful in relatively inaccessible areas. For these reasons, we adapted the procedure to the upper gastrointestinal tract. The present study reports our first experiences of the surgical efficacy using an esophagogastric double-stapled end-to-end anastomosis for subtotal esophagectomy and cardia resection. We retrospectively studied 31 patients treated between January 1991 and January 1997 with respect to hospital mortality, anastomotic leakage, cancer recurrence, and benign stricture rate. No hospital mortality was seen. One nonfatal anastomotic leak occurred (3%). In three patients, esophageal resection was not radical (10%). Of the remaining 28 patients, one had an anastomotic cancer recurrence (4%). Eleven of the remaining 27 patients (41%) developed a benign anastomotic stricture. All achieved normal swallowing after a median of two endoscopic dilatation procedures using TTS balloons. In conclusion, the double-stapled end-to-end anastomosis technique after resection for esophagogastric or cardia cancer is a simple and expeditious procedure, carrying an acceptable perioperative morbidity and cancer recurrence rate. Larger staplers are recommended to lower the high stricture rate observed after the usage of a 21-mm stapler in this study.

The influence of PaO2, pH and SaO2 on maximal oxygen uptake

Influence of arterial oxygen pressure (PaO2) and pH on haemoglobin saturation (SaO2) and in turn on O2 uptake (VO2) was evaluated during ergometer rowing (156, 276 and 376 W; VO2max, 5.0 L min-1; n = 11). During low intensity exercise, neither pH nor SaO2 were affected significantly. In response to the higher work intensities, ventilations (VE) of 129 +/- 10 and 155 +/- 8 L min-1 enhanced the end tidal PO2 (PETO2) to the same extent (117 +/- 2 mmHg), but PaO2 became reduced (from 102 +/- 2 to 78 +/- 2 and 81 +/- 3 mmHg, respectively). As pH decreased during maximal exercise (7.14 +/- 0.02 vs. 7.30 +/- 0.02), SaO2 also became lower (92.9 +/- 0.7 vs. 95.1 +/- 0.1%) and arterial O2 content (CaO2) was 202 +/- 3 mL L-1. An inspired O2 fraction (F1O2) of 0.30 (n = 8) did not affect VE, but increased PETO2 and PaO2 to 175 +/- 4 and 164 +/- 5 mmHg and the PETO2-PaO2 difference was reduced (21 +/- 4 vs. 36 +/- 4 mmHg). pH did not change when compared with normoxia and SaO2 remained within 1% of the level at rest in hyperoxia (99 +/- 0.1%). Thus, CaO2 and VO2max increased to 212 +/- 3 mL L-1 and 5.7 +/- 0.2 L min-1, respectively. The reduced PaO2 became of importance for SaO2 when a low pH inhibited the affinity of O2 to haemoglobin. An increased F1O2 reduced the gradient over the alveolar-arterial membrane, maintained haemoglobin saturation despite the reduction in pH and resulted in increases of the arterial oxygen content and uptake.

Tolerance to head-up tilt and suspension with elevated legs

OBJECTIVE

Orthostatic hypotension is usually a benign event. However, some patients are disabled by frequent syncopal events, and vertical transportation during helicopter rescue, for example, may even be fatal. Normal orthostatic tolerance is poorly defined, so we evaluated the response to 50 degrees head-up tilt. Also, the effect of leg elevation was examined in order to establish the influence of venous return, and a fatal accident associated with orthostasis is reported.

METHODS

There were 79 volunteers who were subjected to 50 degrees head-up tilt, and 9 subjects performed 1 h of suspension by double strops placed around the thorax and knee bends, respectively. The time to presyncope and changes in BP, heart rate, thoracic electrical impedance, central venous pressure and central venous and muscle oxygen saturations were measured.

RESULTS

Head-up tilt resulted in hypotension, bradycardia and presyncopal symptoms in 69 subjects within 1 h (87%; half time 27 min), but during suspension with elevated legs in only one subject (11%; p < 0.02). In presyncopal subjects the central blood volume was reduced as reflected by an elevated thoracic electrical impedance and reduced central venous and muscle oxygen saturations.

CONCLUSIONS

During 50 degrees head-up tilt, half of 79 subjects near-fainted within 27 min, whereas elevation of the legs secured venous return to the heart and prevented presyncopal symptoms. The high rate of near-fainting in normal subjects should be taken into account during evaluation of patients with syncope, and it emphasizes the use of a position that secures venous return during transportation.

Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation

BACKGROUND

Cancer of the oesophagus and the cardia tends to present late. Palliation of dysphagia is the prospect of most of the patients. This paper reports the use of argon electrocoagulation in 83 patients with inoperable cancer strictures in the oesophagus and cardia.

METHODS

The argon electrocoagulation was done by a fibre conducting electricity and argon air to the site of coagulation. After treatment the patients were allowed to take fluids and normal food the same evening or the next morning. After recanalization the patients were treated regularly every 3-4 weeks.

RESULTS

Recanalization enabling passage for normal food was achieved with 1 treatment in 48 patients (58%), whereas 22 (26%) needed more than 1 treatment. In 13 patients (16%) the ability to eat normal food was not achieved. In these patients dysphagia improved at least one grade. Perforation was seen in seven patients (8%) and in 1% of treatments. Perforations were successfully treated conservatively in six of the seven patients. Sixty-three patients (76%) died during the investigation period, on average 146 days (range, 43-397 days) after diagnosis.

CONCLUSION

Argon electrocoagulation offers an easy, cheap, and safe alternative to treatment with laser photocoagulation and expandable metal stents.

Muscle oxygen saturation during surgery in the lithotomy position

Surgery in the lithotomy position can provoke ischaemic lesions in the lower leg. We assessed lower leg oxygen saturation using near-infrared spectroscopy (NIRS) in 42 patients undergoing urinary tract surgery. Lower leg perfusion pressure was calculated as the difference of mean arterial pressure to pressure in an air bag supporting the lower leg and the hydrostatic pressure difference from the level of the lower leg to the heart. During elevation of the lower leg for 25 (3-65) min (median and range), mean arterial pressure decreased from 100 (73-125) to 77 (53-112) mmHg and the lower leg perfusion pressure dropped from 103 (80-122) to 21 (-6-65) mmHg, corresponding to a reduction in oxygen saturation of the medial gastrocnemius muscle from 68% (40-100%) to 58% (20-96%) (P < 0.01). The results demonstrate significant desaturation of the calf muscles during surgery in the lithomy position.

Hereditary non-polyposis colorectal cancer: clinical features and survival. Results from the Danish HNPCC register

BACKGROUND

Hereditary non-polyposis colorectal cancer (HNPCC) is a dominantly inherited syndrome characterized by the development of colorectal cancer (CRC) and other carcinomas. Our aim was to evaluate tumour parameters and survival in HNPCC.

METHODS

One hundred and eight Danish HNPCC patients were compared with 870 patients with sporadic colorectal cancer.

RESULTS

The median age at CRC diagnosis was 41 years in the HNPCC group. HNPCC patients had significantly more carcinomas located to the right colon (68% against 49% in controls), more synchromous tumours (7% versus 1%), more metachronous CRC after 10 years (29% versus 5%), more localized carcinomas (62% versus 39%), and significantly higher crude cumulative 5-year survival (56% versus 30%).

CONCLUSIONS

CRC in HNPCC behaves differently compared to sporadic cases concerning age of onset, frequency of multiple lesions, and location. The metastatic tendency is less than in sporadic CRC and the survival is better.

Nonsurgical treatment of esophageal perforations after endoscopic palliation in advanced esophageal cancer

BACKGROUND AND STUDY AIMS

Iatrogenic esophageal perforation during palliative endoscopic treatment in patients with incurable esophageal or cardiac cancer is a severe complication, associated with a high rate of mortality. The treatment remains controversial, since both nonsurgical and surgical treatment regimens are used. The present study describes a nonsurgical regimen.

PATIENTS AND METHODS

Nine cases of perforation occurred in 142 consecutive patients referred for endoscopic palliation of dysphagia, corresponding to a perforation rate of 6%. Laser therapy was the main treatment used (argon plasma coagulation or Nd:YAG photocoagulation).

RESULTS

Nonsurgical treatment was successful in six patients (75%). Two patients died (22%) as a direct result of esophageal perforation following endoscopic palliation procedures.

CONCLUSION

These findings show an acceptable mortality rate using a nonsurgical treatment regimen involving broad-spectrum antibiotics, nasogastric suction, and parenteral nutrition, with pleural drainage and endoprosthesis placement in addition when indicated.

Pulsed dose rate (PDR) brachytherapy of anal carcinoma

BACKGROUND AND PURPOSE

With radiotherapy of anal carcinomas, sphincter preservation can be obtained at survival rates similar to those obtained with radical surgery. By combining external beam irradiation with interstitial irradiation, superiority over standard external irradiation has been obtained. With the introduction of pulsed dose rate equipment, where a single high activity source moves through catheters, a more individualized dose distribution and a further elimination of radiation exposure to the staff can be achieved.

MATERIALS AND METHODS

Between June 1993 and November 1994, 17 patients with anal carcinoma (T1:4, T2:4, T3:6, T4:3) have been treated at the Finsen Center. The treatment consisted of three-field external irradiation 46 Gy/23 fractions with five fractions a week to the anal canal and regional pelvic lymph nodes. Seven to 33 days after completion of external irradiation, the tumorspace was given 25.2 Gy PDR brachytherapy with 42 pulses of 0.6 Gy, one pulse every hour.

RESULTS

One isolated local recurrence has been noted 13 weeks after implantation. One additional local recurrence was seen in a patient with concomitant hepatic and inguinal recurrence. In three patients inguinal recurrence had occurred, two of these patients were irradiated without any further evidence of disease, and one patient with a primary advanced tumour, had local failure. So far necrosis has been observed in 13 patients within 1-49 weeks (median 16 weeks) after implantation. Eight of these patients required colostomy. No relation was observed between the number of implanted needles and the occurrence of necrosis.

CONCLUSIONS

The results indicate that the treatment is highly effective, but with substantial toxicity.

Validation of transcranial near-infrared spectroscopy for evaluation of cerebral blood flow autoregulation

The aim of the study was to evaluate a new noninvasive transcranial near-infrared spectroscopy (TNIRS) technique for determination of the lower limit of cerebral blood flow (CBF) autoregulation by comparing this technique with the standard cerebral arteriovenous oxygen saturation difference (AVDo2) method. In eight healthy volunteers, mean arterial blood pressure was increased by infusion of angiotensin and decreased by the combination of lower-body negative pressure and labetalol. For each 5-mm Hg change in mean arterial pressure, blood was sampled from the bulb of the internal jugular vein and a radial artery, and simultaneously, the oxygen saturation of hemoglobin in the brain was measured with an INVOS 3100 Cerebral Oximeter (Somanetics). The lower limit of autoregulation was then calculated by a computer using (a) AVDo2 and (b) the difference between arterial oxygen saturation and the saturation determined with the cerebral oximeter (ACDo2). The median lower limit of autoregulation determined by the two methods was 73 and 78.5 mm Hg, respectively (p > 0.05). A statistically significant correlation between relative CBF (percentage of baseline) determined with the two methods was found below the lower limit of autoregulation (1/AVDo2 = 12 + 0.8 x 1/ACDo2; r = 0.55; p < 0.001). For all the 98 pairs of saturations registered, the correlation was 0.37 (p < 0.001), the mean difference was 16%, and the limits of agreement were -2.2 and 33.8%. We conclude that the cerebral oximeter might be useful in evaluation of the lower limit of cerebral autoregulation. This method, however, is of no value for estimation of levels of global cerebral oxygen saturation.

Hyperplastic polyposis of the large bowel. Three cases and a review of the literature

Small hyperplastic polyps of the large bowel constitute a frequent non-neoplastic lesion, whereas large or multiple hyperplastic polyps are rare. Here we report three cases of multiple small polyps together with some large hyperplastic ones. Two of the cases had a primary carcinoma in the bowel before onset of the polyps. The neoplastic potential of the hyperplastic polyp is discussed on the basis of the most recent investigations and the three presented cases. The hyperplastic polyp does not seem to be directly involved in the adenoma-carcinoma sequence, but dysplastic changes can be found in large hyperplastic polyps. In cases of multiple hyperplastic polyps a tendency towards a more uniform distribution of the polyps throughout the large bowel is observed. Hyperplastic colonic polyps may exist as a clinical entity, and a definition based on distribution, multiplicity, size, and symptoms is proposed. Patients with multiple or large hyperplastic polyps should have colonoscopy performed at short intervals, with removal of all lesions larger than 5 mm for histologic examination.

[Compartment syndrome as a postoperative complication of lithotomy position]

Surgical procedures necessitating the use of the lithotomy position can be associated with neuromuscular lesions, usually arising from compression of nerves and muscles. Compartment syndrome of the lower extremities is a grave complication which, if unrecognized, can lead to either permanent neuromuscular dysfunction or limb loss. We report two cases of compartment syndrome complicating surgery in the lithotomy position.

Effect of labetalol on cerebral blood flow, oxygen metabolism and autoregulation in healthy humans

We have studied the effects of labetalol on cerebral blood flow (CBF) and cerebral oxygen metabolism (CMRO2) in eight healthy volunteers. CBF was measured by single photon emission computerized tomography before and during infusion of labetalol. CMRO2 was calculated as CBF x cerebral arteriovenous oxygen content difference (CaO2-CvO2). CBF autoregulation was tested during infusion of labetalol by changing arterial pressure and estimating relative changes in global CBF from changes in (CaO2-CvO2). CBF before and during infusion of labetalol was 67 and 65 ml/100 g min-1, respectively (P > 0.05). CMRO2 was 2.9 and 2.8 ml/100 g min-1, respectively (P > 0.05). CBF autoregulation was preserved in all subjects. The lower limit of CBF autoregulation was 88 mm Hg (94% of baseline mean arterial pressure). We conclude that labetalol did not influence global or regional CBF, or CMRO2, and CBF autoregulation was preserved.

Exercise-induced gastric mucosal acidosis

Gastric acidosis as assessed by tonometry was applied to evaluate changes in splanchnic blood flow during exercise. In six healthy male oarsmen, we determined gastric acidosis in response to 30 min of maximal ergometer rowing. The gastric mucosa carbon dioxide tension was determined by equilibration of isotonic saline to the tonometer. Arterial bicarbonate (HCO3-), pH, arterial oxygen tension (PaO2), and saturation (SaO2) were obtained simultaneously, while pH (pHi) of the gastric mucosa was calculated using the Henderson-Hasselbach equation. During rowing PaO2 and SaO2 decreased to values of 73.7 mm Hg and 95.5%, respectively (P < 0.05). However, during the last minute of rowing the values were normalized with a hyperventilation reducing PaCO2 to 27.1 mm Hg (P < 0.05). Rowing decreased HCO3- from 25.8 (21.4-28.5) to 14.1 (11.6-17.4) mmol l-1, while the gastric carbon dioxide tension increased from 36.8 (24.1-63.9) to 61.7 (48.9-82.0) mm Hg (P < 0.05). Accordingly, pHi decreased from 7.25 (7.04-7.48) to 6.79 (6.67-6.85) (P < 0.05). Arterial pH also decreased (from 7.42 (7.41-7.44) to 7.29 (7.26-7.33) (P < 0.05)), with the enlarged difference between pH and pHi suggesting marked splanchnic hypoperfusion during rowing.

Cimetidine as an adjuvant treatment in colorectal cancer. A double-blind, randomized pilot study

PURPOSE

To evaluate the influence of a H2 receptor antagonist (cimetidine) on survival in patients with colorectal carcinoma, a randomized, controlled pilot study was performed in three university hospitals in Copenhagen, Denmark.

METHODS

A total of 192 patients, who had undergone a resection or an exploratory operation for adenocarcinoma of the colon or rectum between May 1988 and May 1991, were enrolled in the study. After a median observation time of 40 months, outcome was noted for each patient concerning cancer-specific mortality rate.

RESULTS

In patients operated with curative intent (n = 148), no difference was found in cancer-specific mortality between the two treatments. However, a tendency toward reduction in mortality rate was found in patients with curatively operated Dukes Stage C carcinoma (P = 0.11, log-rank test; difference, 29 percent; 90 percent confidence interval, 2 to 57 percent) in the cimetidine-treated group. In patients with disseminated disease no total difference was found between the two treatment groups.

CONCLUSIONS

Cimetidine does not seem to reduce mortality in patients with colorectal cancer, but there seems to be a tendency toward a survival benefit in patients undergoing surgery for Dukes Stage C carcinoma. Results seem to justify trials in this patient category to reveal a benefit of H2 receptor antagonists in adjuvant therapy of colorectal carcinoma.

[Paracetamol poisoning]

Administration of paracetamol (acetaminophen) has analgetic and antipyretic effect. After trauma paracetamol has an anti-inflammatory activity. It was presumed that paracetamol in therapeutic doses had fewer and more acceptable side-effects than other analgetic drugs such as acetylsalicylic acid and NSAID-drugs. However, in toxic concentrations, paracetamol is more life-threatening. The toxic effects of paracetamol most often occur in the liver and kidneys. Phosphate and lactate turn-over can also be impaired. Paracetamol poisoning can induce temporary liver dysfunction or even irreversible liver failure with liver transplantation as the only therapeutic possibility. Chronic alcoholics are especially at risk, as liver damage may occur following paracetamol even in recommended doses. When intoxication with paracetamol is presumed, administration of N-acetylcysteine is vital. N-acetylcysteine therapy should be initiated not later than 15 hours after paracetamol intake. Moreover, the antitoxic effect has been observed even when N-acetylcysteine therapy is initiated 24-36 hours after presumed paracetamol intake. Measures of preventing further absorbtion of paracetamol from the gastrointestinal tract should be taken. Activated charcoal should be given if less than two hours have passed since paracetamol intake. Between two and four hours following paracetamol intake gastric lavage should be performed. During the last 10 years the incidence of paracetamol self-poisoning has increased, but death following paracetamol poisoning is relatively constant at around nine per year in Denmark. It is suggested that the incidence of serious cases of paracetamol poisoning could be reduced by simple measures. Special attention should be paid to the risk-group of chronic alcoholics.

[Paracetamol poisoning]

Administration of paracetamol (acetaminophen) has analgetic and antipyretic effect. After trauma paracetamol has an anti-inflammatory activity. It was presumed that paracetamol in therapeutic doses had fewer and more acceptable side-effects than other analgetic drugs such as acetylsalicylic acid and NSAID-drugs. However, in toxic concentrations, paracetamol is more life-threatening. The toxic effects of paracetamol most often occur in the liver and kidneys. Phosphate and lactate turn-over can also be impaired. Paracetamol poisoning can induce temporary liver disfunction or even irreversible liver failure with liver transplantation as the only therapeutic possibility. Chronic alcoholics are especially at risk, as liver damage may occur following paracetamol even in recommended doses. When intoxication with paracetamol is presumed, administration of N-acetylcysteine is vital. N-acetylcysteine therapy should be initiated not later than 15 hours after paracetamol intake. Moreover, the antitoxic effect has been observed even when N-acetylcysteine therapy is initiated 24-36 hours after presumed paracetamol intake. Measures of preventing further absorption of paracetamol from the gastrointestinal tract should be taken. Activated charcoal should be given if less than two hours have passed since paracetamol intake. Between two and four hours following paracetamol intake gastric lavage should be performed. During the last 10 years the incidence of paracetamol self-poisoning has increased, but death following paracetamol poisoning is relatively constant at around nine per year in Denmark. It is suggested that the incidence of serious cases of paracetamol poisoning could be reduced by simple measures. Special attention should be paid to the risk-group of chronic alcoholics.

Closure of rectal stump after colectomy for acute colitis

In a retrospective study complications, mortality and morbidity following acute colectomy for severe colitis with intra-abdominal closure of the rectal stump were reviewed in 147 consecutive patients (71 women and 76 men, median age of 40 years, range 18-95 years). Five patients (3%) died within 30 days postoperatively; none of the deaths were related to the rectal stump. Three patients (2%) had a pelvic abscess due to leakage of the rectal closure, all were treated successfully with percutaneous drainage, guided by ultrasonography. No difficulties in locating the rectal stump or performing intended subsequent surgery were reported. The overall complications and mortality rate in this study are low and comparable to the best results reported from centers using the mucous fistula. Closure of the rectal stump is a safe procedure, and has the advantage of not leaving the patient with a second stoma.

The establishment of an HNPCC register

Guidelines for the establishment of an HNPCC-register are presented. The aims of a register are discussed. Steps in identification of families and persons at risk are suggested, and possible sources of family and pedigree data are mentioned. The role of a register in surveillance, information of family members and medical colleagues, research and international collaboration are discussed.

[Radiological findings in patients with a J-shaped ileal reservoir]

This study comprised 116 patients with either ulcerative colitis or familial adenomatous polyposis, who were treated from 1983 to 1990. The patients were subjected to total colectomy followed by formation of an ileoanal reservoir (J-pouch). In a retrospective study the radiological findings of the J-pouch and the reservoir related complications are presented and a description of the applied technique for pouchography is given. A total of 513 radiological investigations were performed--median two per patient (range: 1-44). All 116 patients were subjected to pouchography while 59 patients additionally underwent conventional X-ray investigations, 42 patients were referred to ultrasound and ten patients to CT. Fourty-five percent of the patients presented no radiological complications at all. Patients with a normal primary pouchogram showed a significantly lower risk of long term complications related to the pouch. Pouchography was a useful method for excluding pouch pathology before restoring intestinal continuity as well as showing fistulas or cavities. In cases of leakage and especially stenosis and pouchitis pouchography was, however, less reliable. Ultrasound examination combined with CT-scan was beneficial in diagnosing abscesses.