Arild Horn

Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial.

Objective:The aim of this trial was to investigate whether a routine of allowing normal food at will increases morbidity after major upper gastrointestinal (GI) surgery. Summary Background Data:Nil-by-mouth with enteral tube feeding is widely practiced for several days after major upper GI surgery. After other abdominal operations, normal food at will has been shown to be safe and to improve gut function. Methods:Patients were randomly assigned to a routine of nil-by-mouth and enteral tube feeding by needle-catheter jejunostomy (ETF group) or normal food at will from the first day after major upper GI surgery. Primary end point was rate of major complications and death. Secondary outcomes were minor complications and adverse events, bowel function, and length of stay. All patients were invited to a follow-up at 8 weeks after discharge from the hospital. Results:Four hundred fifty-three patients who underwent major open upper GI surgery in 5 centers were enrolled between 2001 and 2006. Four hundred forty-seven patients were correctly randomized. Of 227 patients 76 (33.5%) had major complications in the ETF group compared with 62 (28.2%) of 220 patients allowed normal food at will (P = 0.26, 95% CI for the difference in rate from −3.3 to 13.9). In the ETF group, 36 (15.9%) patients were reoperated compared with 29 (13.2%) in the group allowed normal food at will (P = 0.50) and 30-day mortality was 10 (4.4%) of 227 and 11 (5.0%) of 220 patients, respectively (P = 0.83). Time to resumed bowel function was significantly in favor of allowing normal food at will (P = 0.01), as were the total number of major complications, length of stay, and rate of postdischarge complications. Conclusions:Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding.

Low‐dose preoperative radiation postpones recurrences in operable rectal cancer: Results of a randomized multicenter trial in western norway

A randomized, multicenter clinical trial was conducted in Western Norway to study the effectiveness of preoperative radiation therapy in operable rectal cancer, given at a dosage of 3150 cGy in 18 fractions, 2 to 3 weeks before radical surgery. Three hundred nine patients were entered into the trial between May 1976 and December 1985. After radiation no tumor was seen in 4.5% of the patients. There was no increased morbidity or mortality at surgery. the 5‐year survival for evaluable patients was 57.5% in the control group and 56.7% in the radiotherapy group. For patients operated on for cure the 5‐year survival was 60.9% and 64.2% in the control group and radiotherapy group, respectively. Radiation significantly delayed both local and distant recurrences in patients in the radiation group who had curative resection from 13.3 months in controls to 27.1 months. the local recurrence rate in the corresponding groups was 21.1% and 13.7%, respectively. We conclude that higher preoperative radiation doses should be used in new trials as a higher dosage may transform the observed positive effects into a survival benefit.

Venous and neural invasion as predictors of recurrence in rectal adenocarcinoma

After radical surgery for rectal adenocarcinoma, the presence of venous and neural invasion of tumor cells was correlated with the pattern of treatment failure, local in the pelvis or distant. Of 128 operation specimens, venous and neural invasion was demonstrated in 22 percent and 32 percent, respectively. A significant decrease of the distant recurrence-free 5-year survival (Kaplan-Meier method) was seen when venous invasion was demonstrated (32.9 percentvs.84.3 percent;P<0.0001), whereas more local failures were registered in patients with neural invasion. The local recurrence-free 5-year survival in patients with neural invasion was 64.3 percent, compared with 81.1 percent when neural invasion was not demonstrated (P=0.03). Their prognostic value was then studied in a Cox regression model including stage and grade. Neural invasion had the strongest association with local recurrences, whereas venous invasion was found to be the third strongest independent predictor of metastasis, after lymph node status and extent of local tumor infiltration. We conclude that examining for the presence of venous and neural invasion gives reliable prediction of recurrences after radical resection of rectal cancer. Recording of tumor recurrence pattern may lead to a better selection of patients for adjuvant therapy after surgery.

Acute pancreatitis in Bergen, Norway. A study on incidence, etiology and severity.

Background: Studies on the incidence and etiology of acute pancreatitis show large regional differences. This study was performed to establish incidence, etiology and severity of acute pancreatitis in the population of Bergen, Norway. Methods: A study of all patients with acute pancreatitis admitted to Haukeland University Hospital over a 10-year period was performed. Information was obtained about the number of patients with acute pancreatitis admitted to the Deaconess Hospital in Bergen. Results: A total of 978 admissions of acute pancreatitis were recorded in these two hospitals giving an incidence of 30.6 per 100 000. Haukeland University Hospital had 757 admissions of acute pancreatitis in 487 patients. Pancreatitis was severe in 20 % (96/ 487) of patients, more often in males (25 %) than in females (14 %). Mortality due to acute pancreatitis was 3 % (16/487). Gallstones were found to be an etiological factor in 48.5 % and alcohol consumption in 19 % of patients. The risk of recurrent pancreatitis was 47 % in alcohol induced and 17 % in gallstone induced pancreatitis. The last five years of the study period, endoscopic sphincterotomy of patients with gallstone pancreatitis, resulted in drop in relapse rate from 33 % to 1.6 %. Conclusion: The incidence of acute pancreatitis was found to be 30.6 per 100 000 with 48.5 % associated with gallstones and 17 % alcohol induced. Incidence of first attack was 20/100 000. Pancreatitis was classified as severe in 20 % of cases with a mortality of 3 %.

Preoperative radiotherapy in operable rectal cancer.

The effect of preoperative radiotherapy (31.5 Gy in 3.5 weeks) in operable rectal cancer was examined with respect to resectability and prognosis after two surgical procedures, abdominoperineal resection, or low anterior resection. Preoperative radiation did not influence the surgeons selection of low anterior resection, which was similar (40 percent) in each group. Radiation improved five-year survival probability and decreased the incidence of local recurrence significantly after low anterior resection. In contrast, no improvement of treatment results was found in patients treated by abdominoperineal resection after radiotherapy.

Tumour shrinkage and down staging after preoperative radiation of rectal adenocarcinomas

In order to analyse the influence of low radiation doses on human rectal adenocarcinomas, gross and microscopical changes after preoperative radiation were compared to controls treated with immediate surgery in a randomised, prospective trial. The X-ray doses given were 31.5 Gy in 3.5 weeks, and the interval between radiation and operation was 2 to 3 weeks. A total of 138 patients having preoperative radiotherapy and 131 controls were analysed. The overall tumour size was reduced after radiation. Complete tumour regression was obtained in six (4.4%) patients. All of these tumours were exophytic and mobile at the initial examination and all were either well or moderately well differentiated. A significant downstaging was found after preoperative radiation. The incidence of positive lymph nodes was 27.5% in the resected specimens in controls and 18.4% after radiation (p less than 0.05). The total number of recurrences was reduced after radiation in stage C2 tumours, but not in the other stages. Preoperative radiation did not influence the histological grade of the tumours. There was no difference between the two randomised groups with respect to 5-year survival or disease-free survival in any histopathological stage.

The role of venous and neural invasion on survival in rectal adenocarcinoma

A total of 254 rectal adenocarcinomas were examined for the presence of venous and neural invasion. Both the incidence of venous and neural invasion increased with Astler-Collers stage, except for stage Cl related to neural invasion. Both prognostic factors predicted significantly reduced actuarial survival rates in patients with nodenegative tumors. Thus, examination for the presence of venous and neural invasion can add information to conventional staging in nodenegative tumors for assessing prognosis after radical surgery for rectal adenocarcinoma.

Effects of prolonged increased intra-abdominal pressure on gastrointestinal blood flow in pigs

BackgroundThe aim of the study was to investigate the effects of prolonged intra-abdominal pressure on systemic hemodynamics and gastrointestinal blood circulation.MethodsThe intra-abdominal pressure in anesthetized pigs was elevated to 20 mmHg (7 animals), 30 mmHg (7 animals), and 40 mmHg (4 animals), respectively. These pressures were maintained for 3 h by intra-abdominal infusion of Ringer’s solution. A control group of seven animals had normal intra-abdominal pressure (IAP). Transit time flowmetry and colored microspheres were used to measure blood flow.ResultsAn IAP of 20 mmHg did not cause significant changes in systemic hemodynamics or tissue blood flow. An IAP of 30 mmHg caused reduced blood flow in the portal vein, gastric mucosa, small bowel mucosa, pancreas, spleen, and liver. Serum lactate increased in animals with an IAP of 30 mmHg, but microscopy did not disclose mucosal damage in the stomach or small bowel. An IAP of 40 mmHg was followed by severe circulatory changes.ConclusionsProlonged IAP at 20 mmHg did not cause changes in general hemodynamics or gastrointestinal blood flow. Prolonged IAP at 30 mmHg caused reduced portal venous blood flow and reduced tissue flow in various abdominal organs, but no mucosal injury. A prolonged IAP of 40 mmHg represented a dangerous trauma to the animals.

DO ACUTE SIDE-EFFECTS DURING RADIOTHERAPY PREDICT TUMOUR RESPONSE IN RECTAL CARCINOMA ?

Patients given preoperative radiotherapy (31.5 Gy in 18 fractions) in a prospective, randomized trial of presumably operable rectal adenocarcinoma, were examined for a possible relation between bowel toxicity manifested as diarrhoea, and tumour size in the operative specimen, in addition to recurrence rate. The group requiring drugs for diarrhoea had significantly smaller tumours at surgery (2.5 cm versus 3.5 cm, p < 0.05). Patients without significant radiation-induced diarrhoea had also more recurrences (37.5% against 14.3%, p = 0.01). The disease-specific survival rate was also significantly better (p = 0.02) at 1.5 and 10 years in patients with diarrhoea WHO grade 3 and 4; 89.5%, 75.9% and 65.1% compared to 83.5%, 49.3% and 44.4% in patients with no or minimal radiation-induced loose bowels. These results indicate that the reaction of the normal bowel to radiation may correlate to radiation sensitivity of tumours derived from the same tissue.

Transanal extirpation for early rectal cancer

Transanal extirpation was performed in 38 patients with adenocarcinoma of the rectum. In 17 patients (group I) the tumor extended into the submucosa only, and in 14 patients (group II) tumors extended into, but not through, the muscularis propria. There was a significant difference in local recurrence between groups I and II. None of the patients in group I and six of the patients (42.6 percent) in group II developed local recurrences (P=0.02). The 5-year actuarial survival probability was 100 and 82.6 percent, respectively. Transanal extirpation is an alternative to transsphincteric and abdominoperineal resection in the treatment of early well or moderately well-differentiated cancer of the rectum. The surgical procedure is simple and has few complications; however, only tumors extending no deeper than the submucosa are suitable for this treatment. The operation should be followed by frequent sigmoidoscopies and rectal palpation. The procedure should be defined as an excisional biopsy until results from the histologic examination are presented.