Göran Ekelund

Recurrence rates after curative surgery for rectal carcinoma, with special reference to their accuracy

Is the observed recurrence rate after curative surgery for rectal cancer always a good measure of therapeutic improvements? In an attempt to answer this question, the rates of local and distant recurrences were studied in two complete series of patients operated on for cure for rectal carcinoma. One hundred one consecutive patients were followed for five years in one series and 231 were followed for at least 18 years in the other series. The recurrence rate in the first series was 39 percent and in the second, with the longer observation time, 54 percent. The local recurrence rates were 24 and 38 percent, respectively. Both local and total recurrence rates increased with the length of the follow-up period. This was especially true for patients with combined local and distant disease. Autopsy sometimes demonstrated recurrences, clinically undiscovered. It is concluded that completeness, long follow-up, and intensive search for recurrence, including a high autopsy rate, are factors that raise both total and local recurrence rates. All these factors are important to consider when comparing results of different treatment modalities.

Multiple carcinomas of the colon and rectum

In a series of 960 cases comprising almost all cases of colorectal carcinoma diagnosed intra vitam during a 10‐year period in a defined population, there were 62 (6.5%) patients with multiple primary colorectal carcinoma. The average annual incidence was 2.6/100,000 inhabitants. Males were affected more often than females, and the frequency of patients with coexisting adenomas was higher than that in the parent series. The survival rates did not differ from those in the parent series. Synchronous lesions were seen twice as often as metachronous lesions, but the frequency of the latter is regarded as provisional. The findings suggest an interrelationship between colorectal adenoma and carcinoma. It may be concluded that every case of colorectal carcinoma requires a thorough preoperative examination of the entire large intestine. It is also concluded that all patients with colorectal carcinoma operated upon for cure should be regularly followed up for the rest of their lives for metachronous carcinomas. Cancer 33:1630–1634, 1974.

Metachronous colorectal polyps: comparison of development of colorectal polyps and carcinomas in persons with and without histories of polyps.

A D E N O M A S O F T H E C O L O N a n d r e c t u m occur more frequently in patients with carcinoma of the large intestine than in patients without such tumors. 2-~, 7-9 It has also been shown that patients who have had colorectal carcinomas removed have an increased risk of developing subsequent (metachronous) colorectal carcinomas. The risk is higher if the patient has coexisting adenomas of the large intestine, s Such a sequence of events may be explained by a common cause of adenomas and carcinomas, or by development of carcinomas from adenomas. In either case, the cause may be a constitutional disposition, and/or carcinogenic substances present in the contents of the large intestine.iS Although numerous investigations show increased frequencies of colorectal adenomas in patients with carcinomas, there have been only a few reports 4, 10, la, 14, ~6 of increased frequencies of subsequent additional adenomas or carcinomas in patients with adenomas.

Is CEA analysis of value in screening for recurrences after surgery for colorectal carcinoma

The progress of 139 patients operated upon for cure of colorectal carcinoma, was followed postoperatively with a standardized protocol. A CEA test was performed for comparison with other parameters. Median observation time was four years. When an upper limit for CEA of 7.5 μg/l was allowed, sensitivity was found to be 78 per cent, specificity 91 per cent, and predictive value of an elevated CEA concentration, 83 per cent. In general, CEA measurement traced, recurrence six months before clinical diagnosis. In only a few cases was recurrence first heralded by an abnormality in other blood chemistry test results. CEA may thus be used in postoperative screening for recurrence even though most recurrences, when detected, are not curable.

Compartment syndrome after prolonged surgery with leg supports

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8–8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.

Surgery for fulminating colitis during pregnancy

Two cases of fulminating colitis presenting during pregnancy are described. In both cases, resectional surgery was performed. In the first case, cesarean section was combined with subtotal colectomy and ileostomy during the 32nd week of gestation. In the second case, cesarean section was performed during the 33rd week of gestation and proctocolectomy in the puerperium. In both cases, histopathologic examination showed colitis more consistent with Crohns disease. It is concluded that if fulminating colitis appears during pregnancy it should be treated in the same manner as in the nonpregnant state.

Crohn's disease confined to the appendix

Crohns disease confined to the appendix is a rare entity, less than 50 cases having been reported. The present study reports on another 12 cases representing 6 per cent of all 194 patients operated upon for Crohns disease in a total, unselected series. The indications for surgery were appendicitis in eight patients, appendiceal abscess in two, suspected pyosalpinx in one, and an ovarian cyst in one. The appendices were in all cases strikingly enlarged. Giant-cell granulomas, without microabscesses, were detected in all but one patient. Two patients had early septic postoperative complications. Fistulization from the cecum did not occur. The median observation time after operation was 13.8 years. Since none of the patients had further manifestations of the disease, it is concluded that patients with Crohns disease confined to the appendix have a favorable prognosis.

Pre- and Post-Operative Complications in Crohn's Disease with Special Reference to Duration of Preoperative Disease History

In an analysis of a consecutive series of 133 patients with a diagnosis of Crohns disease established preoperatively and in which early surgical intervention was the prevailing policy, the median time between diagnosis and operation was short. For patients with predominantly small-bowel disease it was 4 months and for patients with predominantly colonic involvement 8 months. The frequencies of preoperative and early postoperative complications were low compared with those in other reports. Local complications, such as intra-abdominal fistulae and abscesses, were preoperatively seen in only 4% of the patients. Arthritis, iritis, or erythema nodosum was not seen in patients with predominantly small-bowel disease. The early postoperative death rate was 1.5%, the late mortality rate related to Crohns disease 2.3%. In conclusion, early resectional surgery seems to be justified as one form of treatment for Crohns disease in that it diminishes the rate of serious complications. The risk of recurrence is, however, not influenced by early surgical intervention.

Metabolie epidemiology of colon cancer: Dietary pattern and fecal sterol concentrations of three populations

The nutrient intake, fecal neutral sterol concentration, and bile acid concentration of populations with a varied risk for colon cancer development were investigated. High-risk populations in the metropolitan New York area and Malmo, Sweden, were compared with an intermediate-risk population in Umea, Sweden. The mean daily intake of protein and fat was comparable in all groups, but the total daily fiber intake was higher in Umea, as was the total daily stool output. There was no difference in the total fiber intake and stool output between Malmo and metropolitan New York. The fecal secondary bile acid concentration was lower in Umea than in the other two areas; no difference was observed between Malmo and metropolitan New York. These results suggest that high fiber intake may be considered protective against colon cancer even in a population with a high risk intake. A high dietary fiber intake may limit colon cancer risk by increasing stool bulk, and thus diluting and/or binding tumor promoters.

Population-based screening for colorectal cancer with faecal occult blood test--do we really have enough evidence?

IntroductionPopulation-based randomised controlled trials (RCT) have shown that invitation to biennial screening with faecal occult blood testing (FOBT) during 10 or more years reduced colorectal cancer-specific mortality. These results have stimulated plans to introduce mass screening in various countries; however, none of these trials has been able to show any reduction of total mortality, which should be expected with reduced disease-specific mortality in a RCT.MethodsThe aim of this review is to analyse, in more detail, the findings in these trials. The results of the trials have, in this review, been systematised and discussed in the context of potential bias, validity and effectiveness.ResultsIt is found that the reduced cancer-specific mortality is modest and that the clinical significance may be discussed. The number of persons needed to be invited for multiple screening rounds to avoid one death in colorectal cancer (CRC) is high, ranging from about 600 to 1,200. A remarkable finding is that only one fourth of the carcinomas in those invited to the screening were actually detected by this intervention. The absence of reduced total mortality in all series is a serious problem and evokes questions about the validity in determination of cause of death. None of these trials showed any effect on incidence of CRC by removal of precancerous adenomas.ConclusionsIt seems reasonable to conclude that the scientific evidence to support introduction of population-based screening programmes with FOBT appears not yet strong enough. In addition, harm/benefit and cost/effectiveness ratios are not well determined.