Heikki Kiviniemi

Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis.

AbstractPURPOSE: To identify the risk factors for anastomotic leakage after left-sided colorectal resections with rectal anastomosis. nMETHODS: Forty-four patients with anastomotic leakage identified from a computer-generated database were compared with 44 control patients standardized for gender, age, and operative indication. nRESULTS: The mean hospital stay was significantly prolonged in the leakage group, which resulted in a higher total cost of hospital treatment. The preoperative variables significantly associated with anastomotic leakage included malnutrition, weight loss, hypoalbuminemia, cardiovascular disease, two or more underlying diseases, and use of alcohol. The surgery-related factors that turned out to be significant were The American Society of Anesthesiologists physical status, operation time greater than two hours, multiple blood transfusions, intraoperative contamination of the operative field, and a short distance of the anastomosis to the anal verge. Obesity, body mass index, diabetes, smoking, serum hemoglobin, serum creatinine, serum bilirubin, bowel preparation, mode of antibiotic prophylaxis, type of anastomosis, technique of stapling, size of stapler used, and use of drain were nonsignificant variables. Malnutrition, weight loss, use of alcohol, intraoperative contamination, long operation time, and multiple blood transfusions remained significant in logistic regression model. Eighty-six percent of the patients with three or more risk factors of anastomotic leakage belonged to the leakage group. nCONCLUSIONS: Patients with multiple risk factors have higher risk for anastomotic leakage. When patients have three or more risk factors, the creation of a protective stoma should be considered in cases with a low rectal anastomosis, and all these patients should be carefully monitored postoperatively for signs of possible leak.

Factors influencing wound dehiscence after midline laparotomy

PURPOSEnTo identify patients who have high risk of wound dehiscence and who might benefit from the use of internal retention sutures.nnnPATIENTS AND METHODSnForty-eight patients with midline abdominal wound dehiscence were compared with 48 control patients standardized by sex, age, and operative indication.nnnRESULTSnThe mean hospital stay was significantly prolonged in the dehiscence group, resulting in a higher total cost of hospital treatment. The variables that were significantly associated with wound dehiscence included hypoalbuminemia, anemia, malnutrition, chronic lung disease, and emergency procedure. The additional postoperative factors that were found to be significant were vomiting, prolonged intestinal paralysis, repeated urinary retention, and increased coughing. Obesity, chronic heart disease, diabetes, alcoholism, preoperative intestinal obstruction, jaundice, systemic and local infection, use of steroids, type of incision, operating time, and type of wound closure were nonsignificant variables. The number of wound dehiscences increased significantly (P = 0.0001) when the number of risk factors increased from zero to five.nnnCONCLUSIONnWe recommend using internal retention sutures for patients who have three or more risk factors.

Percutaneous aspiration and alcohol sclerotherapy for symptomatic hepatic cysts. An alternative to surgical intervention.

Eight patients with 15 symptomatic nonneoplastic congenital hepatic cysts underwent ultrasound-guided percutaneous aspiration and temporary injection of 99% ethanol into the cyst. All cysts were treated at least twice at the same sitting. The volume of alcohol injected varied from 20 to 100 ml, depending on the size of the cyst. A cure was usually achieved with one alcohol sclerotherapy treatment. Only minor side effects such as transient pain and temperature elevation occurred. No recurrences were found during a follow-up period of 12 to 32 months. The results indicate that aspiration and alcohol sclerotherapy is a feasible alternative to surgical intervention in patients with symptomatic nonneoplastic congenital hepatic cysts. We recommend it as the treatment of choice in cases with high surgical risk or polycystic liver disease.

Natural history of diverticular disease

PURPOSE: The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period. METHODS: Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records. RESULTS: There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions. CONCLUSIONS: Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.

Evidence of Founder Mutations in Finnish BRCA1 and BRCA2 Families

This study was supported by the University of Oulu, Oulu University Hospital, the Finnish Cancer Society, the Cancer Foundation of Northern Finland, and the Finnish Breast Cancer Group. We also wish to thank Ake Borg, Arto Mannermaa, Jarmo Korkko, Helena Rahja, and Kari Mononen.

Human familial and sporadic breast cancer : analysis of the coding regions of the 17β-hydroxysteroid dehydrogenase 2 gene (EDH17B2) using a single-strand conformation polymorphism assay

Abstract17β-Hydroxysteroid dehydrogenase (17HSD) is one of the key enzymes in estrogen metabolism, catalyzing the reversible reaction between estradiol and the less active estrogen, estrone. The gene encoding this enzyme, EDH17B2, has been mapped to chromosome 17, region q12–q21, in the vicinity of BRCA1, an as yet unidentified gene that appears to be involved in familial breast cancer and in familial ovarian cancer. The possibility that EDH17B2 gene is the same as BRCA1 was tested by screening for mutations in the coding regions of EDH17B2, using a polymerase chain reaction/single-strand conformation polymorphism method. An A→G transition creating a new BstUI site at exon 6 was the only frequent sequence alteration found in the coding region of the gene. This mutation also led to an amino acid substitution of serine to glycine at position 312 (312S→312G) in the 17HSD protein. Since the nucleotide change was detected both in specimens from patients with familial or sporadic cancer and in control samples, and at similar rates, this mutation appears to be of a polymorphic nature. In addition, a rare polymorphism located at intron 5 was detected. This C→T substitution creates a BbvI site and is not thought to have any effect on 17HSD activity. The results indicate that there are no major alterations in the coding areas of EDH17B2 and thus studies testing the hypothesis that EDH17B2 may be the same as BRCA1 should be extended to the promoter and regulatory elements of EDH17B2.

Prognostic Factors of Perforated Sigmoid Diverticulitis in the Elderly

Background: The Finnish population is aging fast and the prevalence of perforated sigmoid diverticulitis is simultaneously increasing in northern Finland. The fact that an increasing number of elderly patients, with their age-specific problems, are subjected to emergency surgery for acute diverticulitis underlines the importance of risk stratification.Methods: One hundred and seventy-two patients admitted to Oulu University Hospital because of diverticular perforation from 1983 to 2002 were identified from the computer database. The clinical variables were evaluated as prognostic indicators of postoperative complications, mortality and time of hospitalization. Results: The resection rate was 91%; 64 primary anastomoses, 93 Hartmann’s procedures and two covering colostomies were performed. The overall complication rate was 33%. In patients under 70 years, a stepwise logistic regression analysis showed that the Mannheim Peritonitis Index (MPI) score and American Society of Anesthesiologists (ASA) score were independent prognostic factors. None of factors predicted morbidity in patients over 70 years. Overall mortality rate was 8%, without any significant difference between the procedures. Of the clinical variables, MPI score, ASA score, Hinchey classes and malnutrition correlated with mortality. All patients who died presented with ASA scores of III–IV, and 12 out of 14 patients had an MPI score of II. In a stepwise logistic regression analysis, only the MPI score seemed to be an independent predictor of mortality. Conclusions: Mortality is related to age but age alone is not an independent predictor of mortality. The MPI score is useful in predicting the risk of death in patients with perforated diverticulitis.

Determinants of positive histologic margins and residual tumor after lumpectomy for early breast cancer : A prospective study with special reference to touch preparation cytology

Removal of the entire tumor by breast‐conserving surgery is important, but the determinants of adequate excision have not been established.

Survival after operations for colorectal cancer in patients aged 75 years or over

OBJECTIVEnTo define factors that predict mortality and survival in patients with colorectal cancer who are aged 75 or over.nnnDESIGNnRetrospective study.nnnSETTINGnUniversity hospital, Finland.nnnSUBJECTSn231 patients aged 75 or over who were admitted to hospital with colorectal cancer during the 14-year period 1980-93.nnnMAIN OUTCOME MEASURESnMorbidity, mortality, recurrence, and survival.nnnRESULTSnIn-hospital mortality after any kind of operation was 8/211 (4%), and 8/175 (5%) of those who had their tumours resected. Morbidity was 35/175 (20%). Factors associated with mortality were weight loss, Dukesstage, extent of resection, and type of operation. Overall 5-year survival was 28%, overall 10-year survival was 4%, and median survival was 33 months (range 0-150). Survival was most closely related to Dukes stage, extent of resection, and recurrent disease on univariate analysis, but multivariate analysis identified only mode of recurrence (p < 0.0001), recurrent disease (p < 0.004), and extent of resection (p < 0.009) as independent predictors of survival. The recurrence rate after radical resection was 49/141 (35%) and the median disease-free interval was 10 months (range 4-64). Mortality after resection for recurrent cancer was 3/17 (18%) and morbidity 5/17 (29%).nnnCONCLUSIONnAge alone is not a risk factor for postoperative mortality or a predictor of long-term survival. Low mortality and acceptable long-term survival can be achieved in patients aged 75 or over if those with extensive distant metastases, and those whose general condition is too poor to stand a major operation, are treated conservatively.

Diagnosis and Treatment of Acute Lower Gastrointestinal Bleeding

Diagnostic sigmoidoscopy and barium enema examinations (n = 214) or colonoscopy (n = 52) were performed for acute lower gastrointestinal (GI) bleeding. The cause of bleeding was detected in 76% (203 of 266) of the primary examinations, and the cause remained unclear after subsequent examinations in 17% of the cases. Hemorrhoids were the cause of bleeding in 28% (56 of 203) of the cases, colonic diverticular disease in 19% (39 of 203), adenomatous polyps in 11% (23 of 203), and colorectal cancer in 10% (20 of 203). The sources of bleeding did not differ significantly by sex. An anorectal site of bleeding was most often detected in patients less than 50 years of age (p < 0.0001) and a left colonic site in those more than 70 years (p < 0.0001). Hemorrhoids significantly more often caused rectal bleeding among the youngest patients (p < 0.0001) and colonic diverticular disease among the oldest patients (p < 0.0001) and colonic diverticular disease among the oldest patients (p < 0.0001) than among the others. Of the 266 patients, 19% have been operated on for the bleeding lesion. The mortality related to lower GI bleeding was 4% (11 of 266). The mean age of the patients who died was higher than that of those who survived (p < 0.05).